Deficiency Records for Frederick Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Frederick Health and Rehabilitation 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 maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-18 | 2023-07-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-05-18 | 2023-07-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-18 | 2023-07-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-18 | 2023-07-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-05-18 | 2023-07-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-18 | 2023-07-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-18 | 2023-07-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-18 | 2023-07-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-18 | 2023-07-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-18 | 2023-07-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-17 | 2023-06-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-17 | 2023-06-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-17 | 2023-06-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-17 | 2023-06-28 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-05-17 | 2023-06-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-17 | 2023-06-28 | Y |
| 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 | 2023-05-17 | 2023-06-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-17 | 2023-06-28 | 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 | 2023-05-17 | 2023-06-28 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-05-17 | 2023-06-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-17 | 2023-06-28 | 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 | 2023-05-17 | 2023-06-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-17 | 2023-06-28 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-17 | 2023-06-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-06-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-05-17 | 2023-06-28 | 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 | 2023-05-17 | 2023-06-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-17 | 2023-06-28 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-05-17 | 2023-06-28 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-05-17 | 2023-06-28 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-05-17 | 2023-06-28 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-05-17 | 2023-06-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-17 | 2023-06-28 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-17 | 2023-06-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-17 | 2023-06-28 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-05-17 | 2023-06-28 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-05-17 | 2023-06-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-17 | 2023-06-28 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-05-17 | 2023-06-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-17 | 2023-06-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-17 | 2023-06-28 | 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 | 2023-05-17 | 2023-06-28 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-05-17 | 2023-06-28 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-05-17 | 2023-06-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-17 | 2023-06-28 | Y |
| 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 | 2023-05-17 | 2023-06-28 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-05-17 | 2023-06-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-17 | 2023-06-28 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-05-17 | 2023-06-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-17 | 2023-06-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-17 | 2023-06-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-17 | 2023-06-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-17 | 2023-06-28 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-05-17 | 2023-06-28 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-17 | 2023-06-28 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-09-10 | 2020-02-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-10 | 2020-02-10 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-09-10 | 2020-02-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-10 | 2020-02-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-10 | 2020-02-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-10 | 2020-02-10 | 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 | 2019-09-10 | 2020-02-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-10 | 2020-02-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-10 | 2020-02-10 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-09-10 | 2020-02-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-09-10 | 2020-02-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-10 | 2020-02-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-10 | 2020-02-10 | N |
| Dispose of garbage and refuse properly. | Health | 2019-09-10 | 2020-02-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-10 | 2020-02-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-09-10 | 2020-02-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-10 | 2019-11-11 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-09-10 | 2019-11-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-10 | 2019-11-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-10 | 2019-11-10 | 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 | 2019-09-10 | 2019-11-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-10 | 2019-11-10 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-09-10 | 2019-11-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-09-10 | 2019-11-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-10 | 2019-11-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-10 | 2019-11-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-10 | 2019-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-10 | 2019-11-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-10 | 2019-11-10 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-09-10 | 2019-11-10 | 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 | 2019-09-10 | 2019-11-10 | 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 | 2019-09-10 | 2019-11-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-09-10 | 2019-11-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-10 | 2019-11-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-10 | 2019-11-10 | 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 | 2019-09-10 | 2019-11-10 | 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 | 2019-09-10 | 2019-11-10 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2019-09-10 | 2019-11-10 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-09-10 | 2019-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-10 | 2019-11-10 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-09-10 | 2019-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-10 | 2019-11-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-09-10 | 2019-11-10 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-09-10 | 2019-11-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-26 | 2019-10-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-08-26 | 2019-10-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-26 | 2019-10-05 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-03-23 | 2018-05-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-03-23 | 2018-05-07 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-03-23 | 2018-05-07 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-03-23 | 2018-05-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-23 | 2018-05-07 | 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 | 2018-03-23 | 2018-05-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-03-23 | 2018-05-07 | N |
| Respond appropriately to all alleged violations. | Health | 2018-03-23 | 2018-05-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-03-23 | 2018-05-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-03-23 | 2018-05-07 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-03-23 | 2018-05-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-23 | 2018-05-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-23 | 2018-05-07 | 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 | 2018-03-23 | 2018-05-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-03-23 | 2018-05-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-23 | 2018-05-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-23 | 2018-05-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-03-23 | 2018-05-07 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-03-23 | 2018-05-07 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-03-23 | 2018-05-07 | N |
| Post nurse staffing information every day. | Health | 2018-03-23 | 2018-05-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-23 | 2018-05-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-23 | 2018-05-07 | 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 | 2018-03-23 | 2018-05-07 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-03-23 | 2018-05-07 | N |
| Provide or obtain dental services for each resident. | Health | 2018-03-23 | 2018-05-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-03-23 | 2018-05-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-03-23 | 2018-05-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-23 | 2018-05-07 | N |
| Keep all essential equipment working safely. | Health | 2018-03-23 | 2018-05-07 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-03-23 | 2018-05-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-15 | 2018-05-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-03-15 | 2018-05-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-03-15 | 2018-05-04 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-03-15 | 2018-05-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-03-15 | 2018-04-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-03-15 | 2018-04-28 | N |
