Deficiency Records for Fredericksburg Nursing and Rehabilitation LP
Updated as of April 01, 2024
A list of the most recent deficiencies for Fredericksburg Nursing and Rehabilitation LP. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-26 | 2023-04-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-26 | 2023-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-26 | 2023-04-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-26 | 2023-04-14 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-03-26 | 2023-04-14 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-03-26 | 2023-04-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-03-26 | 2023-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-26 | 2023-04-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-26 | 2023-04-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-03-26 | 2023-04-14 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-03-26 | 2023-04-14 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-03-22 | 2023-04-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-22 | 2023-04-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-22 | 2023-04-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-22 | 2023-04-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-22 | 2023-04-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-04 | 2022-12-05 | Y |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-02-08 | 2022-03-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-08 | 2022-03-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-08 | 2022-03-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-08 | 2022-03-03 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-02-08 | 2022-03-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-08 | 2022-03-03 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-08 | 2022-03-03 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-02-08 | 2022-03-03 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-02-08 | 2022-03-03 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-02-08 | 2022-03-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-08 | 2022-03-03 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-02-08 | 2022-03-03 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-08 | 2022-03-03 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-01-13 | 2022-02-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-17 | 2021-08-11 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-06-17 | 2021-07-17 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2021-06-17 | 2021-07-17 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2020-02-28 | 2020-03-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-02-28 | 2020-03-31 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-02-28 | 2020-03-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-28 | 2020-03-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-02-28 | 2020-03-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-28 | 2020-03-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-28 | 2020-03-31 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2020-02-28 | 2020-03-31 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2020-02-28 | 2020-03-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-28 | 2020-03-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-28 | 2020-03-31 | N |
| Dispose of garbage and refuse properly. | Health | 2020-02-28 | 2020-03-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-28 | 2020-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-28 | 2020-03-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-02-28 | 2020-03-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-02-28 | 2020-03-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-26 | Not Fixed | N |
