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 Fredericksburg Health And Rehab during CMS and state inspections, most recent first.
Facility staff failed to follow a baseline care plan for a resident with COPD and altered respiratory status who had a physician order for oxygen at 2 L/min. The resident was observed twice receiving oxygen at higher, unprescribed flow rates between 2–4 L/min, as shown on the concentrator flow meter, and the oxygen concentrator was not within the resident’s reach. An LPN reported that nurses are expected to use the care plan and physician orders to verify correct oxygen flow by checking the flow meter at eye level, and facility policy requires a baseline care plan within 48 hours of admission to ensure needs are met until a comprehensive care plan is completed.
Staff failed to follow oxygen safety and administration requirements for two residents on oxygen therapy. One resident receiving O2 at 2 L/min for shortness of breath had no “Oxygen in Use” signage posted at the doorway or in the room, despite facility policy requiring such signs due to oxygen being a fire hazard. Another resident with COPD and an order for O2 at 2 L/min was observed twice with the concentrator flow meter set above the ordered rate, and the concentrator was not within the resident’s reach. An LPN acknowledged that nurses should verify the physician’s order and ensure the flow meter ball is centered on the prescribed liter line, consistent with the manufacturer’s instructions and facility policy.
Failure to Follow Baseline Care Plan for Oxygen Administration
Penalty
Summary
Facility staff failed to implement the baseline care plan for a resident requiring oxygen therapy. The resident had a physician’s order dated 1/30/26 for oxygen at two liters per minute for chronic obstructive pulmonary disease and a baseline care plan dated 2/2/26 documenting altered respiratory status, including wheezing, shortness of breath, and obstructive sleep apnea, with instructions to administer oxygen as needed per physician order. On 2/4/26 at 11:30 a.m., the resident was observed in bed receiving oxygen at a rate between three and four liters per minute, as indicated by the position of the ball in the oxygen concentrator flow meter between the three-liter and four-liter lines. Later the same day at 2:14 p.m., the resident was again observed in bed receiving oxygen at a rate between two and three liters per minute, with the ball in the flow meter between the two-liter and three-liter lines. During both observations, the oxygen concentrator was not within the resident’s reach. In an interview at 3:02 p.m., an LPN stated that care plans provide information so staff can meet residents’ needs, that nurses have access to residents’ care plans, and that nurses should check physician orders to ensure the correct oxygen amount is administered by verifying at eye level that the middle of the ball runs through the ordered liter line on the flow meter. The facility’s policy on care plans stated that a baseline care plan must be developed within 48 hours of admission to ensure residents’ needs are met appropriately until the comprehensive care plan is completed.
Failure to Follow Oxygen Safety Signage and Prescribed Flow Rates
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for two residents receiving oxygen therapy. For one resident with a physician’s order for oxygen at two liters per minute for shortness of breath, surveyors twice observed the resident in bed on oxygen via nasal cannula and concentrator without any cautionary or safety signage indicating oxygen use at the doorway or in the room. An LPN stated that when a resident is receiving oxygen, a sign is supposed to be posted outside the room door to alert staff that the resident requires oxygen and because oxygen is flammable. Facility policy on oxygen administration documented that oxygen is considered a fire hazard and that “Oxygen in Use” signage should be posted where applicable. For another resident with a physician’s order for oxygen at two liters per minute for chronic obstructive pulmonary disease, surveyors observed the oxygen concentrator flow meter set above the ordered rate on two occasions. The first observation showed the ball in the flow meter between the three- and four-liter lines, and the second observation showed the ball between the two- and three-liter lines, while the concentrator was not within the resident’s reach during either observation. The LPN interviewed stated that nurses should check the physician’s order and verify the correct oxygen amount by viewing the flow meter at eye level and ensuring the middle of the ball runs through the prescribed line. The manufacturer’s instructions for the concentrator specified that the flow should be adjusted until the ball is centered on the line marking the specific flow rate, and the facility’s oxygen administration policy required verification of the physician’s order prior to initiation and application of the prescribed flow rate.
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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) |
|---|---|---|---|---|
| Carriage Hill Health & Rehab Center | 1.2 mi | — | 2 | 0 |
| Woodmont Center | 4.3 mi | — | 5 | 0 |
| Falls Run Nursing And Rehabilitation | 5.4 mi | — | 0 | 0 |
| Berea Health & Rehab Center | 5.4 mi | — | 14 | 0 |
| Heritage Hall King George | 18 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.