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 Manassas Health And Rehab Center during CMS and state inspections, most recent first.
Improper Disposal of Refuse in Dumpster Area: Surveyors observed the dumpster area outside the kitchen with blue and white gloves and a plastic straw on the ground beside the dumpster. The dining services director stated staff only wear black gloves and believed the items were trash from the facility. The facility did not have a policy related to the dumpster.
A resident with chronic pain and another resident with CVA-related weakness had care plans that were not implemented as written. Staff gave PRN hydromorphone outside the ordered pain-level parameters, and for the other resident, daily ambulation assistance recommended after PT was not documented on multiple occasions. Interviews with the resident, LPN, CNA, PT, and DON showed the care plan expectations, but the record did not evidence consistent follow-through.
Failure to Provide Individualized Activities: Three residents in the memory care unit did not receive activities aligned with their assessed preferences and needs. One resident with memory impairment, one resident with Alzheimer’s disease and intact BIMS, and one severely cognitively impaired resident were repeatedly observed in bed or in their rooms while limited group activities were available in the day room. Activity records showed many days without group participation and no documented one-on-one activities matching resident interests, and the ADON/activities staff reported no documentation for individual resident activities.
Improper food storage was observed in the kitchen when surveyors found an opened, undated bag of hash browns and an expired chicken salad sandwich in walk-in refrigerators. The dining services director stated the items should not have been there. The facility policy required leftover prepared foods to be labeled and dated and opened packages to be securely closed and identified.
Facility staff failed to ensure that a resident’s discharge needs were met when the resident, who was non–weight bearing, required supervision for transfers, and lived alone in a multi-level home with the only bathroom up 13 stairs, was discharged home without confirmed delivery of a recommended 3-in-1 bedside commode. Admission and therapy assessments documented substantial assistance needs for toileting and transfers, frequent incontinence, severe pain, and inability to negotiate stairs, and social services had identified the home’s stairs and lack of support as major barriers. Therapy recommended DME including an elevated toilet seat/3-in-1 commode, and the social services assistant placed the DME order late in the afternoon before discharge; the DME vendor accepted the order but only attempted to reach the resident around midday on the discharge date and did not complete delivery. Home health records later showed multiple unsuccessful attempts to contact the resident and documented that the resident reported falling at home on the day of discharge and being admitted to another facility, while interviews confirmed that social services was responsible for arranging DME and that there was no evidence the bedside commode was in place before the resident left.
A resident’s incontinence brief was repeatedly left exposed and visible from the hall while the resident lay in bed with a gown pulled above the waist. CNA staff said the resident had been moved to a different room because of COVID and did not have clothes in the room, and an LPN stated she would not want her own brief exposed because she would feel embarrassed.
Failure to provide ADL dressing assistance: A resident who was only oriented to self was repeatedly observed lying in bed wearing only an incontinence brief or with a gown pulled above the waist, leaving the brief exposed and visible from the hall. The CNA reported the resident did not have clothes in the current room after a room move related to COVID, and the DON stated staff had asked the resident's daughter to bring clothing, but it had not been brought in.
A resident with a history of CVA and left-sided weakness was discharged from PT after making gains in ambulation with a walker, but staff did not consistently carry out the care plan intervention to offer daily ambulation. PT said nursing was supposed to ambulate the resident with a hemi-walker and gait belt while following behind with a wheelchair, yet ADL documentation did not show ambulation or refusals on multiple occasions, and the resident said staff did not have time to walk with them.
PRN Opioid Given Below Ordered Pain Parameters: A resident with chronic pain and intact cognition received hydromorphone 4 mg on multiple occasions for pain ratings below the ordered severe-pain parameter of 8-10. The MDS noted almost constant pain, the care plan addressed pain management, and an LPN stated PRN pain meds with parameters should be given only when the resident meets the ordered threshold.
Improper Disposal of Refuse in Dumpster Area
Penalty
Summary
Facility staff failed to dispose of refuse properly when surveyors observed the dumpster area outside the kitchen on 1/20/26 at 11:50 AM. During the observation, blue and white gloves and a plastic straw were found on the ground on the left side of the dumpster, indicating the dumpster area was not maintained in a clean condition. During an interview at 1:10 PM the same day, the dining services director stated that staff only wear black gloves and that the items appeared to be trash from the facility. The administrator was informed of the concern on 1/21/26 at 11:00 AM, and the facility did not have a policy related to the dumpster.
Failure to Follow Pain Medication Parameters and Daily Ambulation Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident with chronic pain by not following the ordered pain medication parameters for hydromorphone. The resident’s care plan directed staff to administer pain medication as ordered and to report signs and symptoms of negative side effects, breakthrough pain, or unrelieved pain for further assessment and treatment. The resident’s record showed a BIMS score of 14/15, indicating cognitive intactness, and the MDS documented scheduled and as-needed pain medication with almost constant pain. The physician order specified hydromorphone 4 mg every 4 hours as needed for severe pain rated 8-10, with instructions to hold for sedation or confusion. Review of the eMAR showed that hydromorphone 4 mg was administered on multiple occasions when the documented pain levels were between zero and seven, rather than within the ordered parameter of 8-10. This occurred repeatedly across the reviewed medication administration periods. During interview, the resident stated they had chronic pain and took medication every four hours as needed, and staff interviews confirmed that when PRN pain medications have pain-level parameters, they are to be given only when the pain level is within those parameters. The facility policy on comprehensive care planning did not provide guidance on implementing the comprehensive care plan. The facility also failed to implement the comprehensive care plan for another resident by not offering ambulation daily as documented. The resident had a history of CVA with left-sided weakness, used a wheelchair, and had a BIMS score of 15/15. The care plan directed staff to offer assistance with ambulation daily, and PT discharge documentation stated the resident continued to require minimal assistance for sit-to-stand and could ambulate with contact guard or stand-by assist, with SNF care recommended. The resident stated that after PT discharge, staff were supposed to walk behind them with a wheelchair and assist with the walker, but this was not being done, and the resident was concerned about losing mobility gained in therapy. ADL documentation failed to evidence ambulation or refusal to ambulate on multiple dates, and the clinical record did not show refusals on those dates.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide activities to promote the highest level of wellbeing for three residents in the memory care unit. Resident #24 had short-term and long-term memory problems and preferred snacks between meals, reading books/newspapers/magazines, listening to music, and doing things with groups of people. Resident #17 had no short-term or long-term memory problems on the most recent assessment, scored 15 out of 15 on the BIMS, had Alzheimer’s disease, and preferred listening to music, being around animals, going outside, and participating in religious services. Resident #72 was severely cognitively impaired and preferred keeping up with the news, going outside when the weather was good, and participating in religious services. On multiple observations, the residents were found in their rooms or in bed while activities were not occurring in the memory care day room. Resident #24 was observed sitting up in bed being fed, later sitting up in bed looking around, and there was no music playing in the room. Resident #17 was observed in her room on the side of her bed while a word and [NAME] activity was occurring in the day room. Resident #72 was observed in bed at several different times on multiple days. During one observation, several residents were seated in the day room and two residents were ambulating, but no activity was occurring. Review of the activities calendars showed limited planned activities on the memory care unit, with some days having only one activity listed. Review of the residents’ activity participation records showed that Resident #24 did not participate in any group activity on 31 days, Resident #17 did not participate in any group activity on 41 days, and Resident #72 did not participate in any group activity on 32 days. The records also showed days with no information documented. There was no evidence of attempts by staff to provide individual activities matching the residents’ assessed interests on the days they did not participate in group activities. The activities director stated she was the primary person planning and implementing activities on the unit, relied on training and a dementia-focused website, tried to plan two activities each day, and did not have documentation for any one-on-one resident activities for any resident on the memory care unit.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner. During an observation in the kitchen on 1/20/26 at 10:55 AM, surveyors found an opened and undated five-pound bag of hash browns in walk-in refrigerator #1 and one half chicken salad sandwich in walk-in refrigerator #2 that was dated with a prep time of 1/16/26 at 1:39 PM and an expiration time of 1/18/26 at 1:39 PM. When asked about these items during the tour, the dining services director stated that they should not be in there and said both items were being thrown out. The facility’s Safe Food and Supply Storage policy stated that leftover prepared foods must be stored in approved containers, labeled with contents and a use-by date, and that opened packages must be securely closed and product identified. The administrator was informed of the concerns on 1/21/26 at 11:00 AM.
Failure to Ensure DME Delivery Prior to Discharge for Dependent Resident Living Alone
Penalty
Summary
Facility staff failed to ensure that all discharge needs were met for a resident who was discharged home without confirmed delivery of essential durable medical equipment (DME), specifically a bedside commode, despite the resident’s inability to negotiate stairs and the bathroom being located on the second floor of a multi-level home. The resident’s admission MDS documented partial/moderate assistance needs for bathing, upper body dressing, and standing from sitting, and substantial/maximal assistance for toileting and lower body dressing. Toilet transfers and walking were not attempted due to medical or safety concerns, and the resident was frequently incontinent of bowel and bladder, had frequent severe pain, and had a recent fall and major surgery prior to admission. The social services admission assessment identified significant barriers to a safe discharge, including that the resident lived alone, had 13 steps to reach the bathroom level, had no supervision, and no family supports, and it documented that social services would arrange home health and any needed equipment at discharge. A safe transition meeting documented that the resident’s goal was to return home alone and again identified barriers such as living alone and the 13 steps to the second-floor bathroom. Therapy discharge documentation later specified that the resident required supervision or touching assistance for toilet transfers and recommended home health services and multiple environmental and equipment modifications, including an elevated toilet seat/3-in-1 commode, shower bench, grab bars, assistance with ADLs, and a Lifeline for safety. PT documentation indicated the resident required supervision for all bed mobility and transfers and remained non–weight bearing on the right leg, unable to go up or down stairs at discharge. Progress notes showed that the resident repeatedly appealed Medicare non-coverage decisions, stating they were not ready for discharge, were unable to put weight on one leg, and that the other leg had become weak, but the appeals were ultimately denied and liability began prior to discharge. On the day before discharge, a late-entry social services note documented that the writer attempted to order oxygen and a bedside commode due to the resident’s bathroom being on the second floor and the resident’s inability to walk or climb stairs, and that the resident did not qualify for oxygen. A nurse practitioner note on the day of discharge stated the resident was in stable condition for discharge home with home health and skilled nursing, and referenced coordinating DME with social work. The facility’s internal DME chat log showed the social worker created the order for a 3-in-1 bedside commode in the late afternoon the day before discharge, with the DME provider accepting the order that evening and marking it pending further review. The DME company attempted to contact the resident around midday on the day of discharge and later documented awaiting a callback to discuss financial obligation and delivery, with the order ultimately canceled nearly two months later. A faxed email chain from the home health agency showed that staff were unable to reach the resident on the day of discharge and subsequent attempts, and later documented that when they finally spoke with the resident several days after discharge, the resident reported having fallen at home on the day of discharge and going to the emergency room, then refusing return to the original facility and being admitted to another facility. Interviews with the social services assistant and rehab director confirmed that therapy had recommended a bedside commode, that social services was responsible for arranging DME, that the resident was non–weight bearing and unable to manage stairs at discharge, and that there was no evidence the bedside commode had been delivered to the home prior to discharge.
Resident’s incontinence brief left exposed and visible from the hall
Penalty
Summary
The facility failed to ensure dignity for Resident #133 by allowing the resident’s incontinence brief to remain exposed and visible from the hall. The resident was admitted on [DATE], and a nursing admission assessment signed on 1/13/26 documented that the resident was only oriented to self. On 1/20/26 at 12:45 p.m., the resident was observed lying in bed wearing only an incontinence brief and visible from the hall. The same concern was observed again on 1/20/26 at 2:25 p.m., 1/21/26 at 3:55 p.m., and 1/22/26 at 10:41 a.m., when the resident was lying in bed with a gown pulled above the waist and the incontinence brief exposed and visible from the hall. During interview, CNA #8 stated she had pulled the gown down three times that morning, but the resident kept pulling it up, and also stated the resident had been moved to a different room because of COVID and did not have clothes in the current room. LPN #9 stated she would not want her own incontinence brief exposed because she would feel very embarrassed. The Administrator and DON were informed of the concern, and the DON later stated staff had asked the resident’s daughter to bring clothes, but she had not done so because she was sick; staff also reported the resident kicked the sheets off and did not have clothes available in the room.
Failure to Provide ADL Dressing Assistance
Penalty
Summary
Facility staff failed to provide ADL care for one resident who was unable to dress himself. Resident #133 was admitted to the facility and a nursing admission assessment signed on 1/13/26 documented that the resident was only oriented to self. On 1/20/26 at 12:45 p.m., the resident was observed lying in bed wearing only an incontinence brief. The resident was visible from the hall. The resident continued to be observed in bed with a gown pulled above the waist on 1/20/26 at 2:25 p.m., 1/21/26 at 3:55 p.m., and 1/22/26 at 10:41 a.m., with the incontinence brief exposed and visible from the hall. During an interview on 1/22/26, the CNA caring for the resident stated she had pulled the gown down three times that morning, but the resident kept pulling it up, and also stated the resident did not have clothes in the current room after being moved because of COVID. The DON later stated staff had asked the resident's daughter to bring clothes, but she had not done so, and that the CNAs said the resident did not have clothes and kicked the sheets off.
Failure to Provide Daily Ambulation Support
Penalty
Summary
The facility failed to implement interventions to prevent a decrease in mobility for a resident with a history of CVA and left-sided weakness. The resident’s quarterly MDS documented use of a wheelchair and that walking was not attempted due to medical condition or safety concerns, and the resident stated they had recently been discharged from PT after walking with a walker during therapy. The resident reported that staff had told them CNAs would walk behind them with a wheelchair and assist them to walk with the walker, but that staff did not have time to do so, and the resident was concerned about losing the mobility gained in therapy. The PT discharge summary documented that the resident continued to require minimal assistance for sit-to-stand from the wheelchair and could perform transfers and ambulation with contact guard assist/stand-by assist, with SNF care recommended. The care plan included an intervention to offer assistance with ambulation daily, and PT staff stated nursing was supposed to ambulate the resident 50 to 150 feet with a hemi-walker and gait belt while following behind with a wheelchair. However, ADL documentation failed to evidence ambulation or a refusal to ambulate on multiple dates, and the clinical record did not show refusals on those dates. Staff interviews indicated CNAs and nurses were aware of PT recommendations and that ambulation should have been documented when offered or refused, but the DON stated there was no FMP for the resident and that refusals should have been documented.
PRN Opioid Given Below Ordered Pain Parameters
Penalty
Summary
The facility failed to implement a complete pain management program for one resident who was cognitively intact and reported chronic pain. The resident’s MDS documented scheduled and as-needed pain medication and almost constant pain. During interview, the resident stated they had chronic pain and took medication every four hours as needed, and that the medication helped with knee pain. The physician order for hydromorphone 4 mg directed administration every 4 hours as needed for severe pain rated 8-10, with instructions to hold for sedation or confusion. Review of the eMAR showed hydromorphone 4 mg was administered 44 times in December 2025 and 23 times in January 2026 for pain levels documented between 0 and 7, which was below the ordered pain parameter of 8-10. The care plan identified pain or potential for pain and included interventions to administer pain medication as ordered and report breakthrough or unrelieved pain for further assessment and treatment. An LPN stated that when PRN pain medications have pain level parameters, they are administered only when the pain level is within those parameters, and that if a resident requests medication for a lower pain level, the physician should be contacted because the medication may need adjustment. The facility policy stated that pain management must be provided consistent with professional standards, the care plan, and the resident’s goals and preferences, and that staff will notify the medical practitioner if pain is not controlled by the current treatment regimen.
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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 Manassas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birmingham Green | 2.7 mi | ★★★★★ | 0 | 0 |
| Gainesville Health And Rehab Center | 5.9 mi | ★★★★★ | 0 | 0 |
| Lake Manassas Health & Rehabilitation Center | 8.1 mi | ★★★★★ | 5 | 1 |
| Fair Oaks Health & Rehabilitation | 10 mi | ★★★★★ | 8 | 0 |
| Fairfax Rehabilitation And Nursing Center | 11.7 mi | ★★★★★ | 7 | 0 |
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