Inspection Reports for Knopp Healthcare & Rehab
1208 Llano St, Fredericksburg, TX 78624, United States, TX, 78624
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
47% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 56
Capacity: 119
Deficiencies: 6
Jan 9, 2026
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing homes, including investigation of alleged violations, resident safety, and facility operations.
Findings
The facility was found deficient in timely reporting and investigating injuries of unknown origin, ensuring accurate PASRR screenings for residents with mental health disorders, maintaining a functioning wander guard system, employing a qualified dietician, and maintaining essential laundry equipment in safe working condition.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to timely report and investigate injuries of unknown origin involving bruising for Resident #1, resulting in minimal harm. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have evidence that all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate PASRR Level 1 screening and referral for Resident #7 with bipolar disorder. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the facility's wander guard system was functioning properly; an exit door had a disabled wander guard system with exposed loose wires, placing residents at risk of elopement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to employ a qualified dietician or clinically qualified nutrition professional and designate a full-time director of food and nutrition services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain all essential laundry equipment in safe operating condition; one commercial washer and one dryer were inoperable. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents census: 56
Licensed beds: 119
Number of commercial washers: 3
Number of commercial dryers: 4
Number of inoperable washers: 1
Number of inoperable dryers: 1
Residents assessed for wander guard: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in injury reporting and investigation findings for Resident #1 |
| CNA A | Certified Nursing Assistant | Named in injury reporting and investigation findings for Resident #1 |
| CNA B | Certified Nursing Assistant | Provided information on hoyer lift use and injury observation for Resident #1 |
| CNA C | Certified Nursing Assistant | Assisted Resident #48 and provided information on wander guard bracelet |
| LVN D | Licensed Vocational Nurse | Provided information on disabled wander guard system door |
| Dietary Manager | Dietary Manager | Provided information on lack of qualified dietician and food service operations |
| LPNM | Licensed Practical Nurse MDS Nurse | Provided information on PASRR screening process and documentation |
| DON | Director of Nursing | Named in injury reporting and investigation findings for Resident #1 and PASRR process |
| ADM | Administrator | Named in injury reporting and investigation findings and dietary staffing |
| Hospice Nurse Practitioner | Hospice Nurse Practitioner | Provided information on Resident #1 bruising and hospice care |
| Activities Director | Activities Director | Responsible for wander guard system checks and monitoring |
Inspection Report
Routine
Deficiencies: 2
Oct 16, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service safety standards and pest control program requirements.
Findings
The facility failed to properly store and dispose of food contaminated with pests, including maggots in pudding cups, and failed to maintain an effective pest control program as numerous crickets were observed throughout the facility.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to store, prepare, distribute, and serve food in accordance with professional standards, including failure to recognize and dispose of food with pests such as maggots. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective pest control program resulting in numerous crickets observed throughout the facility. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Residents Affected: 1
Number of crickets observed: 10
Inspection Report
Routine
Census: 50
Deficiencies: 6
Oct 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, equipment maintenance, and resident safety.
Findings
The facility was found deficient in multiple areas including failure to transmit timely MDS discharge assessments, improper respiratory care practices, lack of stop dates on psychotropic medication orders, high medication error rates, inoperable laundry equipment, and failure to ensure call lights were within residents' reach.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to electronically transmit encoded, accurate, and complete MDS data to the CMS System within 14 days for a discharged resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure nebulizer tubing was bagged for a resident receiving respiratory care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to limit PRN orders for psychotropic drugs to 14 days or document rationale for extension. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate of 24%, including crushing delayed release medications and late administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain laundry equipment in safe operating condition; multiple washers and dryers inoperable. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure call light was within reach of a resident in a wheelchair. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication error rate: 24
Census: 50
Washers inoperable: 2
Dryers inoperable: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | MDS Coordinator | Named in failure to transmit MDS discharge assessment |
| DON | Director of Nursing | Named in oversight failures related to MDS transmission, respiratory care, psychotropic medication monitoring, medication errors, and call light policy |
| RN A | Registered Nurse | Named in failure to bag nebulizer tubing and medication administration errors |
| RN B | Registered Nurse | Named in medication administration errors including crushing delayed release medications and late administration |
| Laundry Aide D | Laundry Attendant | Named inoperable laundry equipment and ability to provide clean linens |
| CNA E | Certified Nursing Assistant | Named in repositioning call light for resident |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of resident abuse made by Resident #4 on 09/10/24, as required by facility policy.
Findings
The facility failed to report an alleged abuse incident involving Resident #4 immediately to the administrator, as required. Additionally, the facility failed to update care plans for Residents #1 and #3 after assessments indicated changes in their care needs, specifically regarding transfer assistance and use of mechanical lifts.
Complaint Details
The complaint involved an allegation by Resident #4 accusing two CNAs of hitting him, which was later revealed to be a joke. The facility staff failed to report the allegation immediately to the administrator as required. Interviews with staff and the administrator confirmed the failure to report and the importance of immediate reporting. The allegation was eventually reported to the administrator approximately 5 hours after the incident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to review and revise Resident Care Plans after each assessment for 2 of 4 Residents (Resident #1 and Resident #3), resulting in care plans not reflecting current transfer needs. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 4
Residents affected: 1
Residents reviewed for care plan revision: 4
Residents affected: 2
BIMS score: 6
Dates of assessments: Jul 20, 2024
Dates of assessments: Aug 24, 2024
Dates of admission records: Sep 18, 2024
Dates of admission records: Sep 19, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Authored health status and behavior notes related to the abuse allegation involving Resident #4 | |
| CNA D | Involved in the abuse allegation incident and interviews regarding failure to report | |
| CNA C | Involved in the abuse allegation incident and interviews regarding failure to report | |
| DON | Director of Nursing | Interviewed regarding reporting procedures and care plan updates |
| Administrator | Interviewed regarding reporting requirements and incident handling | |
| CNA H | Interviewed regarding care plan access and resident transfer practices | |
| Physical Therapist G | Interviewed regarding resident transfer needs and care plan updates | |
| CNA I | Interviewed regarding resident transfer practices and care plan information | |
| MDS nurse | Interviewed regarding care plan updates and resident transfer needs |
Inspection Report
Routine
Deficiencies: 2
Aug 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights to a safe, clean, comfortable, and homelike environment, and to evaluate the completeness and accuracy of resident medical records.
Findings
The facility failed to maintain a safe and homelike environment in three communal shower rooms due to storage of soiled linens and trash barrels and disrepair of equipment. Additionally, the facility failed to maintain complete, accurate, and updated medical records for three residents, including missing updates to advance directives and diet orders.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Barrels containing soiled linens and trash were stored in three communal shower rooms, and equipment in Shower Room C was in disrepair. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain medical records that are complete, accurately documented, readily accessible, and systematically organized for 3 of 8 residents, including failure to update Advance Directive code status and diet orders. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Confirmed storage practice of soiled linens and trash in communal shower rooms and discussed facility policies regarding resident dignity and care plan updates. |
| LVN F | Licensed Vocational Nurse | Authored progress note regarding Resident #188's DNR status. |
| LVN E | Licensed Vocational Nurse | Authored progress note regarding Resident #33's nutrition. |
| FSS | Authored progress notes regarding Resident #28 and Resident #33's diet and nutritional status. | |
| Med Rec clerk | Contacted FSS regarding missing Status Report sheets related to diet orders. | |
| Social Worker | Confirmed barrels containing soiled linens and trash in communal shower room A. |
Inspection Report
Annual Inspection
Deficiencies: 9
Aug 24, 2023
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment, incomplete and inaccurate care plans, inadequate pharmaceutical services, unsecured medication storage, lack of full-time registered nursing coverage, failure to coordinate hospice services properly, and failure to provide mandatory training on the facility's QAPI program to staff.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Barrels containing soiled linens and trash were stored in communal shower rooms, and equipment in Shower Room C was in disrepair, risking psychosocial harm to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Care plans for residents #188 and #33 were not reviewed and revised by the interdisciplinary team after assessments, including failure to update advance directive and diet orders. | Level of Harm - Minimal harm or potential for actual harm |
| Resident environment was not free from accident hazards; hazardous materials, sharp tools, and equipment in disrepair were accessible to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to employ a Director of Nursing and sufficient full-time registered nurses for at least eight consecutive hours per day, seven days per week for 3 of 13 months reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Pharmaceutical services failed to ensure vital signs were obtained immediately prior to administration of metoprolol for Resident #12 and liquid medications were not measured accurately for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| The 200-wing treatment cart was unlocked and unattended at the nurses' station, risking medication loss or misuse. | Level of Harm - Minimal harm or potential for actual harm |
| Medical records for residents #188, #28, and #33 were incomplete or not updated, including failure to update advance directive status and diet orders. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to designate a member of the interdisciplinary team responsible for hospice coordination and failed to obtain hospice documentation for residents #7 and #26. | Level of Harm - Minimal harm or potential for actual harm |
| Twenty of twenty-five staff reviewed had not received mandatory training regarding the facility's Quality Assurance and Performance Improvement (QAPI) program. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 2
Months without full-time DON and RN coverage: 3
Residents affected: 2
Staff without QAPI training: 20
Residents affected: 3
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN F | Licensed Vocational Nurse | Administered metoprolol without obtaining vital signs immediately prior to administration |
| DON | Director of Nursing | Confirmed lack of facility policies on resident dignity, accident hazards, RN coverage, medication storage, hospice coordination, and QAPI training |
| Administrator | Facility Administrator | Confirmed lack of full-time DON prior to October 2022 and lack of QAPI training policy |
| LVN E | Licensed Vocational Nurse | Left treatment cart unlocked and administered liquid medication without measuring in graduated cup |
| Office Manager | Office Manager | Confirmed hazardous materials and equipment in disrepair accessible to residents |
| Social Worker | Social Worker | Confirmed barrels with soiled linens and trash stored in communal shower rooms |
| Med Rec clerk | Medical Records Clerk | Reported no documentation regarding missing diet orders from electronic health record |
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