Deficiency Records for Frederick Health and Rehabilitation Center
Updated as of July 01, 2021
This is not the most recent data for Frederick Health and Rehabilitation Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Keep complete, dated laboratory records in the resident's record. | Health | 2021-01-29 | 2021-03-12 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-01-29 | 2021-03-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-10-22 | 2020-11-20 | 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 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 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 |
| 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 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-10 | 2020-02-10 | Y |
| 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 |
| 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 |
| 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 |
| 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 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-10 | 2019-11-10 | Y |
| 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 |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-04-12 | 2019-05-27 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-12 | 2019-05-27 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-04-12 | 2019-05-27 | Y |
| 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 |
| Have exits that are accessible at all times. | Fire Safety | 2016-12-27 | 2017-02-17 | 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 | 2016-12-27 | 2017-02-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2016-12-27 | 2017-02-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2016-12-27 | 2017-02-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2016-12-27 | 2017-02-17 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2016-12-27 | 2017-02-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-12-22 | 2017-02-06 | N |
| Provide care for each resident in a way that maintains or improves their quality of life. | Health | 2016-12-22 | 2017-02-06 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-12-22 | 2017-02-06 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2016-12-22 | 2017-02-06 | N |
| Provide housekeeping and maintenance services. | Health | 2016-12-22 | 2017-02-06 | N |
| Provide adequate and comfortable lighting levels in all areas. | Health | 2016-12-22 | 2017-02-06 | N |
| Maintain comfortable and safe temperature levels. | Health | 2016-12-22 | 2017-02-06 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-12-22 | 2017-02-06 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-12-22 | 2017-02-06 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-12-22 | 2017-02-06 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-12-22 | 2017-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-22 | 2017-02-06 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-12-22 | 2017-02-06 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2016-12-22 | 2017-02-06 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-12-22 | 2017-02-06 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-12-22 | 2017-02-06 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-12-22 | 2017-02-06 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-22 | 2017-02-06 | N |
| Keep all essential equipment working safely. | Health | 2016-12-22 | 2017-02-06 | N |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2016-12-22 | 2017-02-06 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-12-22 | 2017-02-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-12-22 | 2017-02-06 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-03-04 | Not Fixed | Y |
