Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Knopp Healthcare And Rehab Center Inc during CMS and state inspections, most recent first.
The facility failed to adhere to food safety standards, as observed when a Life Safety Code inspector found an opened box of vanilla pudding cups with a foul odor and bugs in the kitchen's dry storage area. Maggots and insect eggs were present on the pudding cups. A staff member mistakenly believed it was acceptable to serve a contaminated pudding cup to residents, contrary to the facility's policy and training. The Dietary Manager confirmed that such actions were unacceptable.
The facility failed to maintain an effective pest control program, resulting in numerous crickets, both alive and dead, being found throughout the facility. The administrator stated that the pest control company visits monthly, but the facility could not provide a pest control policy upon request.
A resident with severe cognitive impairment and swallowing difficulties experienced medication administration errors in an LTC facility. RN B crushed delayed-release medications, which should not be crushed, and administered whole pills against physician orders. Additionally, medications were given one hour late without reporting to the supervisor, resulting in a 24% medication error rate.
The facility failed to maintain operational laundry equipment, with only one of three washers and two of four dryers functional. This issue persisted for months, as confirmed by a laundry aide and the administrator, who was attempting to secure repairs or replacements. The facility lacked a specific policy for equipment maintenance, relying on HHSC guidelines.
A facility failed to transmit a discharge MDS assessment to the CMS system for a resident discharged to an assisted living facility. The MDS coordinator did not recognize the discharge, and the DON admitted to oversight failure. The facility lacked a specific policy for MDS transmittals, relying on HHSC guidelines.
A resident with COPD and other conditions did not receive proper respiratory care as her nebulizer tubing was found unbagged. Interviews revealed inconsistencies in the facility's practice of bagging nebulizer tubing, with the RN and DON acknowledging the oversight and the risk of infection. No policy was in place to ensure compliance.
A facility failed to limit PRN orders for psychotropic drugs to 14 days without proper documentation, affecting a 98-year-old resident with anxiety. The resident's Lorazepam order lacked a stop date, and the medication was not administered PRN in September. RN A and the DON expressed concerns about the oversight, which could lead to overmedication.
A resident with Parkinson's disease and other medical conditions was found in her wheelchair without access to her call light, which was dangling off the bed and out of reach. This deficiency was identified during an observation, where the resident expressed discomfort and pain. The facility's policy required call lights to be within reach to prevent falls, but this was not followed, placing the resident at risk for delayed care.
A resident jokingly accused two CNAs of hitting him, but the incident was not reported immediately to the administrator as required by facility policy. The resident, who had a history of canker sores, was found with blood in his mouth, leading to the joking accusation. Despite the resident later confirming he was joking, the incident was not reported to the administrator until several hours later, highlighting a failure in following reporting protocols.
Two residents' care plans were not updated following significant assessments and changes in their conditions. One resident's care plan was outdated despite requiring staff assistance for ADLs, while another's lacked details on ADLs or transfers. Staff relied on verbal reports and judgment for transfer methods, as care plans were not accessible or updated. This failure to revise care plans could lead to inadequate care and safety risks.
Food Safety Violation in Kitchen Storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, as observed during a survey. A Life Safety Code inspector discovered an opened box of vanilla pudding cups in the dry storage area of the kitchen, which emitted a foul odor and had bugs flying out of it. Further inspection revealed maggots and insect eggs on and around the pudding cups. This incident occurred after a food delivery, and the staff responsible for putting away the delivery were not present at the facility during the inspection. An interview with a staff member, referred to as [NAME] A, revealed a lack of awareness regarding the inappropriateness of serving potentially contaminated food to residents. [NAME] A believed it was acceptable to serve a pudding cup with an insect egg on it, mistaking it for dirt. The Dietary Manager (DM) later stated that serving such food was unacceptable and contrary to staff training. The facility's policy on purchasing and storage mandates that leaking cans and spoiled foods be discarded immediately, which was not adhered to in this instance.
Ineffective Pest Control Program Leads to Cricket Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of numerous crickets throughout the facility. During an observation on October 16, 2024, more than 10 crickets, both alive and dead, were found scattered across a hallway and a common sitting area. The facility's administrator indicated that the contracted pest control company was scheduled to visit the following day and confirmed that the company provides monthly treatments for general pests, including crickets. However, the facility was unable to provide a pest control policy upon request during the survey exit.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 24% due to six errors out of 25 opportunities. These errors involved a resident with severe cognitive impairment and swallowing difficulties. The resident was prescribed medications that should be crushed due to her condition, but RN B administered some medications incorrectly by crushing delayed-release pills, which should not be crushed according to professional standards. RN B crushed and administered three delayed-release medications: bisacodyl, duloxetine, and divalproex, which compromised their intended therapeutic effects. Additionally, RN B administered acetaminophen in whole form, contrary to the physician's order for crushed medications due to the resident's swallowing difficulties. Furthermore, RN B administered carvedilol and acetaminophen one hour later than scheduled, which was not reported to the supervisor or the DON. The resident involved had multiple medical conditions, including dysphagia, heart failure, dementia, and a seizure disorder, which necessitated careful medication management. The facility's policy required medications to be administered as ordered and within one hour of the scheduled time. The errors in medication administration were not reported immediately, and the facility's policy on medication errors was not followed, leading to a significant deficiency in medication management.
Deficiency in Laundry Equipment Maintenance
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically within the laundry department. Observations revealed that out of four installed dryers, only two were operational, and out of three washers, only one was functional. This deficiency was identified during a review of the facility's laundry department, which is crucial for providing clean and sanitary linens to the residents. The facility's census at the time was 50 residents, and the limited operational equipment could potentially challenge the facility's ability to meet the laundry needs if the resident census increased. Interviews conducted with the laundry aide and the administrator highlighted that the inoperable equipment had been an issue for months. The laundry aide confirmed the limited functionality of the washers and dryers and expressed concerns about meeting increased demand. The administrator acknowledged the ongoing efforts to secure bids and funding for repairs or replacements but had not yet succeeded in resolving the issue. Additionally, the facility lacked a specific policy for maintaining essential equipment, relying instead on adherence to HHSC guidelines.
Failure to Transmit MDS Data for Discharged Resident
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System within 14 days of a resident's discharge. This deficiency was identified for one resident who was reviewed for transmitted MDS data. The resident, a male with a history of heart disease and hypertension, was admitted to the facility and later discharged to an assisted living facility. Despite the requirement to transmit a discharge MDS assessment, the facility did not complete this task for the resident. The MDS coordinator, who began her role in June 2024, did not recognize the resident's discharge and failed to initiate the necessary MDS discharge assessment. The electronic record system, which should have prompted the coordinator to complete the assessment, was not utilized effectively. The Director of Nursing (DON) acknowledged the oversight and admitted to failing to ensure the resident's MDS discharge assessment was captured and transmitted. The facility lacked a specific policy for MDS transmittals, relying instead on HHSC guidelines.
Failure to Bag Nebulizer Tubing for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, specifically by not ensuring that the resident's nebulizer tubing was properly bagged. This deficiency was observed in one of the three residents reviewed for oxygen therapy. The resident in question, an 84-year-old female with diagnoses including Chronic Obstructive Pulmonary Disease, Gastroesophageal Reflux Disease, and Major Depressive Disorder, was found to have her nebulizer tubing unbagged on her bedside table during an observation. Interviews conducted with the resident, a registered nurse (RN), and the Director of Nursing (DON) revealed inconsistencies in the facility's practice of bagging nebulizer tubing. The resident mentioned that the tubing was only bagged occasionally, depending on the nurse. The RN acknowledged that it was the responsibility of all nurses to change and bag the nebulizer tubing weekly but was unsure why it was not done in this instance. The DON confirmed that the tubing should have been bagged by the night shift and recognized the risk of respiratory infection due to the unbagged tubing. However, there was no policy in place to ensure the nebulizer was bagged.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner documented their rationale for extending the order in the resident's medical record. This deficiency was identified for a 98-year-old female resident with a diagnosis of anxiety, Type II Diabetes, and depression. The resident's comprehensive care plan indicated the use of antianxiety medication as ordered by the physician, with interventions to monitor and document reactions such as confusion and disorientation. However, the order for Lorazepam 0.5 mg, prescribed as needed for anxiety, did not have a stop date, and the medication was not administered PRN throughout September 2024. During interviews, RN A expressed concern about the indefinite period of the Lorazepam order, noting that psychotropic medications should not exceed 14 days without reassessment by a physician. The Director of Nursing (DON) confirmed the absence of a stop date on the order and acknowledged that the oversight could lead to overmedication. The facility's policy required the pharmacist to report any drug irregularities to the DON, but this process was not effectively followed, contributing to the deficiency.
Inaccessible Call Light Leads to Deficiency in Resident Care
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for a resident, leading to a deficiency in care. Specifically, Resident #16, who was admitted with diagnoses including Parkinson's disease, spinal stenosis, and incontinence, was found seated in her wheelchair without access to her call light. The call light was observed to be dangling off the bed, approximately 4-6 feet away from the resident, making it inaccessible. This situation was discovered during an observation and interview, where the resident expressed discomfort and pain due to her position and inability to reach the call light for assistance. The resident's care plan highlighted her high risk for falls and the necessity for the call light to be within reach, yet this was not adhered to. The Director of Nursing (DON) confirmed that the facility's policy required call lights to be within residents' reach to prevent falls. The facility's call light policy, dated 2005, emphasized the importance of ensuring the call system is in proper working order and accessible to residents. The failure to comply with this policy placed the resident at risk for delayed care and potential injury.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident in a timely manner, as required by their policy. The incident involved a resident who jokingly accused two CNAs of hitting him, which was not reported immediately to the administrator. The resident, who had a history of canker sores, was found with blood in his mouth, leading to the joking accusation. Despite the resident later confirming he was joking and felt safe at the facility, the incident was not reported to the administrator until several hours later. The nursing staff, including an LVN and two CNAs, did not follow the facility's policy to report the allegation immediately. The LVN, who was informed of the incident, decided not to report it to the DON or the administrator, believing it was unnecessary since the resident was joking. The DON was informed of the incident the following morning but did not report it to the administrator until later that afternoon, after reviewing the documentation and realizing it appeared as an abuse allegation. Interviews with the staff revealed a lack of understanding of the importance of reporting such allegations immediately, regardless of the resident's intent. The administrator emphasized that all allegations should be reported to her immediately, allowing her to determine if further reporting to state authorities was necessary. The facility's policy clearly stated that any alleged mistreatment or abuse should be reported to the administrator immediately, which was not adhered to in this case.
Failure to Update Care Plans After Resident Assessments
Penalty
Summary
The facility failed to update and revise care plans for two residents following significant assessments and changes in their conditions. Resident #1's care plan was not updated after an annual MDS assessment indicated she was dependent on staff for activities of daily living (ADL) care. Despite having a BIMS score indicating severely impaired cognition and requiring assistance for various transfers, her care plan remained unchanged since its last revision in 2022. Similarly, Resident #3's care plan lacked any section on ADLs or transfers, even though her quarterly MDS assessment showed she required assistance for transfers. Interviews with staff revealed inconsistencies in the information available to them regarding the residents' transfer needs. CNA H reported that Resident #1 required a mechanical lift for transfers, but this information was not accessible on her POC screen or Kardex report. CNA H and other staff members relied on verbal reports and their judgment to determine the appropriate transfer methods. The MDS nurse confirmed that Resident #1's care plan did not reflect the need for a mechanical lift, and Resident #3's care plan lacked details on ADL care, which could lead to safety issues. The facility's policy required care plans to be reviewed and revised by the interdisciplinary team after each assessment or significant change in condition. However, the care plans for both residents were not updated to reflect their current needs, as confirmed by the DON and other staff members. This lack of updated care plans could potentially lead to residents not receiving the necessary care and services, posing a risk of injury or falls.
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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 Enchanted Rock | 1.9 mi | ★★★★★ | 19 | 1 |
| Avir At Fredericksburg | 1.9 mi | ★★★★★ | 2 | 1 |
| Knopp Nursing & Rehab Center Inc | 2.3 mi | ★★★★★ | 17 | 0 |
| Avir At Comfort | 21.7 mi | ★★★★★ | 10 | 0 |
| Hilltop Village Nursing And Rehabilitation | 22.8 mi | ★★★★★ | 11 | 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 July 2026) and official state health department websites.