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Deficiency Records for Fredericksburg Nursing and Rehabilitation LP
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.
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? |
|---|---|---|---|---|
| Establish policies and procedures including evacuation. | Fire Safety | 2024-05-16 | 2024-06-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-05-16 | 2024-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-16 | 2024-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-16 | 2024-06-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-16 | 2024-06-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-17 | 2024-06-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-17 | 2024-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-17 | 2024-06-17 | 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 | 2024-05-17 | 2024-06-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-17 | 2024-06-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-17 | 2024-06-17 | N |
| 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 | 2024-05-17 | 2024-06-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-17 | 2024-06-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-17 | 2024-06-17 | 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 | 2024-05-17 | 2024-06-17 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-05-17 | 2024-06-17 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-05-17 | 2024-06-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-05-17 | 2024-06-17 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-05-17 | 2024-06-17 | N |
| Dispose of garbage and refuse properly. | Health | 2024-05-17 | 2024-06-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-17 | 2024-06-17 | N |
| Keep all essential equipment working safely. | Health | 2024-05-17 | 2024-06-17 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-05-17 | 2024-06-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-16 | 2024-06-13 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-05-17 | 2024-06-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-16 | 2024-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-07 | 2024-03-08 | Y |
| 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 |
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