Lake Manassas Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lake Manassas Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 10, 2026

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care in a timely manner to prevent serious injury and/or death to two of 12 residents in the survey sample, Residents #1 and #2, resulting in the identification of immediate jeopardy.The findings include:1. For Resident #1 (R1), on [DATE], the facility staff failed to assess and accurately identify signs and symptoms of sepsis (1) and to transfer the resident to the hospital in a timely manner. The resident's significant change of condition was identified on [DATE] at 7:30 a.m., the resident was not transferred to the local hospital for treatment until approximately 12:30 p.m., and the resident died at the hospital at 3:37 p.m. from sepsis. […]

• No harm, potential for more than minimal, widespreadF865Apr 10, 2026

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement an effective QAPI (Quality Assurance/Performance Improvement) process for one of one facility.The findings include:The facility failed to implement its QAPI plan following an incident in which a resident, who was displaying signs and symptoms of sepsis (1), was not transferred to the hospital in a timely manner.On 9/1/24 at 6:27 a.m., the weekend on-call licensed provider was contacted about the resident's low blood pressure (documented as 84/49). The on-call provider ordered a hold on the resident's aspirin and medications to treat high blood pressure, a test for blood in the resident's stool, and hourly blood pressure checks. […]

• No harm, potential for more than minimal, patternF698Apr 17, 2024

  Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services, for one of 40 residents in the survey sample, receiving dialysis services, Resident #76. The findings include: For Resident #76, the facility staff failed to evidence the monitoring of the resident's dialysis access, an arterial - venous fistula. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 3/30/2024, the resident scored a nine out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. […]

• No harm, potential for more than minimal, patternF656Jun 14, 2023

  Based on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of seven residents in the survey sample, Resident #3. The findings include: For Resident #3, the facility staff failed to implement the comprehensive care plan for turning and repositioning. Resident #3's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 9/29/22, coded the resident as scoring 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. MDS Section G- Functional Status: coded the resident as extensive assistance with bed mobility. […]

• No harm, potential for more than minimal, patternF686Jun 14, 2023

  Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide the care and services to promote healing and prevention of pressure ulcers/injuries, for one of seven residents in the survey sample, Resident #3. The findings include: The facility failed to evidence that turning and repositioning consistently occurred for Resident #3. Resident #3 was admitted to the facility on [DATE] with diagnoses that included but not limited to: wedge compression fracture T11-T12 (thoracic 11-12 vertebrae). […]