Deficiency Records for Fredericka Manor Care Center
Updated as of October 01, 2023
This is not the most recent data for Fredericka Manor Care Center. For the most recent information, click here.
A list of the most recent deficiencies for Fredericka Manor Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-06 | 2022-10-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-15 | 2022-10-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-15 | 2022-10-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-15 | 2022-10-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-15 | 2022-10-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-11 | 2022-09-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-08-11 | 2022-09-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-11 | 2022-09-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-08-11 | 2022-09-11 | N |
| Post nurse staffing information every day. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-08-11 | 2022-09-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-11 | 2022-09-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-11 | 2022-09-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-11 | 2022-09-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-09-11 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-16 | 2022-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-10 | 2022-07-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-10 | 2022-07-15 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-06-10 | 2022-07-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-18 | 2022-06-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-03 | 2022-06-06 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-03 | 2022-06-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-03 | 2022-06-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-24 | 2022-02-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-24 | 2022-02-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-22 | 2022-01-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-17 | 2021-12-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-13 | 2021-12-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-06 | 2021-12-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-29 | 2021-10-31 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-09-21 | 2021-10-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-01 | 2021-07-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-24 | 2021-04-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-21 | 2020-02-12 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-10-21 | 2020-02-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-21 | 2020-02-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-21 | 2020-02-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-21 | 2020-02-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-10-21 | 2020-02-12 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-10-21 | 2020-02-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-21 | 2020-02-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-10-21 | 2020-02-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-21 | 2020-02-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-10-21 | 2019-12-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-10-21 | 2019-12-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-10-21 | 2019-12-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-10-21 | 2019-12-12 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-10-21 | 2019-12-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-21 | 2019-12-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-10-21 | 2019-12-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-21 | 2019-12-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-21 | 2019-12-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-21 | 2019-12-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-10-21 | 2019-12-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-21 | 2019-12-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-21 | 2019-12-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-21 | 2019-12-12 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-10-21 | 2019-12-12 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-10-21 | 2019-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-21 | 2019-12-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-21 | 2019-12-12 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-11-13 | 2019-12-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-13 | 2019-12-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-13 | 2019-12-10 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-11-13 | 2019-12-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-11-13 | 2019-12-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-13 | 2019-12-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-13 | 2019-12-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-13 | 2019-12-10 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-10-21 | 2019-12-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Develop a communication plan. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-13 | 2019-01-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-04 | 2018-11-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-10-04 | 2018-11-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-10-04 | 2018-11-04 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-10-04 | 2018-11-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-04 | 2018-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-04 | 2018-11-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-04 | 2018-11-04 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-04 | 2018-11-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-10-04 | 2018-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-04 | 2018-11-04 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-10-04 | 2018-11-04 | N |
