$3,100,000Pressure sore death
$2,333,000Fall involving traumatic brain injury
$1,500,000Bedsore settlement
$1,499,000Dementia patient injury
$1,250,000Repeated fall injuries

Fredericksburg Health & Rehab Center

To ensure residents remain safe in a nursing home environment, the Centers for Medicare and Medicaid Services (CMS), and the state of Virginia routinely conduct interviews and surveys at every facility in the state. These inspections allow easy identification of serious to minor concerns, violations, and deficiencies. When major problems arise, the facility is provided the chance to make immediate adjustments and corrections before the federal and state nursing home regulatory agencies take harsher steps to protect the health and well-being of every resident.

Serious violators often receive heavy fines or are placed on a designated Special Focus Facility watchlist where they will remain for a minimum of one to two years. During that time, state investigators and surveyors will perform double or triple the normal amount of inspections through schedule appointments and unannounced visits to the facility. Even if the Home makes quick corrections, the investigators will continue to monitor the place to ensure that any positive improvements that protect the residents are permanent.

In recent months, Fredericksburg Health and Rehab Center was designated a Special Focus Facility (SFF) by the CMS. This designation alerts the nursing staff and Administrator that if the serious problems continue to exist, the facility may be forced to close their doors, sell their operation to other companies to provide nursing care or break their contract with Medicare and Medicaid.

Fredericksburg Health and Rehab Center

This 177-certified bed Medicare/Medicaid-participating nursing facility provides care and services to the residents of Fredericksburg and Gillespie County, Virginia. The Home is located at:

3900 Plank Rd.
Fredericksburg, VA 22407
(540) 786-8351

Current Nursing Home Resident Safety Concerns

To ensure the public remains aware of the level of care provided every nursing facility in the US, the Centers for Medicare and Medicaid Services routinely updates their Medicare.gov star rating summary system. This data along with information on health inspections conducted at the facility by investigators and surveyors help identify deficiencies and violations occurring and nursing homes throughout local communities nationwide.

Currently, Fredericksburg Health and Rehab Center maintains overall a much-below average one out of five stars ranking compared to other facilities in America. This ranking includes one out of five stars for health inspections, two out of five stars for staffing, and two out of five stars for quality measures. Over the past three years, twenty complaints have been filed against the facility. These complaints include some of the concerns, violations, and deficiencies involving Fredericksburg Health and Rehab Center listed below.

  • Failure to Develop, Implement and Enforce Policies and Prevent Abuse, Neglect or MistreatmentIn a summary statement of deficiencies dated April 28, 2017, the state investigator noted the facility’s failure to “screen employees per their abuse policy before employment.” This deficiency involved three Certified Nursing Assistants at the facility. It was also documented that the facility staff had “failed to obtain license verification or a sworn statement” on one of the employees reviewed and “did not obtain reference checks on two” employees before their employment.”A review of the employee records identified a deficiency where a Certified Nursing Assistant was “hired on January 21, 2016.” However, the license verification occurred “on December 29, 2016, eleven months later. There is no evidence of the documentation regarding the employee’s sworn statement.”A review of a different employee’s records revealed that that Certified Nursing Assistant “was hired on November 7, 2016.” However, the license verification occurred “on December 29, 2016, almost two months later. There was no evidence of documentation regarding reference checks.” A third Certify Nursing Assistant’s Employee Records revealed that “the employee was hired on January 21, 2016. There is no evidence of documentation regarding reference checks been completed.”The surveyor interviewed another staff member who “when asked who obtained reference checks” stated “we just took over human resources two weeks ago. The HR person is supposed to get references.” The staff member “was asked why they do reference checks” to which they replied “to make sure these people are good employees” and that “they need to have a criminal background check before they start working.”During an interview with the facility Administrator, it was revealed that the nursing home does “reference checks to validate employees’ work history and character. To confirm what they have put on the resume.” The administrator stated that they check for crimes [using] background checks and [they] check a license to confirm [the employee] can operate [within] the scope of their practice.”The state investigator reviewed the facility’s Resident Abuse policy that read in part:
    • “It is inherent in the nature and dignity of each resident at the facility that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property.”
    • “The management of the facility recognizes these rights and hereby establishes… Statements, policies, and procedures to protect these rights and to establish a disciplinary policy…”
    • “Persons applying for employment with the facility will be screened for a history of abused, neglected, or mistreated residents to include: References from previous or current employers… A criminal background check, Abuse check with appropriate licensing Board and registries prior to hire.…”
  • Failure to Provide Medically-related Social Services to Assist the Individual in Achieving the Highest Possible Quality of LifeIn a summary statement of deficiencies dated April 20, 2017, the state investigator noted the facility failed “to provide medically-related social services [to a resident and failed to] investigate and follow up [on that resident’s] concern about a nurse providing her care.” The investigator’s findings included a review of a resident’s Progress Notes revealing a written entry by a social worker and another staff member who “met with the resident to discuss issues of concern that the resident has voiced to staff over the past week.”The document revealed that it was “suggested [that the] resident compromise, and receive her medications from any of the nurses, and offer a thank you. The resident said she would.” The document said that the social worker would continue to observe and monitor. However, the surveyor reviewed the facility’s grievance/concern log that provided “no evidence of any concerns expressed by [the resident] during March 2017” when the meeting occurred.The surveyor interviewed the other worker identified as the Social Services Director who stated “her role, once a concern is expressed by residents or staff, is to log it in the Concern Log and proceed to resolve the concern. She stated [that] staff members fill out the form with the details of the concern, and then they submit the form to the social workers.” The Director stated that “I do [the logs] month by month. I put the resolution in the action plan in the log.”The State surveyor asked the Social Services Director “to locate the log entry regarding concerns expressed by [the resident] in March 2017.” The Director replied that “I don’t see any. If it’s not given to me as a grievance, it does not go on the log.”However, another staff member interviewed by the surveyor revealed that she had written a note on March 15, 2017, and “asked to provide details of the concerns expressed by [the resident] in the week prior to March 15, 2017.”That staff revealed that the resident “did not want to have some particular nurses assigned to her.” The Director said that “we say thank you when I get meds, and I told her I expect her to say thank you. When asked to clarify exactly what she stated to the resident about the need for the resident to express gratitude the staff, the staff member stated “this is not being respectful. Whenever nurses offer the medication, you need to accept it and offer a thank you. I told her that the only way we are going to get past this.”The surveyor asked the Director “if it is the resident’s responsibility to get past anything with the staff, or if, rather, it is the staff’s responsibility to navigate around the resident.” The Director stated “well don’t you say thank you when someone offers you something? It is just courtesy. When asked if she talked to any of the nurses named by [the resident, the Director] stated she had not.
  • Failure to Revise a Comprehensive Care Plan for Residents to Prevent FallingIn a summary statement of deficiencies dated April 28, 2017, the state investigator noted the facility failed to “review and revise a comprehensive care plan for [four residents at the facility].” The surveyor also noted the facility “failed to review [one resident’s] comprehensive care plan to ensure it included a Fall Plan of Care. Other failures including:
    • “The facility failed to revise [a second resident’s] comprehensive care plan after the urinary catheter was removed.”“The facility failed to revise [a third resident’s] comprehensive care plan following the development of a pressure injury on the sacrum on December 7, 2016, and the development of a pressure injury on the right heel and left buttock on April 19, 2017.”“The facility staff failed to review and revise [a fourth resident’s] comprehensive care plan after two skin alterations were found on February 3, 2017, and March 22, 2017.”
    The Director of Nursing and the Administrator were made aware of the failures listed above on the afternoon of April 26, 2017. It was revealed that the facility “uses Lippincott” for guidance that reads in part:“A written care plan serves as a communication tool for healthcare team members that help ensure continuity of care. The nursing care plan is a vital source of information about the patient’s problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care…”
  • Failure to Ensure the Services Provided Residents by the Nursing Staff Meet Professional Standards of QualityIn a summary statement of deficiencies dated April 28, 2017, the stated investigator noted that the facility “failed to follow professional standards of practice for [seven residents].” This included:
    • “The facility staff failed to clarify physician’s orders” for a resident.
    • “The facility staff failed to transcribe a physician’s recommendations into orders” for a second resident.
    • “The facility staff failed to clarify the parameters for admission of [as needed] pain medication” a third resident.
    • “The facility failed to obtain physician’s orders” to treat a sacral wound.
  • Failure to Provide Necessary Care and Services to Ensure the Resident Maintains Their Highest Well-BeingIn a summary statement of deficiencies dated April 20, 2017, the state investigator noted the facility’s failure to “maintain the highest level of practicable well-being for [5 residents at the facility.” These failures included:
    • “The facility staff failed to obtain physician ordered daily weights for [a resident].”
    • “The facility staff failed to administer an antibiotic medication [to another resident] after receiving an order…”
    • “The facility staff failed to attempt non-pharmacological interventions prior to the administration of [as needed] pain medication for [a third] resident.”
    • “The facility staff failed to offer non-pharmacological interventions prior to administering pain medication and failed to follow up with the resident on the effectiveness of the medication for [a fourth] resident.”
    • “The facility staff failed to obtain vital signs as ordered by a physician for every shift…”
  • Failure to Provide Treatment and Services to Not Only Continue But Improve the Resident’s Ability to Care for ThemselvesIn a summary statement of deficiencies dated April 28, 2017, the state investigator noted the facility failed to “implement restorative nursing services [for a resident].” It was also noted that the facility failed to evaluate the resident “before discontinuing the service.”The resident’s documents revealed that “the most recent rehabilitation documented completed for [a resident] was a therapy screening signed by a physical therapist on January 24, 2017, that documented… no change in functional status noticed. Will continue to monitor with nursing.”However, the resident’s revised February 24, 2017, Comprehensive Care Plan stated that the resident “requires restorative nursing services for an active range of motion, transfers, and bed mobility. Goals: I will maintain my current range of motion. Interventions: Resident to participate an Active Range of Motion Program to include use of [an exercise device] to maintain and/or improve strength for self-care activities…”

If you, or loved one, were injured while residing in a nursing facility, like Fredericksburg Health and Rehab Center, it’s important to take quick legal action to secure your financial compensation to can recover your damages. However, these cases are complex and often require the skills of a successful nursing home negligence attorney who specializes in abuse and neglect claims.

Typically, no upfront fees are required because these cases are usually handled through contingency arrangements. This agreement allows you to have immediate access to legal services, counsel, and representation without making a payment. Your attorney will be paid only after successfully resolving your case by winning your lawsuit at trial or negotiating an acceptable out of court settlement.


For information on the laws and regulations related to Virginia nursing homes, look here.

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