Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Citizens Care And Rehabilitation Center Of Frederi during CMS and state inspections, most recent first.
A resident with cognitive and psychiatric diagnoses reported missing money from a personal lock box. The facility's investigation included staff interviews but did not include interviews with other residents who might have had relevant information. Facility leadership acknowledged that not all investigative avenues were explored, resulting in an incomplete investigation of the alleged misappropriation.
Staff did not ensure that all prior MOLST forms in a resident's electronic medical record were properly voided as required, resulting in both voided and un-voided copies of the same forms being present. This did not meet accepted professional standards for maintaining accurate medical records.
The facility failed to ensure proper food safety and hygiene practices, affecting all 158 residents. Observations revealed unlabeled, undated, and expired food items in storage, improper dishwashing protocols, and staff not wearing appropriate hair coverings. The General Manager and Administrator acknowledged the need for compliance and training.
The facility failed to discard expired insulin pens from five medication carts, including those in the RCU, second-floor LTC, third-floor LTC, and memory care units. Observations revealed that several insulin pens were used beyond their 28-day expiration period, with some lacking proper labeling. The DON confirmed that insulin pens should be checked for correct open dates and discarded if expired, which was not followed.
The facility failed to maintain proper infection control during blood glucose testing and wound care. LPNs did not perform hand hygiene or use barriers as required, and a Treatment Nurse did not change gloves or perform hand hygiene during wound care for a resident with a stage IV pressure ulcer. These actions were contrary to facility policy, placing residents at risk for infections.
A facility failed to conduct a required Level II PASARR evaluation for a resident with PTSD, bipolar disorder, and anxiety, who was readmitted with a Level I PASARR indicating the need for further evaluation. The social worker confirmed the oversight, noting that counseling was considered unhelpful due to the resident's low BIMS score, and the VA did not provide further counseling upon readmission.
A facility failed to include a condom catheter in a resident's care plan, despite a physician's order. The resident, with multiple health issues and moderate cognitive impairment, was at risk for incomplete care. The DON and Unit Manager confirmed the omission, which violated the facility's policy for comprehensive care planning.
A facility failed to update a comprehensive care plan for a resident with multiple pressure and non-pressure ulcers. Despite changes in the resident's wound status, the care plan was not revised to reflect the healing of certain wounds and the development of new ones. The Unit Manager acknowledged the oversight, and the Director of Nursing confirmed the care plan should represent the care being provided, which it did not.
An LPN in an LTC facility was observed using a Novolog Insulin Pen on one resident and preparing to use the same pen on another, contrary to facility policy. The surveyor intervened, and the LPN acknowledged the mistake. Interviews confirmed that each resident should have their own pen to prevent bloodborne pathogen transmission.
The facility failed to provide and document education on the benefits and risks of pneumonia and influenza immunizations for three residents after vaccine refusals. The Infection Preventionist was unaware of some refusals, and the Administrator expected education to be documented. This oversight placed residents at risk for pneumonia and influenza.
Failure to Thoroughly Investigate Missing Property Incident
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident involving missing property reported by a resident's representative. The incident involved a resident with multiple diagnoses, including vascular dementia, depression, anxiety, and cognitive communication deficit, who had been residing in the facility for long-term care since October 2019. The resident reported approximately $500 missing from a lock box kept in their room. The facility's investigation included interviews with staff but did not include interviews with other residents who may have been potential witnesses or victims, despite the possibility that they could have relevant information. During interviews, the Nursing Home Administrator and Chief Operating Officer confirmed that resident interviews were not conducted, citing that the resident typically kept their room door closed and had the only key to the lock box. However, the lack of resident interviews was acknowledged as a concern by both administrators, and it was noted that the facility had not fully explored all possibilities regarding the missing funds. The deficiency was identified due to the incomplete investigative process, specifically the omission of resident interviews.
Failure to Properly Void and Maintain MOLST Forms in Medical Records
Penalty
Summary
Facility staff failed to ensure that all prior Maryland Orders for Life Sustaining Treatment (MOLST) forms in a resident's medical record were properly voided according to MOLST instructions. Review of the electronic medical record (EMR) for one resident revealed the presence of both voided and un-voided copies of multiple MOLST forms for the same dates, in addition to the most recent MOLST form. According to MOLST protocol, when a change is made to any order, the previous form must be voided by drawing a diagonal line through the sheet, writing VOID in large letters, and signing and dating below the line. While the paper record contained voided originals for all but the most recent MOLST, the EMR retained both voided and un-voided versions, which is not in accordance with accepted professional standards for maintaining medical records. The deficiency was identified during a review of the resident's EMR and confirmed through interviews with the facility Administrator and Corporate Nurse. The Administrator acknowledged that the EMR contained both voided and active copies of each MOLST form, despite the paper record being properly maintained. This failure to properly void and manage MOLST forms in the EMR resulted in noncompliance with requirements to safeguard resident-identifiable information and maintain accurate medical records.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, which had the potential to affect all 158 residents consuming food from the facility. Observations revealed that food items in the walk-in freezer, refrigerator, and dry storage were not labeled, dated, or sealed properly. Specifically, bags of chicken, sausage, and a metal container in the freezer lacked labeling and dating, while some items were expired. Similarly, the refrigerator contained expired items such as salami, boiled eggs, tuna, fortified pudding, feta cheese, and cut potatoes. Additionally, the dry storage room had a bag of dried cranberries that was not labeled, dated, or sealed. The facility also failed to adhere to proper dishwashing and personal hygiene protocols. Newly washed dishes were not allowed to air dry, as evidenced by wet metal pans and a wet Robot Coupe container. Furthermore, staff members, including the Dietary Manager and Dietary Aides, were observed not wearing appropriate hair coverings, which is against the facility's policy and FDA Food Code guidelines. The General Manager and Administrator acknowledged the need for compliance with food safety regulations and continuous training for kitchen staff.
Expired Insulin Pens Not Discarded
Penalty
Summary
The facility failed to ensure that expired insulin pens were discarded from five medication carts, which included the respiratory care unit (RCU) cart two, second-floor long-term care (LTC) medication carts one and two, third-floor LTC medication cart one, and memory care medication cart one. During observations, it was found that several insulin pens had exceeded their expiration dates but were still in use. For instance, on the RCU cart two, a Lantus insulin pen for a resident had an orange label indicating it should not be used after a certain date, and an Aspart insulin pen had an open date label, both of which were past the 28-day discard period. Similarly, on the second-floor LTC cart two, a Humalog insulin pen was found with an open date that exceeded the 28-day usage period. Further observations revealed additional expired insulin pens on other carts. On the second-floor LTC cart one, a Novolog insulin pen was found with an open date that had surpassed the 28-day discard period. On the third-floor LTC cart one, a Humalog insulin pen had an open date that was past the expiration, and another Humalog pen lacked an open date entirely. Additionally, an Aspart insulin pen on the same cart was also past its discard date. In the memory care medication cart one, a Novolog insulin pen had an unreadable open date, leading to its continued use beyond the recommended period. The Director of Nursing confirmed that the expectation was for insulin pens to be checked for correct open dates and discarded if expired, which was not adhered to in these instances.
Infection Control Deficiencies in Blood Glucose Testing and Wound Care
Penalty
Summary
The facility failed to implement and maintain proper infection control measures during blood glucose testing for four residents. Observations revealed that LPNs did not perform hand hygiene before or after the procedure, and glucometers were not placed on barriers as required by the facility's policy. In one instance, an LPN placed a dirty glucometer on top of clean supplies, and in another, the glucometer was cleaned without wearing gloves. These actions were contrary to the facility's policy, which mandates hand hygiene and the use of barriers to prevent contamination. Additionally, the facility did not ensure wound care was performed in a manner to prevent infection for a resident with a stage IV pressure ulcer. During a wound care observation, the Treatment Nurse did not change gloves or perform hand hygiene when transitioning from cleaning the wound to applying treatment. The nurse used the same gauze to clean both inside and around the wound, which is against proper wound care protocol. The nurse acknowledged the mistake, attributing it to nervousness. Interviews with the Director of Nursing, the Administrator, and the Infection Preventionist highlighted expectations for staff to follow infection control policies, including proper hand hygiene and equipment handling. However, the observed practices during blood glucose testing and wound care did not align with these expectations, placing residents at risk for infections.
Failure to Conduct Required Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure a Level II PASARR was obtained for a resident with serious mental illness, as required by Medicaid regulations. The resident, who was readmitted to the facility with diagnoses including PTSD, bipolar disorder, and anxiety, had a Level I PASARR completed during a psychiatric hospital stay in 2022. This Level I PASARR indicated that a Level II evaluation was necessary, as the resident met two of the three criteria for serious mental illness. However, the facility did not conduct the required Level II PASARR evaluation. During an interview, the social worker confirmed that the Level I PASARR from 2022 indicated the need for a Level II evaluation, which was not completed. The social worker mentioned that counseling was deemed unhelpful due to the resident's low BIMS score and that the VA did not provide further counseling upon the resident's readmission. This oversight placed the resident at risk of not receiving specialized services for their mental health conditions.
Failure to Document Condom Catheter in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was using a condom catheter. The resident, who was admitted with chronic kidney failure, malignant neoplasm of the pancreas, chronic respiratory failure with ventilator dependence, tracheostomy, and gastrostomy, was moderately cognitively impaired with a BIMS score of eight out of 15. Despite a physician's order dated 11/13/24 to maintain a 35mm condom catheter, the care plan did not document this aspect of the resident's care. During an interview, the Director of Nursing and Unit Manager confirmed that the condom catheter was not included in the care plan and acknowledged that it should have been added following the physician's order. The facility's policy mandates the development of a comprehensive, person-centered care plan that includes measurable objectives and timeframes to address the resident's needs as identified in their comprehensive assessment. The omission of the condom catheter from the care plan increased the risk of incomplete or inconsistent care for the resident.
Failure to Update Comprehensive Care Plan for Wound Management
Penalty
Summary
The facility failed to review and revise a comprehensive care plan for a resident, identified as R155, to reflect the resolution and development of pressure ulcers and non-pressure wounds. R155 was admitted with multiple diagnoses, including malignant neoplasm of the pancreas, chronic respiratory failure, and several pressure and non-pressure ulcers. The resident's Minimum Data Set (MDS) indicated a moderate cognitive impairment and a risk for developing pressure ulcers. Despite changes in the resident's wound status, such as the healing of certain wounds and the emergence of new ones, the care plan was not updated to reflect these changes. The care plan, dated 11/26/24, only included the wounds present at admission and did not document the healing of the right 4th toe, sacrum, and left and right plantar foot wounds, nor the addition of new pressure wounds to the right heel and right buttock. During an interview, the Unit Manager admitted to not updating the care plan when wounds healed or new ones were found. The Director of Nursing confirmed that the care plan should represent the care the resident was receiving, which it did not. The facility's policy stated that the comprehensive care plan should be reviewed and revised as necessary when a resident experiences a status change, which was not adhered to in this case.
Insulin Pen Misuse During Medication Administration
Penalty
Summary
The facility failed to adhere to its policy regarding the use of insulin pens, which states that each pen must be used only for a single resident and never shared. During a medication administration observation, an LPN was seen using a Novolog Insulin Pen on one resident and then preparing to use the same pen on another resident. The surveyor intervened before the second administration occurred, prompting the LPN to acknowledge the mistake and express that they should have obtained a new pen for the second resident. Interviews with the Unit Manager and the Director of Nursing confirmed that the facility's policy requires each resident to have their own individual insulin pen. The incident involved two residents, one of whom was almost administered insulin with a pen previously used on another resident, posing a risk of bloodborne pathogen transmission. The Director of Nursing confirmed the policy and acknowledged the error when informed of the incident.
Failure to Provide Education on Immunization Risks and Benefits
Penalty
Summary
The facility failed to ensure that education on the benefits and risks of immunizations for pneumonia and influenza was provided after refusals for vaccinations for three residents. The facility's policy required that education be documented in the clinical record prior to offering pneumococcal and influenza immunizations. However, for Resident 36, the responsible party refused the pneumococcal vaccine, and no documented education was provided. For Resident 20, a voicemail was left for the responsible party to obtain consent for the influenza and pneumococcal vaccines, but no follow-up was conducted, and no education was documented. Resident 80's responsible party agreed to the vaccine, but the resident refused, and no education documentation was provided, nor was there an attempt to contact the responsible party for assistance. During interviews, the Infection Preventionist expressed concern about not always being informed of vaccine refusals and acknowledged the need to review the immunization process. The Administrator stated that the expectation was for the Infection Preventionist to review vaccines and refusals and provide education on the risks and benefits, with documentation in the resident's records. The lack of documented education placed the residents at risk for pneumonia and influenza.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Frederick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Frederick Crossing Of Journey | 1.5 mi | — | 36 | 0 |
| Northampton Manor Nursing And Rehabilitation Cente | 1.8 mi | — | 1 | 0 |
| Homewood Living Frederick | 3 mi | — | 0 | 0 |
| Autumn Lake Healthcare At Braddock Heights | 4.6 mi | — | 3 | 0 |
| Autumn Lake Healthcare At Glade Valley | 5.2 mi | — | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.