SeniorHomeViolations
B+
81/100

FALLS RUN NURSING AND REHABILITATION Inspection Report, Violations & Safety Grade (FREDERICKSBURG, Virginia)

140 BRIMLEY DRIVE, FREDERICKSBURG, Virginia 22406

Phone: 5407520111

CMS Overall:4/5

Overview & Bed Count

Certified Beds
90
Avg Residents/Day
83.7
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Stafford
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall4/5
Health3/5
Staffing3/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityVirginia AvgDifference
RN Hours per Resident per Day0.820.71+0.11
Total Nurse Hours per Resident per Day3.843.88-0.03
CMS Staffing Rating3/52.5/5-
Nursing Staff Turnover44.7%47.5%-

Health Citation History

28 health citations on record

DateCategoryDescriptionSeverity
2023-03-16Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.E – Moderate Harm Potential
2023-03-16Quality of Life and Care DeficienciesProvide safe, appropriate pain management for a resident who requires such services.E – Moderate Harm Potential
2023-03-16Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.E – Moderate Harm Potential
2023-03-16Resident Rights DeficienciesHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.D – Moderate Harm Potential
2023-03-16Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2023-03-16Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.D – Moderate Harm Potential
2023-03-16Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2023-03-16Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2023-03-16Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D – Moderate Harm Potential
2021-08-26Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.E – Moderate Harm Potential
2021-08-26Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2021-08-26Resident Rights DeficienciesReasonably accommodate the needs and preferences of each resident.D – Moderate Harm Potential
2021-08-26Resident Assessment and Care Planning DeficienciesCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedD – Moderate Harm Potential
2021-08-26Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2021-08-26Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2021-08-26Nursing and Physician Services DeficienciesObserve each nurse aide's job performance and give regular training.D – Moderate Harm Potential
2021-08-26Pharmacy Service DeficienciesEnsure each resident’s drug regimen must be free from unnecessary drugs.D – Moderate Harm Potential
2021-08-26Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2019-09-06Resident Rights DeficienciesHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.E – Moderate Harm Potential
2019-09-06Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2019-09-06Resident Rights DeficienciesKeep residents' personal and medical records private and confidential.D – Moderate Harm Potential
2019-09-06Resident Rights DeficienciesNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.D – Moderate Harm Potential
2019-09-06Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.D – Moderate Harm Potential
2019-09-06Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.D – Moderate Harm Potential
2019-09-06Resident Assessment and Care Planning DeficienciesCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedD – Moderate Harm Potential
2019-09-06Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2019-09-06Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2019-09-06Quality of Life and Care DeficienciesTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.D – Moderate Harm Potential

Fire Safety Citation History

6 fire safety citations on record

DateCategoryDescriptionSeverity
2023-03-16Gas, Vacuum, and Electrical Systems DeficienciesHave a battery powered remote alarm panel in a location accessible by operating personnel.D – Moderate Harm Potential
2019-09-06Egress DeficienciesAdd 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.F – Moderate Harm Potential
2019-09-06Smoke DeficienciesEnsure that corridors are separated from use areas by walls constructed to limit the passage of smoke.F – Moderate Harm Potential
2019-09-06Egress DeficienciesProvide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.D – Moderate Harm Potential
2019-09-06Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.D – Moderate Harm Potential
2019-09-06Services DeficienciesHave elevators that firefighters can control in the event of a fire.D – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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