Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0801
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on interview and record review, the facility failed to employ staff with the appropriate competencies
and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager
reviewed for qualified dietary staff.
The facility failed to employ a certified dietary manager as required.
This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of
food borne illness and not receiving adequate nutrition.
Findings included:
Record review of the job titled Food Services Supervisor, revised 07/2016, revealed under Qualifications,
Graduation from a course in food service supervision which meets the standards established by the
American Dietetic Association or a graduate of another course in food service supervision with 90 or more
hours in classroom instruction with on-the-job counseling by a dietician.
Record Review of Employee List dated 7/18/2022 revealed no employee listed in the Food Service
Supervisor position.
Record review of undated, untitled department head list revealed Food Service Supervisor position blank
In an interview on 07/22/22 at 9:12 AM [NAME] C stated, we don't currently have a dietary manager. We
have been without one for about 3 months or so. I know what it takes to be one, I'm thinking about doing it,
but i am nervous. I like being a cook. I have 3 times a day to make these folks day and hearing that my food
was good, is what i look forward to most.
In an interview on 07/22/22 at 9:23AM Administrator A stated, I don't have a Dietary Manager currently. I
don't know that I've been written up on that yet. I am aware I have to have one. I can't believe I paid for the
previous girl to get her certification and she left. We have ads out everywhere for help in the kitchen.
Record review of the CMS 672 Resident Census and Conditions of Residents, completed by the facility on
7/22/22, revealed all residents in the facility received meals and snacks served from the kitchen.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
675740
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675740
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Knopp Nursing & Rehab Center Inc
202 Billie Dr
Fredericksburg, TX 78624
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations and interviews, the facility failed to maintain an infection control program to provide
an environment to help prevent the development and transmission of disease and infection for 1 of 1
resident (#17) reviewed for infection control practices in that:
Residents Affected - Few
Registered Nurse - F used an ungloved hand to retrieve a pill that fell out of the plastic medication cup
when it was removed from the blister pack, then administered to the resident.
This deficient practice could affect residents who receieve a medication from a blister pack requiring
removal of the medication from a blister pack, thus resulting in the spread of infection.
The findings were:
Observation on 07/27/2022 at 8:15 AM of Registered Nurse - F retrieved a pill that fell out of the plastic
medication cup when it was removed from the blister pack. The medication was a Methadone (Methadone
is a powerful drug used for pain relief) pill.
In an interview on 7/21/2022 at 8:15 AM Registered Nurse F,stated she had used hand gel prior to
preparing the retrieval of the medication for resident #17.
In an interview on 7/22/2022 at 11:45 AM the Director of Nurses (DON) stated there was no excuse for
Registered Nurse - F's actions as she is aware of never touching any medication with ungloved hands.
Record review of the facility policy on Medication Administration failed to state that medications should
never be touched with bare hands. It failed to state what procedure to follow if a pill was dropped. The
Director of Nurses stated a revision was due for several policies. The Medication Administration had no date
on it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675740
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675740
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Knopp Nursing & Rehab Center Inc
202 Billie Dr
Fredericksburg, TX 78624
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0909
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and
mattresses must attach safely to the bed frame.
Based on interview and record review, the facility failed to conduct regular inspection of all bed frames and
bed rails as part of a regular maintenance program to identify areas of possible entrapment for 5 of 5
residents reviewed for bed rails assessments.
The facility failed to have a maintenance program to conduct regular inspections of the beds and bedrails to
identify risks and problems.
This failure could place residents with bed rails at risk of entrapment, injury, or death.
The findings were:
Observation on 07/22/22 at 10:34 AM revealed Resident #2 had bed rail (assist/grab bar) on both left and
right side of bed in the up position.
Observation on 07/19/22 at 01:25 PM revealed Resident #16 had bed rail (assist/grab bar) on both left and
right side of bed in the up position.
Observation on 07/22/22 at 10:24 AM revealed Resident #15 had bed rail (assist/grab bar) on both left and
right side of bed in the up position.
Observation on 07/22/22 at 10:35 AM revealed resident #28 had bed rail (assist/grab bar) on both left and
right side of bed in the up position.
Observation on 07/21/22 at 10:37 AM revealed resident #25 had bed rail (assist/grab bar) on both left and
right side of bed in the up position.
In an Interview on 07/21/22 at 10:31 AM with facility Maintenance E & D stated they were not aware of
monitoring any bed rails. Maintenance E states he has never done it before.
In an interview on 07/22/22 at 12:33 p.m. Maintenance D stated he did not have the manufacturer's manual
for the residents' beds or for the bed rail (assists/grab bars) on the beds.
In an interview on 07/21/22 at 03:04 PM with Maintenance D, he stated that all resident beds were checked
and that there were 4 bed rails loose. He went on to state that he tightened all 4 bed rails.
In an interview on 07/21/22 at 04:00 PM with Administrator, she states that they do not have a policy where
each bed rail is checked preventatively. When asked if they have a preventative maintenance program or
anything that would ensure the bed rails are checked and the frequency at which they are checked, she
replied no we don't, but we should.
In an interview with the Minimum Data Set Coordinator on 07/21/22 at 04:37 PM, she stated the term
restraint was used for bed rails. She added the facility is not using bed rails as a restraint device. The
bedrails are used as assist devices for the resident's ability to move in the bed or assist to get in or out of
bed.
In an interview on 7/22/2022 at 9:15 AM, the two maintenance employees (E and D) who work jointly
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675740
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675740
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/22/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Knopp Nursing & Rehab Center Inc
202 Billie Dr
Fredericksburg, TX 78624
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0909
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
in the facility stated they had not been checking the bed rails for safety to assure the bedrails were not
loose. There was no set routine to inspect the bed rails.
The two maintenance employees (E and D) who work jointly in the facility stated they did not know if the
manufacturer's manual for the residents' beds or for the bed rail (assists/grab bars) on the beds were still
available.
In an interview on 7/22/2022 at 10:40 AM., the Administrator stated the beds in the facility came with the
enabler bars (assist/grab bars/bed rails) on the beds so the residents could use them for repositioning and
to hang the bed remote control on. The Administrator stated if the enabler bars were ¼ bars then
they would be considered bed rails, but they were enabler bars. The Administrator did not state how the
facility monitors the enabler bars (assist/grab bars/bed rails) to ensure they are correctly installed on the
bed.
Record review of U.S. Department of Health and Human Services Food and Drug Administration (FDA)
Center for Devices and Radiological Health's Guidance for Industry and FDA Staff Hospital Bed System
Dimensional and assessment Guidance to Reduce Entrapment issued 3/10/2006, pages 13-17, revealed
the space between the bed rail and mattress was a potential zone of entrapment. The FDA is
recommending a dimensional limit of less than 120 mm (4 ¾ inches) for the area between the inside
surface of the rail and the compressed mattress.
Record review of the facility's undated policy Use of Siderails revealed Each resident shall be provided with
a hospital type bed which includes two side rails, both in good working order. The resident has the right to
be free from any siderail device which would restrict their freedom of movement imposed for purposes of
discipline or staff convenience and not required to treat medical condition Whenever a siderail is used as a
restrain, the nursing staff will determine through a comprehensive written assessment, that the siderails are
necessary to assist the resident in attaining or maintaining their highest practical physical, mental and
psychosocial wellbeing the same procedures will be followed for siderails that are followed as previously
mentioned for the restraints.
The facility had no policy for bed safety to address checking of bedrails on a routine basis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675740
If continuation sheet
Page 4 of 4
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the July 22, 2022 survey of KNOPP NURSING & REHAB CENTER INC?
This was a inspection survey of KNOPP NURSING & REHAB CENTER INC on July 22, 2022. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at KNOPP NURSING & REHAB CENTER INC on July 22, 2022?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nut..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.