Inspection Results » Frederick Health & Rehabilitation Center

Health Inspection on March 23, 2018 ^[1]

1. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-05-07)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-05-07)
   • Provide timely, quality laboratory services/tests to meet the needs of residents. (Corrected 2018-05-07)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-05-07)
   • Keep all essential equipment working safely. (Corrected 2018-05-07)

2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-05-07)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-05-07)
   • 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. (Corrected 2018-05-07)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-05-07)
   • 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. (Corrected 2018-05-07)
   • Provide and implement an infection prevention and control program. (Corrected 2018-05-07)

3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure each resident receives an accurate assessment. (Corrected 2018-05-07)
   • Ensure that residents are free from significant medication errors. (Corrected 2018-05-07)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2018-05-07)
   • Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. (Corrected 2018-05-07)
   • Respond appropriately to all alleged violations. (Corrected 2018-05-07)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2018-05-07)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-05-07)
   • Assure that each residentÂ’s assessment is updated at least once every 3 months. (Corrected 2018-05-07)
   • Provide or obtain dental services for each resident. (Corrected 2018-05-07)
   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2018-05-07)
   • Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. (Corrected 2018-05-07)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-05-07)
   • Allow resident to participate in the development and implementation of his or her person-centered plan of care. (Corrected 2018-05-07)
   • Make sure that a working call system is available in each resident's bathroom and bathing area. (Corrected 2018-05-07)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-05-07)

4. Widespread: No actual harm with potential for minimal harm

   • Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. (Corrected 2018-05-07)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-05-07)
   • Post nurse staffing information every day. (Corrected 2018-05-07)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2018-05-07)
   • Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. (Corrected 2018-05-07)