Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lake Manassas Health & Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with prior documentation of being alert and oriented experienced acute changes in condition characterized by hypotension, altered responsiveness, and respiratory compromise that were not promptly recognized and acted upon as potential sepsis. In one case, an LPN contacted a PCP about low blood pressure, followed orders for IV fluids, and continued monitoring despite persistent unresponsiveness and worsening vitals, with transfer to the hospital not ordered until hours later; the resident was later found by EMS to have sepsis and subsequently died. In the other case, an LPN assessed a resident with sudden hypotension, lethargy, respiratory congestion, labored breathing, and gasping, identified possible sepsis, but delayed nearly an hour before contacting the on‑call provider for transfer orders. In both situations, nursing staff reported believing they could not send residents to the ER without a provider’s order, despite facility policy and DON statements that licensed nurses had autonomy to transfer residents emergently when conditions were acutely life‑threatening.
A resident experienced progressive hypotension, hypoxia, and unresponsiveness consistent with sepsis over several hours, during which on-call and primary care providers ordered medication holds, diagnostic testing, and escalating IV fluids and O2 before eventually ordering hospital transfer. EMS documented sepsis with hypotension as the primary issue, and the resident later died in the hospital with sepsis listed as the cause of death. The DON reported that early sepsis recognition and immediate action are facility nursing standards but acknowledged it would be difficult to say the transfer was timely. She could not locate evidence that the case was reviewed by the QAPI committee, discussed in the weekly risk management meeting, or that any quality improvement plan or action plan was developed, despite a facility QAPI policy requiring systematic identification and monitoring of high-risk, problem-prone processes.
Facility staff failed to provide a resident and their representative with required written notice of discharge reasons and bed-hold options when the resident was sent to the hospital, and also did not document that clinical transfer information, including care plan goals and other key data, was sent to the receiving hospital. Although an LPN reported that her usual practice is to communicate critical information by phone and send printed clinical summaries with EMS, the resident’s record contained no evidence that the required bed-hold notice or continuity of care documents were provided for this transfer, contrary to facility policies on patient transfer and bed reserve.
A resident admitted after hip fracture repair, who was cognitively intact and full code, developed hypotension, unresponsiveness, and worsening respiratory status over the course of a morning. An LPN contacted a PCP who was not on call and obtained orders for IV fluids while the resident remained unresponsive with abnormal vital signs and escalating oxygen needs. The PCP later stated he did not recall the case, believed he had only been told about low blood pressure, and indicated he would have ordered ER transfer if informed of unconsciousness and respiratory decline. The DON stated that timely sepsis recognition and response is a nursing standard and acknowledged the transfer was not timely, while the facility’s President of Operations reported there was no policy on physician services or supervision. EMS documented a primary impression of sepsis with hypotension, and the death certificate listed sepsis as the cause of death.
Two residents experienced significant changes in condition consistent with sepsis, and nursing staff did not demonstrate competent recognition and timely response. One resident, previously alert and oriented after hip fracture surgery, developed severe hypotension, unresponsiveness, and worsening oxygenation over several hours; the assigned LPN contacted the PCP, followed orders for IV fluids and monitoring, did not question the orders, did not identify sepsis when given a similar scenario, and stated she could not send a resident to the ER without a physician’s order. EMS later documented sepsis with hypotension, and the death certificate listed sepsis as the cause of death. Another resident, initially alert and conversant, was later found by an LPN to have hypotension, lethargy, respiratory congestion, labored breathing, and intermittent gasping; although the LPN suspected possible sepsis, she waited nearly an hour before contacting the on-call provider for transfer orders, stating she had to speak with a provider before sending a resident out. The DON reported that nurses are expected to recognize early sepsis signs and act immediately and that nurses have autonomy to send residents to the hospital, while the facility’s President of Operations acknowledged there was no policy regarding competent nursing staff.
A resident who was moderately cognitively impaired and required substantial assistance for toileting did not receive timely incontinence care, going approximately three hours without being offered toileting or having her brief changed after a morning shower. Staff interviews confirmed the absence of a toileting schedule and inconsistent adherence to two-hour rounding expectations, and the facility lacked a policy on toileting or incontinence care.
A resident with a physician's order for Vancomycin to treat C. difficile missed six doses because the medication was not available in the facility. Documentation showed that staff noted the medication was on order or on the way, but it was not administered as scheduled. The facility did not stock Vancomycin in its Omnicell system, and staff did not fully follow procedures for obtaining urgently needed medications.
Failure to Recognize and Respond Timely to Sepsis and Acute Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment, recognition, and response to signs and symptoms of sepsis and significant changes in condition for two residents, resulting in delayed transfer to the hospital. For the first resident, who had been admitted with a surgically repaired hip fracture and was consistently documented as alert and oriented with no cognitive impairment, vital signs on the night before the event showed no physical concerns and a blood pressure of 127/65. Early the following morning, the weekend on‑call provider was contacted about a low blood pressure of 84/49 and ordered holding aspirin and antihypertensives, a stool test for blood, and hourly blood pressure checks. By 7:30 a.m., the resident’s blood pressure had dropped to 80/41, oxygen saturation was 84% on room air, and the resident was unresponsive to verbal stimuli, with this unresponsive neurological status persisting throughout the day. After the 7:30 a.m. change in condition, the primary care physician (PCP) was notified and ordered IV fluids at 100 ml/hr. Subsequent vital signs showed continued hypotension and worsening respiratory status: at 8:00 a.m. blood pressure was 82/38 with O2 saturation 93% on 4 L oxygen; at 10:00 a.m. blood pressure was 85/43, heart rate 132, and O2 saturation 85–90% on 5 L oxygen; and at 11:08 a.m. blood pressure was 79/40 with O2 saturation 99% on 8 L oxygen. The PCP ordered additional IV fluids at 9:30 a.m. and did not order transfer to the hospital until noon, despite the ongoing hypotension and unresponsiveness. EMS was not called until 12:23 p.m., and EMS documented a primary impression of sepsis with hypotension as the primary sign. The resident’s death certificate listed sepsis as the cause of death. The LPN who cared for the resident from 11:00 p.m. to 7:30 a.m. stated he did not remember the resident or events and could not access the electronic record. The LPN who cared for the resident from 7:00 a.m. until transfer stated she did not recall the events, believed she followed the PCP’s orders, did not question those orders, and asserted she could not send a resident to the ER without a provider’s order. When given a scenario similar to the resident’s condition, she did not identify sepsis as a likely outcome and stated she did not know who the facility’s medical director was. For the second resident, who was also consistently documented as alert and oriented with no cognitive impairment and had a full code order, the deficiency involved delayed provider contact and transfer after an acute change in condition suggestive of sepsis. At 8:30 p.m., the resident was documented as alert, responsive, talking, and answering questions. At 9:00 p.m., a CNA reported a change in condition, and an LPN assessed the resident, finding a blood pressure of 78/46 and documenting acute distress, lethargy, respiratory congestion, labored breathing, and intermittent gasping. The LPN later stated she did not know the resident well but had been told the resident was ordinarily alert and oriented and recalled light‑hearted conversation earlier in the shift. She stated she identified the condition as possible sepsis but believed she was not allowed to send the resident to the hospital without a physician’s order and could not explain why she waited almost an hour between assessing the resident and contacting the provider. The on‑call provider was not contacted until 9:52 p.m., at which time an order was given to transfer the resident to the hospital, and the resident was sent to the emergency room around 10:30 p.m. The facility’s own “Significant Change of Condition” policy stated that potentially life‑threatening conditions require nursing assessment and critical thinking to determine whether a patient should be transferred to an acute care setting, and that this decision will be made by a licensed nurse when the patient’s condition is so acute that time does not permit waiting for a provider’s response. The Director of Nursing stated that sepsis had long been a major nursing topic, that nurses in the facility were expected to recognize early signs and symptoms of sepsis and take immediate action, and that nurses had autonomy to use nursing judgment to send residents to the hospital even without a provider’s order, while also acknowledging it would be very hard to say that either resident was transferred in a timely manner.
Failure to Use QAPI After Delayed Sepsis Response
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective QAPI process following a serious clinical incident involving a resident who exhibited signs and symptoms of sepsis and was not transferred to the hospital in a timely manner. On 9/1/24 at 6:27 a.m., the weekend on-call licensed provider was notified that the resident’s blood pressure was 84/49, and orders were given to hold aspirin and antihypertensive medications, check for blood in the stool, and perform hourly blood pressure checks. By 7:30 a.m., the resident’s blood pressure had decreased to 80/41, oxygen saturation was 84% on room air, and the resident was unresponsive to verbal stimuli; the resident’s neurological status of being unresponsive did not change throughout the day. The primary care physician (PCP) was notified and ordered IV fluids at 100 ml/hr. At 8:00 a.m., the resident’s blood pressure was 82/38 and oxygen saturation was 93% on 4 L O2. At 9:30 a.m., the PCP ordered additional IV fluids. At 10:00 a.m., the resident’s blood pressure was 85/43, heart rate was 132, and oxygen saturation was 85–90% on 5 L O2, with IV fluids continuing. At 11:08 a.m., blood pressure was 79/40 and oxygen saturation was 99% on 8 L O2, and at 12:00 noon, blood pressure was 81/41. The PCP then ordered transfer to the hospital. EMS records show the facility called for emergency assistance at 12:23 p.m., with EMS documenting a primary impression of sepsis and hypotension as the primary sign/symptom. The resident’s death certificate listed time of death at the hospital as 3:37 p.m. and sepsis as the cause of death. During an interview on 4/8/26, the DON stated that recognizing early signs and symptoms of sepsis and taking immediate action is a nursing standard in the facility and acknowledged it would be very hard to say the resident was transferred in a timely manner. The DON reported she could not find specific evidence that the sequence of events surrounding the resident’s discharge was reviewed by the QAPI committee or that a quality improvement plan was considered after the delay in treatment. She stated that weekly risk management meetings, considered part of the QAPI process and used to discuss all discharges from the previous week, had no documented evidence of review of this resident’s case, and she was not aware of any action plan developed regarding the situation. Review of the facility’s QAPI policy showed that the Administrator is responsible for directing and implementing a QAPI plan that systematically identifies actual or potential areas of risk or deficiency and targets high-risk, high-volume, or problem-prone processes, but there was no documentation that this incident was addressed through that process.
Failure to Provide Bed-Hold Notice and Clinical Transfer Documentation at Hospital Discharge
Penalty
Summary
Facility staff failed to provide required written notices and clinical documentation at the time of an unplanned discharge to the hospital for one resident in the survey sample. The resident was transferred to the hospital late in the evening, and review of the clinical record showed no written notice to the resident or resident representative explaining the reasons for the discharge and no written bed-hold information. The facility’s own "Bed Reserve" policy requires that when a patient is transferred for overnight hospitalization or observation, the patient and/or responsible representative must be informed and complete a voluntary bed retention agreement with associated private payment if they wish to hold the bed, and this arrangement can be made at the time of transfer or by the close of business on the day of hospitalization, but no later than 10:00 a.m. the following day. The President of Operations confirmed there was no bed-hold or continuity of clinical care information documented for this resident on the date of transfer. In addition, the facility did not provide documented continuity of clinical care information to the receiving hospital as required by its "Patient Transfer" policy. That policy states that a Patient Transfer Form (eINTERACT) should be completed by a licensed nurse and sent with the patient, along with a generated chart for the last seven days and other relevant information. An LPN reported that her usual practice is to communicate critical clinical information by phone and to print and send the resident’s code status, medical history, allergies, vital signs, and other relevant information from the past seven days with EMS, documenting this in the change of condition report. However, review of the resident’s clinical record did not show evidence that such clinical documentation, including care plan goals and other information, was provided to the receiving hospital for this transfer.
Failure to Provide Adequate Physician Supervision During Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate physician supervision and direction for a resident who experienced a significant change in condition. The resident had been admitted following surgical repair of a hip fracture and was documented on the admission MDS as cognitively intact, fully oriented, and able to communicate needs, with a full code status. On the night before the event, the resident’s vital signs and neurological status were documented as stable, with no physical concerns noted. On the following morning, the resident developed hypotension, first identified around 6:27 a.m., when the weekend on‑call provider was contacted and ordered holding aspirin and antihypertensives, testing stool for blood, and hourly blood pressure checks. By 7:30 a.m., the resident’s blood pressure had further declined, he was unresponsive to verbal stimuli, and his oxygen saturation was low on room air. Throughout the morning, nursing documentation showed that the resident remained unresponsive, with persistent hypotension, tachycardia, and declining respiratory status requiring escalating oxygen support. The LPN caring for the resident contacted the resident’s PCP, who was not on call, and obtained orders for IV fluids at 100 ml/hr and later additional IV fluids, which were implemented while the resident’s unresponsiveness and abnormal vital signs continued. The PCP reported that he did not recall the resident or the specific calls but stated he was not on call that day and believed he was likely only informed about low blood pressure, not about unresponsiveness or declining respiratory status. He stated that if he had known the resident was unconscious with worsening respiratory status, he would have ordered immediate transfer to the ER. The DON stated that sepsis recognition and rapid response are a nursing standard in the facility and acknowledged it would be very hard to say the resident was transferred in a timely manner. The facility’s President of Operations reported that the facility did not have a policy regarding physician services or supervision. EMS records later documented a primary impression of sepsis with hypotension, and the resident’s death certificate listed sepsis as the cause of death.
Failure to Recognize and Respond to Sepsis-Related Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and exercised appropriate competencies to recognize and respond to significant changes in condition, including signs and symptoms consistent with sepsis, for two residents. For Resident #1, who had been admitted after surgical repair of a hip fracture and was consistently documented as alert and oriented with no cognitive impairment, the clinical record showed a rapid decline beginning overnight. Late in the evening, his blood pressure was within normal limits and no neurological concerns were documented. By early the next morning, his blood pressure had dropped significantly, and the weekend on-call provider was contacted about hypotension, resulting in orders to hold certain medications, test for blood in stool, and perform hourly blood pressure checks. Subsequently, Resident #1’s condition further deteriorated. At 7:30 a.m., he was documented as unresponsive to verbal stimuli with low blood pressure and decreased oxygen saturation on room air, and his unresponsive neurological status persisted throughout the day. The primary care physician (PCP) was notified and ordered IV fluids at 100 ml/hr, followed by additional IV fluids later in the morning as hypotension, tachycardia, and worsening oxygenation continued despite escalating oxygen support. Vital signs remained unstable, with blood pressures in the 70s–80s systolic and low diastolic readings, heart rate of 132, and fluctuating oxygen saturations requiring up to 8 LPM of oxygen. The PCP eventually ordered transfer to the hospital around midday, and EMS documentation listed sepsis with hypotension as the primary impression. The resident’s death certificate identified sepsis as the cause of death. In an interview, the LPN assigned to Resident #1 during the morning shift stated she did not remember the resident or the events but acknowledged, after reviewing her notes, that she had contacted the PCP and followed his orders for IV fluids and monitoring. She reported that she did not question the provider’s orders, believed it was not her role to judge their appropriateness, and stated she could not send a resident to the ER without an order. When presented with a scenario involving low blood pressure, loss of consciousness, and declining respiratory status, she did not identify sepsis as a likely cause and reiterated that as a nurse she could only follow physician orders. She also stated she did not know who the facility’s medical director was. The DON stated that sepsis recognition and immediate action are expected nursing standards in the facility and that sepsis has been a long-standing focus of nursing education. For Resident #2, the facility also failed to demonstrate competent recognition and timely response to a significant change in condition consistent with sepsis. The resident was documented as alert, responsive, talking, and answering questions with staff in the evening. Shortly thereafter, a CNA reported a change in condition, and an LPN assessed the resident, finding hypotension with a blood pressure of 78/46 and signs of acute distress, including lethargy, respiratory congestion, labored breathing, and intermittent gasping. The LPN identified the condition as possible sepsis but did not immediately contact the on-call provider. Nearly an hour elapsed between the assessment and the call to the provider, who then ordered transfer to the hospital. The LPN later stated she believed she was required to speak with a provider before sending a resident out and could not explain the delay between recognizing the change in condition and contacting the provider. The DON again stated that nurses in the facility are expected to recognize early signs and symptoms of sepsis and take immediate action, and that nurses have autonomy to use their judgment to send residents to the hospital even without a provider’s order. The facility’s President of Operations stated that the facility did not have a policy regarding competent nursing staff. The DON reported that newly hired nurses receive some training on identifying sepsis at hire and that all staff receive annual refresher training on sepsis, but also acknowledged that it would be very hard to say that either resident was transferred to the hospital in a timely manner. These findings, based on staff interviews, physician interviews, facility document review, and clinical record review, support the conclusion that the facility failed to provide competent nursing staff capable of recognizing and appropriately responding to significant changes in condition, including signs and symptoms consistent with sepsis, for two residents in the survey sample.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Facility staff failed to provide timely incontinence care for a resident who was moderately impaired in decision-making and required substantial assistance for toileting. According to the resident's most recent MDS assessment, she was frequently incontinent of both bowel and bladder and needed maximum assistance for toilet transfers. On the day in question, after receiving a shower between 7:00 a.m. and 7:15 a.m., the resident was not offered toileting or had her brief changed for approximately three hours. The resident and her family reported that she had not been assisted with toileting during this period, and the family had previously requested a toileting schedule for her. Staff interviews confirmed that the resident was not on a toileting schedule, and the CNA responsible for her care acknowledged not checking on her until nearly four hours after her shower. The CNA also noted that the resident's pants were damp when she was finally assisted to the bathroom later in the day. The LPN and Director of Nursing both stated that the resident was not on a toileting schedule, although the facility's expectation was for staff to perform purposeful rounding every two hours, including incontinence care. The facility did not have a policy on toileting or incontinence care at the time of the survey.
Failure to Provide Timely Pharmaceutical Services Resulting in Missed Medication Doses
Penalty
Summary
Facility staff failed to ensure the availability and timely administration of Vancomycin for a resident who had a physician's order for the medication to treat C. difficile infection. The medication was ordered to be given four times daily, but the resident missed six doses due to the facility not having the medication on hand. Documentation in the medication administration record and nurse's notes indicated that the medication was not available at the scheduled times, and staff noted that the medication was on order or on the way, but not administered as prescribed. Review of facility procedures and staff interviews revealed that Vancomycin oral capsules were not stocked in the facility's Omnicell system, and the process for obtaining urgently needed medications was not effectively followed. The facility's policy required nurses to notify the provider and activate backup pharmacy procedures when medications were unavailable, but the documentation showed delays in obtaining the medication and incomplete adherence to these steps. The medication was eventually delivered, but not until after multiple scheduled doses were missed.
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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 Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gainesville Health And Rehab Center | 3 mi | ★★★★★ | 0 | 0 |
| Manassas Health And Rehab Center | 8.1 mi | ★★★★★ | 9 | 0 |
| Brookside Rehab & Nursing Center | 8.5 mi | ★★★★★ | 5 | 0 |
| Poplar Hill Health And Rehab | 9.6 mi | ★★★★★ | 10 | 0 |
| Birmingham Green | 10.8 mi | ★★★★★ | 0 | 0 |
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