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Health Inspection Summary
Lake Manassas Health & Rehabilitation Center
14935 Holly Knoll Lane
Gainesville, VA 20155
(703) 743-3999

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Deficiency Category
Inspection Date:
4/17/24
Complaint Reporting Period:
3/1/24 - 2/28/25
Inspection Date:
7/14/22
Complaint Reporting Period:
3/1/23 - 2/29/24
Inspection Date:
2/27/20
Complaint Reporting Period:
3/1/22 - 2/28/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies001
Quality of Life and Care Deficiencies444
Infection Control Deficiencies111
Resident Assessment and Care Planning Deficiencies462
Nursing and Physician Services Deficiencies000
Resident Rights Deficiencies451
Nutrition and Dietary Deficiencies002
Pharmacy Service Deficiencies110
Environmental Deficiencies000
Administration Deficiencies100

Detailed result for inspection on 4/17/24
Date of last standard health inspection:4/17/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25
No complaint inspections
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:15
Average number of Health Deficiencies in Virginia:12.2
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide safe, appropriate dialysis care/services for a resident who requires such services.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Some

Try 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.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few

Allow residents to self-administer drugs if determined clinically appropriate.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident’s drug regimen must be free from unnecessary drugs.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

4/17/247/31/24
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 7/14/22
Date of last standard health inspection:7/14/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:17
Average number of Health Deficiencies in Virginia:11.6
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide safe, appropriate dialysis care/services for a resident who requires such services.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Some

Provide care and assistance to perform activities of daily living for any resident who is unable.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

6/14/237/11/23
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement policies and procedures for flu and pneumonia vaccinations.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Some

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

6/14/237/11/23
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives an accurate assessment.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Honor 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.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Honor 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.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 2/27/20
Date of last standard health inspection:2/27/20Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:11
Average number of Health Deficiencies in Virginia:11.7
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

2/27/203/16/20
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide enough food/fluids to maintain a resident's health.

2/27/203/16/20
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate dialysis care/services for a resident who requires such services.

2/27/203/16/20
2 - Minimal harm or potential for actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

2/27/203/16/20
2 - Minimal harm or potential for actual harm
Some

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

2/27/203/16/20
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

2/27/203/16/20
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

2/27/203/16/20
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2/27/203/16/20
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Reasonably accommodate the needs and preferences of each resident.

2/27/203/16/20
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

2/27/203/16/20
2 - Minimal harm or potential for actual harm
Some

Dispose of garbage and refuse properly.

2/27/203/16/20
1 - Potential for minimal harm
Many
Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide safe, appropriate dialysis care/services for a resident who requires such services.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

7/14/228/22/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

6/14/237/11/23
2 - Minimal harm or potential for actual harm
Some

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

6/14/237/11/23
2 - Minimal harm or potential for actual harm
Some
Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.
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