Manassas Health and Rehab Center

In the surveyor’s words

From the most serious findings on record at Manassas Health and Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF600Feb 13, 2024

  Based on staff interviews, family interview, clinical record review, and facility document reviews, it has been determined that the facility staff failed to ensure that a resident was free from neglect when they neglected to properly assess, monitor, treat, and consult a physician or practitioner for 1 of 15 residents (Resident #15, closed record review) in the survey sample who was unresponsive and presented with respiratory distress, which constituted harm. The findings include: For Resident #15, the facility neglected to properly administer supplemental oxygen, assess, and monitor during signs and symptoms of respiratory distress for approximately two (2) hours before calling 911. Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. […]

• Actual harm, isolatedF695Feb 13, 2024

  Based on staff interviews, Emergency Medical Service (EMS) report, facility document review, and clinical record review, it was determined that the facility staff failed to assess, monitor, and appropriately treat an unresponsive resident who presented with respiratory distress for 1 of 15 residents (Resident #15, closed record review) in the survey sample, which constituted harm. The findings include: For Resident #15, the facility failed to properly administer supplemental oxygen, assess, and monitor an unresponsive resident including vital signs and signs and symptoms of hypoxia for approximately 2 hours before calling 911. Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF814Jan 22, 2026

  Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to dispose of refuse properly. The facility staff failed to maintain a clean dumpster area during the facility task- kitchen observation 1/20/26 at 11:50 AM. The findings include: On 1/20/26 at 11:50 AM, an observation was conducted in the dumpster area outside of the kitchen. On the left side of the dumpster on the ground there were blue and white gloves and plastic straw.An interview was conducted on 1/20/26 at 1:10 PM with OSM #1, the dining services director. When asked about the findings, OSM #1 stated, we only wear black gloves. I will talk with housekeeping about it. […]

• No harm, potential for more than minimal, widespreadF770Mar 5, 2021

  Based on staff interview and clinical record review, it was determined that the facility staff failed to dispose of laboratory vaccutainers upon expiration date in three of three medication storage rooms, (Evergreen, Magnolia and Dogwood medication storage rooms). Expired laboratory vaccutainer tubes were observed available for use in Evergreen, Magnolia and Dogwood medication storage rooms. The Evergreen medication storage room contained 17 expired laboratory (lab) vaccutainer tubes, Magnolia medication storage room contained 18 expired lab vaccutainer tubes and Dogwood medication storage room contained seven expired lab vaccutainer tubes. […]

• No harm, potential for more than minimal, patternF656Jan 22, 2026

  Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for two of 43 residents in the survey sample, Resident #6 and Resident #35.The findings include:1. For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan to administer pain medication as ordered. Pain level parameters for the administration of Hydromorphone (1) were not followed during administration during dates in December 2025 and January 2026. The comprehensive care plan for R6 documented in part, Patient has pain or potential for pain. Date Initiated: 11/07/2025. Under Interventions it documented in part, Administer pain medication as ordered. […]