Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Knopp Nursing & Rehab Center Inc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and physical dependency fell and broke her leg during a transfer when a CNA attempted to use a mechanical lift without the required assistance of another staff member. The facility failed to ensure staff followed protocols for resident transfers, and there was a lack of in-service training on the use of mechanical lifts.
The facility failed to report allegations of abuse and neglect involving three residents. A resident with severe cognitive impairment was injured during a transfer by a single CNA, resulting in a broken leg. Another resident reported feeling threatened by a family member while on pass, and a third resident's oxygen supply was turned off by a roommate. These incidents were not reported to the state agency as required.
A facility failed to investigate and report allegations of abuse and neglect involving three residents. One resident suffered a broken leg during an improper transfer, another felt threatened by a family member while on pass, and a third had their oxygen therapy disrupted by a roommate. These incidents were not reported to the state agency, contrary to facility policy.
A facility reported a medication error rate of 7.69%, exceeding the acceptable 5% threshold. Two residents received medications incorrectly: one had an extended-release tablet crushed, and the other had a delayed-release capsule opened and mixed with applesauce. These actions were against FDA guidelines and were observed during administration. RN G acknowledged the errors and reported them to the DON.
A facility failed to involve a resident and their family in the care plan development process. The resident, with moderate cognitive impairment and no dementia diagnosis, was not invited to care plan meetings, contrary to facility policy. Interviews and record reviews confirmed the absence of invitations, despite claims by the ADON that they were sent.
A facility failed to develop a comprehensive care plan for a resident with depression, pneumonia, and dysphagia. The care plan lacked interventions for the resident's depression and antidepressant therapy, despite the resident being cognitively intact and taking antidepressants. Interviews revealed that the ADON was responsible for care plans but was unsure why the depression diagnosis was omitted, contrary to facility policy requiring comprehensive care plans.
A resident with hemiplegia and hemiparesis did not receive 18 out of 30 scheduled showers, as required by the facility's policy. Despite needing partial assistance for bathing, the resident reported only receiving showers once a week. The ADON suggested memory issues, but no dementia diagnosis was present. The facility's policy mandates showers three times weekly, which was not adhered to.
A resident was administered Mirtazapine, an antidepressant, without a documented diagnosis of depression. The resident's MDS assessment did not reflect a depression diagnosis, yet the medication was prescribed and administered for this condition. The ADON was unable to clarify the lack of diagnosis, indicating a failure to adhere to the facility's policy on unnecessary drugs.
A resident with a Full Code status was found unresponsive, and facility staff failed to provide timely CPR or call emergency services for 25 minutes. The nursing staff lacked current CPR certification, and the crash cart contained expired items. The resident, who had multiple medical conditions, passed away shortly after being admitted to the facility.
The facility failed to maintain accurate records and proper administration of controlled drugs, leading to discrepancies for several residents. A resident received incorrect doses of diazepam due to misinterpretation of packaging. Another resident's hydrocodone acetaminophen was tampered with, and an RN admitted to an error without proper documentation. Additionally, a third resident's medication records showed discrepancies between documented and actual administration, with the previous DON failing to report the issue.
A resident admitted with type 2 diabetes did not have insulin administration or blood glucose checks entered upon admission, despite hospital discharge orders indicating the need for insulin if glucose levels exceeded 150. Interviews revealed confusion among staff regarding responsibility for entering orders, and the facility's medication administration policy was not followed.
A nurse failed to administer hydrocodone acetaminophen to a resident with severe cognitive impairment and multiple diagnoses within the scheduled time frame, as per facility policy. The nurse cited being too busy and used a cheat sheet for tracking, leading to delayed documentation and administration. The DON confirmed that immediate documentation and adherence to scheduled times are required by facility policy.
Failure to Provide Adequate Supervision and Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent accidents for a resident who required assistance with transfers. On a specific date, a CNA attempted to transfer a resident using a mechanical lift without the required assistance of another staff member. This resulted in the resident falling and suffering a broken right leg, which required surgical repair. The resident had been assessed as needing more than one staff member for assistance with transfers due to severe cognitive impairment and physical dependency. The incident occurred when the CNA, who was an agency employee, attempted to transfer the resident alone despite being warned by an LVN not to do so. The resident was known to be non-compliant and combative during transfers, which further necessitated the need for two-person assistance. The facility's records indicated that the resident was dependent on staff for all transfers, and this information was supposed to be available to staff through a care plan and a shower book binder, which was not updated to reflect the resident's needs. Interviews with facility staff revealed a lack of in-service training on the proper use of mechanical lifts and the required number of staff for transfers. The facility's failure to provide adequate training and ensure that staff followed established protocols for resident transfers contributed to the incident. The facility's administration acknowledged the deficiency and took steps to address the issue, but the immediate jeopardy situation was identified due to the failure to prevent the accident and ensure resident safety.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and exploitation in a timely manner for three residents. Resident #140, who had severe cognitive impairment and required assistance from more than one staff member for transfers, was injured during a transfer conducted by a single CNA using a mechanical lift. The resident fell, resulting in a broken leg that required surgical repair. Despite the severity of the injury, the facility's administration did not report the incident to the state agency, as they believed it was not reportable since the injury was witnessed. Resident #17, who had intact cognition, reported feeling vulnerable and threatened while on a pass with a family member. The resident described an incident where she was nude and scared by a drunken, bloodied family member, leading her to crawl to safety. This allegation of abuse was documented by a CNA and the social worker but was not reported to the administrator or state agency for investigation. Resident #5, who had severe cognitive impairment and required oxygen therapy, was involved in an incident where her oxygen supply was turned off by Resident #17 because it was too loud. This action was documented in a grievance form by the social worker, who advised Resident #17 of the danger posed to Resident #5. However, the allegation of neglect was not reported to the administrator or state agency. The facility's policy on abuse, neglect, and mistreatment was not followed, as these incidents were not thoroughly investigated or reported as required.
Failure to Investigate and Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate and report allegations of abuse, neglect, and exploitation for three residents. Resident #140, who had severe cognitive impairment and required assistance from more than one staff member for transfers, was injured during a transfer conducted by a single CNA using a mechanical lift. The resident fell, resulting in a broken leg that required surgical repair. Despite the severity of the injury, the facility did not report the incident to the state agency, as the administrator and ADON concluded it was not a reportable event since the injury was witnessed. Resident #17, who had intact cognition, reported feeling vulnerable and threatened by a family member while out on pass. The resident described an incident where she was nude and scared by a drunken, bloodied family member, leading her to crawl to safety. This allegation of abuse was documented by a CNA and acknowledged by the social worker, but it was not reported or investigated by the facility's administration. Resident #5, who had severe cognitive impairment and required oxygen therapy, was allegedly neglected when Resident #17 turned off her oxygen concentrator and removed her nasal cannula because it was too loud. This incident was documented in a grievance form, but the facility's administration did not recognize it as an allegation of neglect or abuse, and it was not reported or investigated. The facility's policy on abuse, neglect, or mistreatment was not followed, as these incidents were not thoroughly investigated or reported to the appropriate state agencies.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 7.69% due to two medication errors involving two residents. The errors were identified during observations, interviews, and record reviews. RN G administered medications incorrectly to two residents, leading to the deficiency. The first resident, who had severe cognitive impairment and was under hospice care, was prescribed ranolazine 500mg extended-release tablets for heart-related chest pain. Despite the physician's order to administer medications via a PEG tube only if the manufacturer allowed, RN G crushed the extended-release tablet, which should have been swallowed whole according to FDA guidelines. This action was observed during medication administration. The second resident, also with severe cognitive impairment and under hospice care, was prescribed duloxetine 30mg delayed-release capsules for depression. RN G opened the capsule and mixed its contents with applesauce, contrary to FDA guidelines that state the capsule should be swallowed whole. This error was similarly observed during medication administration. RN G acknowledged the errors and reported them to the DON and medical director. The facility's medication error policy emphasizes the importance of avoiding significant medication errors, which was not adhered to in these instances.
Failure to Involve Resident in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident and/or the resident's representative were involved in the development and implementation of the resident's person-centered plan of care. Specifically, the facility did not invite or include the input of a resident and their family member in Care Plan Conference meetings. This oversight was identified for one resident who was reviewed for care plans. The resident, a male with diagnoses including diabetes mellitus, hemiplegia and hemiparesis following a cerebral infarction, and dysphagia, had a BIMS score indicating moderate impairment but no diagnosis of dementia. Interviews and record reviews revealed that the resident and their family member were not invited to any care plan conference meetings prior to a specific date, despite the family member's regular visits to the facility. The facility's ADON claimed that invitations were sent, but no evidence of such invitations was found in the resident's records. The facility's policy requires the inclusion of the resident and their family or POA in the interdisciplinary team for care planning, but this was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is consistent with the resident's rights and includes measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. Specifically, the care plan for a resident with diagnoses including pneumonia, depression, and dysphagia did not include any interventions or mention of the resident's diagnosis of depression or antidepressant therapy. This oversight was identified during a review of the resident's care plan, which was found to be a five-page document lacking these critical elements. Interviews conducted with the Assistant Director of Nursing (ADON) and the Administrator (ADM) revealed that the ADON was responsible for ensuring care plans were completed correctly and addressed all areas of care. However, the ADON was uncertain why the resident's diagnosis of depression was not included in the care plan, despite the expectation that care plans should be done correctly. The facility's policy, dated 2005, requires that care plans include measurable objectives and timetables to meet a resident's needs as identified in the comprehensive assessment, which was not adhered to in this case.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, Resident #28, who required partial/moderate assistance for bathing due to conditions such as hemiplegia and hemiparesis following a cerebral infarction, did not receive 18 out of 30 scheduled showers between July and October 2024. The resident's care plan indicated a self-care performance deficit related to these diagnoses, and the facility's policy required residents to be showered a minimum of three times weekly. However, the resident's shower log showed significant non-compliance with this schedule. Interviews with Resident #28 and their family member revealed that the resident was only receiving showers once a week, contrary to the facility's policy and the resident's care plan. The Assistant Director of Nursing (ADON) suggested that the resident and family member might not remember the shower schedule correctly, implying possible dementia, although no such diagnosis was present in the resident's records. The Director of Nursing (DON) and Administrator (ADM) acknowledged the expectation for residents to receive showers on their scheduled dates, yet the records indicated otherwise.
Unnecessary Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, who had not been diagnosed with depression, was not given psychotropic medication unnecessarily. Specifically, a resident was administered Mirtazapine, an antidepressant, without a documented diagnosis of depression. The resident's comprehensive MDS assessment did not reflect a diagnosis of depression, and the resident's BIMS score indicated moderate cognitive impairment. Despite this, the resident's medication administration record showed that Mirtazapine was prescribed and administered for depression. During an interview, the Assistant Director of Nursing (ADON) was unable to explain why the resident did not have a documented diagnosis of depression and was uncertain about who was responsible for ensuring the correct diagnosis for psychotropic medications. The facility's policy on medications and drug regimen reviews indicated that unnecessary drugs are those given without a diagnosis or reason, highlighting a failure in adhering to this policy. This deficiency could potentially place residents at risk of receiving unnecessary medications.
Failure to Provide Basic Life Support to Resident
Penalty
Summary
The facility personnel failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, who had a Full Code status, was found unresponsive with no pulse or respirations. Despite the professional standards of practice, the facility staff did not obtain an AED or call emergency services for 25 minutes after the resident was found. The nursing staff also lacked current CPR certification, which contributed to the delay in providing life-saving measures. The resident involved was an elderly male with multiple medical conditions, including acute osteomyelitis, type 2 diabetes mellitus, ischemic cardiomyopathy, and chronic heart failure. He was admitted to the facility after a below-the-knee amputation and was noted to have intact cognition. However, his face sheet did not list his code status, and a care plan was not available. The nursing notes indicated that the resident was admitted after dinner service and passed away around midnight the following day. The incident was further compounded by the lack of proper emergency protocol adherence. The LVN on duty found the resident unresponsive and began chest compressions alone, without obtaining the AED or calling for emergency services immediately. The crash cart contained expired items, and the logs for daily checks were incomplete. Interviews with staff revealed that they were not adequately trained or certified in CPR, and the facility's policies for emergency equipment checks were not consistently followed.
Removal Plan
- The facility needs to ensure nursing staff are trained for emergencies to include CPR and AED and emergency response items are in place.
- DON and ADON will have every licensed staff in facility CPR certified.
- DON and ADON started training in AED/CPR training.
- Set up a mandatory in-service for all nursing staff.
- All nurses and CNAs were in serviced in person and were allowed to demonstrate skills to ADON on how to correctly perform CPR.
- In serviced all nursing staff on the use of AED and had them demonstrate to ADON how to fully use the AED machine.
- Nursing staff were able to properly demonstrate to ADON DON proper use of both AED and crash cart location use of and items were identified in crash cart and demonstrated to nursing staff.
- Crash cart will be revised nightly per night shift nurse, there is a current log that we implemented in a binder in nurses station.
- ADON will check log once a week and sign off on log once checked that week.
- Administrator to review these logs at the end of month every month to ensure compliance.
- Safety checks were performed in person per Administrator to ensure the safety of our residents.
- Implemented all nursing staff be current with CPR status.
- Held an in-house in-service training for all licensed personnel.
- Touched on the topic of AED location as well as the importance of the devices and crash carts not being occluded or in their assigned place.
- New implemented mandatory for all licensed personnel to have current status of CPR training and current card demonstrating so.
- All PRN staff follow guidelines as mentioned.
- Business office manager to check licensed personnel file to ensure compliance.
- Included CNA D and CNA E in in service to implement importance of CNA role during code to call for help.
- Our policy states 2 CPR certified staff for each shift we are complying currently.
- A mock code was presented per ADON to the following nurses; RN G, LVN H, DON LVN, LVN J, K RN, CNA D, CNA E, LVN L.
- Plan in place is to in service PRN nurses before any scheduled shift.
- Set up a follow up in service.
- All 11 of 12 nursing staff CPR were verified or completed a hands-on CPR course.
- LVN M was removed from the schedule until she completed a hands-on CPR course.
Medication Mismanagement and Documentation Errors
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled drugs, leading to discrepancies in the administration and documentation of medications for several residents. For Resident #10, the facility dispensed an incorrect number of diazepam pills, contrary to the physician's orders. The staff signed out two tablets of 2 mg diazepam on multiple occasions, despite the order being for one tablet. This discrepancy was attributed to a possible misunderstanding of the packaging, as the LVN involved suggested the tablets might have been half tabs or 1 mg tabs, but this was not documented. Resident #11's medication was tampered with, as observed in a blister pack of hydrocodone acetaminophen, where two pills had broken seals and were taped over. RN K admitted to mistakenly administering the wrong dosage to another resident and attempted to rectify the error by replacing the pill, which was not properly documented. This incident highlights a lack of verification and proper documentation, as well as a failure to report the error to the appropriate authorities. For Resident #13, there was a significant discrepancy between the documented administration of hydrocodone acetaminophen and the actual medication received by the resident. The MAR indicated that 32 doses were dispensed, but the resident's statement and the MAR showed fewer doses were administered. The facility's administrator was informed of the issue by RN G, but the previous DON failed to report the discrepancies, possibly due to a personal relationship with the involved LVN. This lack of oversight and accountability contributed to the misappropriation of medication.
Failure to Enter Admission Orders for Insulin and Blood Glucose Checks
Penalty
Summary
The facility failed to ensure that a resident had appropriate physician orders for immediate care upon admission. Specifically, the resident, who was admitted with a diagnosis of type 2 diabetes mellitus, did not have orders for insulin administration or blood glucose checks entered upon admission. The resident's hospital discharge summary included orders for regular insulin to be administered as needed if glucose levels exceeded 150, but these orders were not reflected in the facility's records. The resident's blood glucose was not checked, and there was no care plan available in the clinical record. Interviews with facility staff revealed a lack of clarity and responsibility regarding the entry of admission orders. An LVN stated that orders should be entered prior to a resident's arrival but indicated that she was not responsible for entering them. The administrator believed the LVN was responsible for entering the orders, while the previous DON, who had resigned, was not present at the time of admission. The facility's policy on medication administration emphasized the importance of preparing, administering, and documenting medications accurately, but this was not adhered to in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide timely medication administration, which is crucial for resident safety and well-being. Specifically, RN K did not administer hydrocodone acetaminophen to Resident #12 within the one-hour window before or after the scheduled time, as per the facility's policy. This resident, who has severe cognitive impairment and multiple diagnoses including Parkinson's disease, migraines, spinal stenosis, and a psychotic disorder, was at risk due to the improper timing of medication administration. RN K admitted to being too busy with other residents, leading to delays in medication administration and documentation. She used a cheat sheet to track medications and often documented after administering to multiple residents, which contributed to the errors. The Director of Nursing (DON) confirmed that staff should document narcotics immediately after dispensing and follow a systematic process for medication administration. The facility's policies on narcotic storage and medication administration emphasize immediate documentation and adherence to scheduled times, which were not followed in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fredericksburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Fredericksburg | 0.4 mi | — | 1 | 0 |
| Avir At Enchanted Rock | 0.5 mi | — | 1 | 0 |
| Knopp Healthcare And Rehab Center Inc | 2.3 mi | — | 9 | 0 |
| Avir At Comfort | 19.7 mi | — | 0 | 0 |
| Hilltop Village Nursing And Rehabilitation | 20.5 mi | — | 0 | 0 |
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