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Nursing Home Inspect > Maryland > Frederick County Data as of March 2024

    Frederick Health & Rehabilitation Center

    For profit - Corporation  ·  30 North Place, Frederick, MD 21701  ·  See home’s Medicare page

    Affiliated With Lexington Health Management
    People or companies with an ownership interest in or managerial control of this home, according to CMS data.
    3.44
    Nurse hours/resident/day
    Reported total nurse staffing hours per resident per day.
    State Average: 3.8
    42.6%
    Nurse turnover
    The percentage of nursing staff who stopped working at the home over a 12-month period.
    State Average: 50.6%
    120
    Certified beds
    Qualifying beds in the certified provider or supplier facility.
    94
    Average residents/day
    Average number of residents based on daily census.
    Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
    Direct owners
    Medical Rehabilitation Centers, Llc (100%)
    Indirect owners
    Lexington Health Management Llc
    Amy Watts
    Walter Watts
    Managerial control
    Walter Watts since Feb, 2022
    Managing employee(s)
    Brenda Campbell since Feb, 2022

    Inspection Reports

    120

    total deficiencies

    5

    infection-related deficiencies

    This home violated federal standards protecting residents from the spread of infections.

    Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
    May 17, 2023
    Complaint report
    7 deficiencies
    D

     to E
    E
    Full report
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
    Failure to: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
    Failure to: Respond appropriately to all alleged violations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0695
    Failure to: Provide safe and appropriate respiratory care for a resident when needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0712
    Failure to: Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0755
    Failure to: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0761
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    May 17, 2023
    Standard report
    38 deficiencies
    (3 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    D

     to E
    E
    Full report
    Resident Rights Deficiency — F0584
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0623
    Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0625
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0656
    Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nursing and Physician Services Deficiency — F0710
    Failure to: Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0578
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0679
    Failure to: Provide activities to meet all resident's needs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0692
    Failure to: Provide enough food/fluids to maintain a resident's health.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Administration Deficiency — F0835
    Failure to: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Administration Deficiency — F0836
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Administration Deficiency — F0865
    Failure to: Have a plan that describes the process for conducting QAPI and QAA activities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Administration Deficiency — F0867
    Failure to: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Infection Control Deficiency — F0887
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Infection Control Deficiency — F0888
    Failure to: Ensure staff are vaccinated for COVID-19
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0947
    Failure to: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0580
    Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0622
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0655
    Failure to: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0686
    Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0740
    Failure to: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0558
    Failure to: Reasonably accommodate the needs and preferences of each resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0624
    Failure to: Prepare residents for a safe transfer or discharge from the nursing home.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0644
    Failure to: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0658
    Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0685
    Failure to: Assist a resident in gaining access to vision and hearing services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0688
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0700
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0711
    Failure to: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0728
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0729
    Failure to: Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0730
    Failure to: Observe each nurse aide's job performance and give regular training.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nutrition and Dietary Deficiency — F0806
    Failure to: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Sep 10, 2019
    Standard report
    44 deficiencies
    (1 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    B

     to G
    G
    Full report
    Quality of Life and Care Deficiency — F0684
    Failure to: Provide appropriate treatment and care according to orders, resident's preferences and goals.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Quality of Life and Care Deficiency — F0686
    Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    Severity
    Actual harm that is not immediate jeopardy
    Scope
    Few people affected
    Seriousness
    G
    Resident Assessment and Care Planning Deficiency — F0656
    Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Nursing and Physician Services Deficiency — F0725
    Failure to: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Nursing and Physician Services Deficiency — F0726
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Nursing and Physician Services Deficiency — F0730
    Failure to: Observe each nurse aide's job performance and give regular training.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Nutrition and Dietary Deficiency — F0812
    Failure to: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0867
    Failure to: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Rights Deficiency — F0550
    Failure to: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0624
    Failure to: Prepare residents for a safe transfer or discharge from the nursing home.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0625
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0655
    Failure to: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nursing and Physician Services Deficiency — F0711
    Failure to: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0758
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0759
    Failure to: Ensure medication error rates are not 5 percent or greater.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Nutrition and Dietary Deficiency — F0814
    Failure to: Dispose of garbage and refuse properly.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Environmental Deficiency — F0925
    Failure to: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0553
    Failure to: Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0558
    Failure to: Reasonably accommodate the needs and preferences of each resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0580
    Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0584
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0622
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0636
    Failure to: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0658
    Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0692
    Failure to: Provide enough food/fluids to maintain a resident's health.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0698
    Failure to: Provide safe, appropriate dialysis care/services for a resident who requires such services.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0700
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0744
    Failure to: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0755
    Failure to: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0756
    Failure to: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0757
    Failure to: Ensure each resident's drug regimen must be free from unnecessary drugs.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0761
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Administration Deficiency — F0775
    Failure to: Keep complete, dated laboratory records in the resident's record.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nutrition and Dietary Deficiency — F0810
    Failure to: Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Administration Deficiency — F0849
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0947
    Failure to: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0577
    Failure to: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Resident Rights Deficiency — F0623
    Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Some people affected
    Seriousness
    B
    Mar 23, 2018
    Standard report
    31 deficiencies
    (1 infection)

    This report includes a citation for violating federal standards protecting residents from the spread of infections.
    C

     to F
    F
    Full report
    Resident Assessment and Care Planning Deficiency — F0656
    Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Assessment and Care Planning Deficiency — F0657
    Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0770
    Failure to: Provide timely, quality laboratory services/tests to meet the needs of residents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Administration Deficiency — F0867
    Failure to: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Environmental Deficiency — F0908
    Failure to: Keep all essential equipment working safely.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Many people affected
    Seriousness
    F
    Resident Rights Deficiency — F0580
    Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0584
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Quality of Life and Care Deficiency — F0686
    Failure to: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Pharmacy Service Deficiency — F0761
    Failure to: 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.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Assessment and Care Planning Deficiency — F0842
    Failure to: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Infection Control Deficiency — F0880
    Failure to: Provide and implement an infection prevention and control program.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Some people affected
    Seriousness
    E
    Resident Rights Deficiency — F0553
    Failure to: Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0558
    Failure to: Reasonably accommodate the needs and preferences of each resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
    Failure to: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
    Failure to: Respond appropriately to all alleged violations.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0638
    Failure to: Assure that each resident's assessment is updated at least once every 3 months.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0641
    Failure to: Ensure each resident receives an accurate assessment.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Assessment and Care Planning Deficiency — F0658
    Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0689
    Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0692
    Failure to: Provide enough food/fluids to maintain a resident's health.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0710
    Failure to: Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Nursing and Physician Services Deficiency — F0711
    Failure to: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0759
    Failure to: Ensure medication error rates are not 5 percent or greater.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Pharmacy Service Deficiency — F0760
    Failure to: Ensure that residents are free from significant medication errors.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Quality of Life and Care Deficiency — F0791
    Failure to: Provide or obtain dental services for each resident.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Environmental Deficiency — F0919
    Failure to: Make sure that a working call system is available in each resident's bathroom and bathing area.
    Severity
    No actual harm, with a potential for more than minimal harm
    Scope
    Few people affected
    Seriousness
    D
    Resident Rights Deficiency — F0559
    Failure to: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Resident Rights Deficiency — F0577
    Failure to: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Resident Rights Deficiency — F0623
    Failure to: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Resident Rights Deficiency — F0625
    Failure to: 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.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C
    Nursing and Physician Services Deficiency — F0732
    Failure to: Post nurse staffing information every day.
    Severity
    No actual harm, with potential for minimal harm
    Scope
    Many people affected
    Seriousness
    C

    Penalties

    This home has no record of fines or payment suspensions for the past three years.