CITIZENS CARE AND REHABILITATION CENTER OF FREDERI

Nursing Home Inspector

1920 ROSEMONT AVENUE
FREDERICK, MD 21702
Frederick County
Phone: 240-772-9200
Provider Number: 215105
Last Inspection: 10/14/2016

About the Nursing Home

Number of Beds: 170
Number of Residents: 154
Beds Available: 16
Percent Occupancy: 91%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Government - City/county
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

22

Facility
37

County
29

MD
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

22

2016
35

2015
41

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

10/14/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 11/25/2016
 
Failed To: 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. Pattern : Minimal 4 11/25/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 11/25/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 11/25/2016
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 11/25/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 11/25/2016
 
Failed To: Keep all essential equipment working safely. Isolated : Minimal 3 11/25/2016
 

8/21/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 10/4/2015
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Pattern : Potential 3 10/4/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 10/4/2015
 
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 10/4/2015
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Pattern : Minimal 4 10/4/2015
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Pattern : Minimal 4 10/4/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 10/4/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Potential 3 10/4/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 10/4/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 10/4/2015
 

6/3/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 7/18/2014
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 7/18/2014
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 7/18/2014
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 7/18/2014
 
Failed To: Give or get x-rays and other tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 7/18/2014
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 7/18/2014
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 7/18/2014
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 7/18/2014
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 7/18/2014
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 7/18/2014
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 7/18/2014
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 7/18/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

5/11/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Minimal 3 4/16/2016
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Isolated : Minimal 3 6/10/2016
 

3/14/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Potential 3 unknown
 

3/18/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Actual 4 3/1/2015
 

1/12/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Potential 3 2/15/2015
 
Failed To: Upon the death of a resident, convey the resident’s personal funds and an accounting of those funds to the appropriate party. Pattern : Potential 3 2/15/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MD State Avg
Number of Residents 154 104.00 107.44
Registered Nurses 1.17 0.95 0.94
Licensed Practical / Vocational Nurses 1.00 0.82 0.87
Certified Nursing Assistants 2.67 2.34 2.35
Total Staff Hours 4.85 4.11 4.16

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MD State Avg%
of high risk long-stay residents with pressure ulcers 6 6 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 97 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 94 95
of long-stay residents experiencing one or more falls with major injury 3 3 2
of long-stay residents who have depressive symptoms 6 3 3
of long-stay residents who lose too much weight 7 4 6
of long-stay residents who received an antianxiety or hypnotic medication 26 22 18
of long-stay residents who received an antipsychotic medication 15 13 12
of long-stay residents who self-report moderate to severe pain 1 4 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 21 21 21
of long-stay residents whose need for help with daily activities has increased 16 19 17
of long-stay residents with a catheter inserted and left in their bladder 2 0 1
of long-stay residents with a urinary tract infection 4 3 3
of low risk long-stay residents who lose control of their bowels or bladder 75 62 58
of short-stay residents assessed and appropriately given the pneumococcal vaccine 99 87 83
of short-stay residents who had an outpatient emergency department visit 8 9 10
of short-stay residents who made improvements in function 74 69 67
of short-stay residents who newly received an antipsychotic medication 1 1 1
of short-stay residents who self-report moderate to severe pain 4 10 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 95 80 82
of short-stay residents who were rehospitalized after a nursing home admission 14 17 20
of short-stay residents who were successfully discharged to the community 71 62 55
of short-stay residents with pressure ulcers that are new or worsened 1 1 1