Frederick Crossing of Journey

Inspectors wroteBased on administrative record review and staff interviews, it was determined that the facility staff failed to immediately report an injury of unknown origin to the facility administration and failed to report the injury of unknown origin to the state agency immediately but not later than 2 hours after becoming aware of the injury. This was evident for 1 (#1) of 1 residents reviewed for a facility reported incident.

Inspectors wroteBased on record review and staff interviews it was determined the facility staff failed to promptly conduct a thorough assessment of a resident after an injury of unknown origin. This was evident for 1 (#1) of 1 resident reviewed for abuse.

Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff provided substandard quality of care for a resident following an unwitnessed fall. This was evident for 1 of 2 observations of residents.

Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff failed to ensure that residents were free of accidents and hazards. This was evident for 1 (#2) of 2 residents reviewed for falls.

Inspectors wroteBased on observation, record review, and interview it was determined that the facility failed to ensure that residents were treated with respect and dignity. This was evident for one resident (Resident #81), and three residents (Resident #68, #48, #110) of 4 residents reviewed for dignity during the recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure information to formulate an advanced directive was provided to a resident. This was evident for 1 (Resident #39) of 1 resident reviewed for advanced directives.

Inspectors wroteBased on record review and interview it was determined that the facility failed to notify residents of their potential financial liability when they were discharged from skilled care. This was evident for one resident (Resident #119) of 3 residents reviewed for beneficiary notification during the recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to complete Significant Change in Status Minimum Data Set (MDS) assessments within 14 days following a significant decline in the Residents' condition. This was evident in 2 (Resident #94 and #4) of 47 residents reviewed during the recertification survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was accurately recorded. This was evident in 1 (Resident #81) of 3 residents reviewed for PASSR.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to develop and implement comprehensive, resident-centered care plans. This was evident in 1 (Resident #42) of 3 residents reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to conduct care plan meetings after the completion of the comprehensive assessments. This was evident for 2 (Resident #5, #41) of 2 residents reviewed for care planning.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers. This was evident in one (Resident #110) of three Residents reviewed for ADL.

Inspectors wroteBased on observations, staff interviews, and record reviews, it was determined that the facility failed to provide activities programs to meet residents' needs and preferences. This was evident for one (Resident#75) of one Resident reviewed for Activities.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure appropriate pressure relieving device settings. This was evident for 3 (Resident #57,#93, and #118) of 3 residents observed with pressure injuries during the annual recertification survey. On 2/17/26 at 9:09 AM, the surveyor observed that Resident #93 had a pressure-relieving mattress on their bed. Resident#93 had a pressure injury and also had an order from the provider for the mattress with parameters for the settings to be within 10 pounds of the resident's current weight. The record revealed Resident #93's last documented weight on 02/03/2026 was 154 pounds. The pressure relieving mattress setting was inflated to 260 pounds. On 2/17/26 at 9:22 AM, the surveyor observed that Resident #57 had a pressure-relieving mattress on their bed. [...]

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure residents with oxygen therapy received oxygen as prescribed. This was evident for 1 (Resident #41) of 3 resident reviewed for respiratory care.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to residents according to professional standards of practice. This was evident for 2 (Resident #9, #41) of 4 residents reviewed for pain management.

Inspectors wroteBased on observation, record reviews, and interviews, it was determined that the facility failed to implement appropriate interventions for a resident with an altered mental status and identified behaviors. This was evident in 1(Resident #42) of 2 residents reviewed for behaviors.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure safe and secure drug storage of resident medications. This was observed for 1 (North Hall) of 3 resident medication carts observed during the annual recertification survey.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to conduct a comprehensive assessment of a resident's dietary dislikes and food preferences. This was evident in 1 (Resident #110) of 3 residents reviewed for food.

Inspectors wroteBased on record review and interview, it was determined that an incompetent resident was documented as having consented to the arbitration process. This was evident for one resident (Resident #10) of 3 residents reviewed for arbitration agreements.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure all staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions. This was evident for 1 (Resident #111) of 5 residents reviewed for pressure ulcers.

Inspectors wroteBased on record review and interview with staff it was determined the facility staff failed to ensure resident medical records were complete and accurately documented. This was evident for 1 (Resident #1) of 2 residents reviewed during the complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to treat residents with dignity and respect by failing to respond to call lights in a timely manner. This was evident for 3 (#2, #4, and #5) of 3 residents reviewed for call light response times.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that an allegation of abuse was reported within the required timeframe. This was evident for 1 (#1) of 1 allegation of abuse.

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to protect their residents from an employee accused of abuse and to conduct a thorough investigation of an allegation of abuse. This was evident for 1 (#1) of 1 resident reviewed for abuse.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure controlled drug counts were maintained and signed by 2 staff members at change of shift. This was found to be evident for 2 out of 4 drug control books reviewed.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide a sanitary environment to prevent the development and transmission of communicable diseases and infections by failing to ensure residents drinkware was clean. This was evident for 4 coffee mugs out of 6 coffee mugs observed during a survey. On 2/25/25 at 9:51 AM an observation of the coffee serving cart revealed a tray of 6 brown coffee mugs face down on a tray. Further observation revealed 4 out of the 6 mugs contained a chalky- grayish brown material inside the cups. This material was easily removed with gentle rubbing On 2/25/25 at 9:45 AM during a brief interview with the kitchen cook Staff # 3, she reported that the cups on the tray were clean and available for use. [...]

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that residents were free of abuse. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 12/13/23. This was evident for 1 resident (Resident #296) of 6 residents reviewed for abuse during the recertification survey.

Inspectors wroteBased on surveyor observation and staff interview, it was determined that the facility staff failed to properly store food items in the kitchen's walk-in refrigerator, and failed to properly label, and date food items stored in the main kitchen. This was evident during the initial tour of the kitchen and had the potential to affect all residents.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections by failing to ensure residents drinkware was clean. This was evident on 2 of 2 observations of drinkware designated for resident use.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to obtain a resident's representative's signature or document refusal to sign the Notice of Medicare Non-Coverage (NOMNC) for a resident who was discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 1 (#88) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure staff reported areas in resident's rooms in need of repair to maintenance. This was found to be evident on one of the three units.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to provide written notification of transfer to Residents and/or Resident representatives upon transfer to the hospital. This was evident for 1) one Resident (#59) of two residents reviewed for hospitalization and 2) one complaint (#MD001973041) of nine complaints reviewed during the recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to notify residents and/or their representatives in writing of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 1) one Resident (#59) of 2 Residents reviewed for hospitalizations and 2) one complaint (#MD001973041) of 9 complaints reviewed during the recertification survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to develop and implement a comprehensive, resident centered care plan for a resident receiving psychotropic medications. This was evident for 1 (#58) of 5 residents reviewed for unnecessary medications:

Inspectors wroteBased on interviews and medical record review, it was determined that the facility failed to ensure participation in the care plan process by a resident's representative. This was evident for 1 (#89) of 2 residents reviewed for care planning.

Inspectors wroteBased on observation, review of facility policy, and interview, it was determined that the facility staff failed to follow standards of professional practice when administering medications to residents. This was evident for 1 opportunity out of 26 opportunities observed for medication administration.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure discharge plans were appropriate for the resident's needs. This was found to be evident for one (Resident #72) out of three residents reviewed for discharge.

Inspectors wroteBased on record review, observations and interviews, it was determined the facility failed to implement physician ordered pressure injury prevention therapies. This was evident for 1 (Resident #77), out of 2 residents reviewed for pressure injuries during a survey.

Inspectors wroteBased on surveyor observation, review of clinical records and interview of facility staff, it was determined that the facility staff failed to provide treatment to maintain an individual's range of motion. This was evident for 1 (Resident #80) out of 2 residents selected for position and mobility, during a survey.

Inspectors wroteBased on observation, medical record review and interviews, it was determined that the facility failed to 1) ensure that as needed pain medication orders included pain scale parameters for administration and 2) document pain assessment to include the location of the pain and type of pain for a Resident reporting pain. This was evident for 2 (#25, #89) of 2 residents reviewed for pain management.

Inspectors wroteBased on review of pertinent documentation and interview it was determined that the facility failed to ensure two staff members completed the controlled drug count at the change of each shift. This was found to be evident for one out of three drug control books reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to document the specific reason for administering a psychotropic medication prescribed as needed (PRN) and failed to implement non-pharmacological intervention before administering the medicine. This was evident for 1 complaint (#MD00192471) of 9 complaints reviewed during the recertification survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure medications and needles were secured as evidenced by observations of unlocked emergency carts in residents' hallways. This was evident for 2 emergency carts out of 2 emergency carts observed during a survey.

Inspectors wroteBased on observation and medical record review it was determined that the facility failed to ensure that the staff only documented interventions that were completed. This was evident for 1 (Resident # 80) out of 35 Resident reviewed during a survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed: to ensure proper decision making and accuracy of MOLST(Maryland Orders for Life Sustaining Treatment); to review Advanced Directives with residents and/or the appropriate decision maker; and manage discontinued MOLST's in the proper way. This was evident for 4 (Residents #68, 97, 76, and 84) out of 10 residents reviewed for advanced directives.

Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed to have a process to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair. This was observed on 2 of 4 nursing units and in 3 of 26 rooms observed during the initial pool process.

Inspectors wroteBased on the record reviews and interviews, the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer, nd failed to provide the resident, the resident representative, or the receiving facility, with a written copy of the bed hold policy. This was evident for 1 resident, #82, of 4 residents reviewed during closed record review of residents with hospitalizations and for for 3 (#109, #110, #111) of 13 residents reviewed for abuse.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility and failed to provide the resident, the resident representative, or the receiving facility, with a written copy of the bed hold policy. This was evident for 3 (#109, #110, #111) of 13 residents reviewed for abuse and 1 (#82) of 4 residents reviewed during closed record review of residents with hospitalizations.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded to make certain that residents' individual needs were identified. This was evident for 1 (Resident # 73) out of 3 residents reviewed for MDS Assessments.

Inspectors wroteBased on record review the facility failed to complete a thorough comprehensive care plan to address all pertinent care and treatment of residents. This was evident in 1 (Resident #68) out of 3 Resident's reviewed for position and mobility.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to assure that the care plan was revised to address a newly identified condition. This was evident for 1 (Resident #84) out of 4 residents reviewed for skin conditions that were non pressure related.

Inspectors wroteBased on observations, record review, and interview it was determined that the facility failed to provide activities based on resident preferences and the resident's care plan. This was evident for1 (Resident #5) out of 7 residents reviewed for activities.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to address significant weight loss at the time it was first documented. This was evident for 1 (Residents #84) out of 11 residents reviewed for nutrition.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that a physician supervised the care of a resident as evidenced by the physician failure to evaluate that a resident had a Stage 3 pressure ulcer upon admission to the facility and give orders for treatment. This was evident for 1 (#117) of 7 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, and interview and record review, it was determined that the facility failed to provide reasonable accommodation for a resident to have access to the sink in the resident's bathroom. This was evident for 1 resident (resident #1) out of 1 Resident reviewed for reasonable accommodations during an annual survey.

Inspectors wrote2) On 4/17/23 at 10:54 AM, Resident #84's medical record was reviewed. The review revealed that the resident experienced a 9.4 lbs weight loss, going from 174.8 lbs on 11/26/22 to 165.4 lbs on 12/6/22 (a 5.3% weight loss within 1 month). No change in condition assessment was found following the 12/6/22 weight loss, nor was there any nursing note indicating that the resident's attending physician or responsible party were notified of the weight loss. On 4/27/23 at 10:47 AM, an interview was conducted with Unit Manager (UM) #23. During the interview, UM #23 stated that significant weight loss was considered a significant change and should be reported to the resident's attending physician and responsible party. When asked what constituted significant weight change, she stated it was 5-7 lbs. On 4/27/23 at 2:42 PM, Licensed Practical Nurse (LPN) #25 was interviewed. [...]

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident / resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer and failed to provide the resident, the resident representative, or the receiving facility, with a written copy of the bed hold policy. This was evident for 3 (#109, #110, #111) of 13 residents reviewed for abuse and 1 (#82) of 4 residents reviewed during closed record review of residents with hospitalizations.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to prepare residents for transfer to the hospital. This was evident for 1 (Resident #5) out of 9 residents reviewed for hospitalization.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to include the recommendations from PASARR into a resident's assessment and care planning. This was evident for 1 (# 73) out of 3 residents reviewed for PASSAR.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide residents and or resident's responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications and failed to initiate a baseline care plan within 48 hours of a newly admitted resident's admission. This was evident for 1 (#113) of 13 residents reviewed for abuse .

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that facility staff failed to follow professional standards of practice by striking-out resident weights without a valid rationale. This was evident for 2 (Residents #84 and #76) of 11 residents reviewed for nutrition.

Inspectors wroteBased on record review, and interview, it was determined that the facility failed to provide quality of care related to weight loss of residents and failed to manage a resident's pressure wound showing signs of infection. This was evident for 1 (#81) of 11 residents reviewed for nutrition concerns and 1 (Resident #5) of 6 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility failed to ensure that a residents missing prescription glasses were reported missing and failed to timely follow-up to make sure the glasses were replaced. This was evident for 1 resident (Resident #98 ) out of 2 residents reviewed for communication and sensory during the annual survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined the facility staff failed to have consistent nursing documentation of when a resident actually developed a pressure ulcer, failed to have appropriate treatment in place to prevent and treat a stage 3 pressure ulcer and failed to deliver the necessary treatment and services to residents with identified pressure ulcers. This was evident for 2 (#117, #73) of 6 residents reviewed for pressure ulcers.

Inspectors wroteBased on medical record review, observation and interview, it was determined that the facility failed to provide ordered treatment to a Resident for contracture management. This is evident for 1 (Resident #68) out of 3 Residents reviewed for limited range of motion.

Inspectors wroteBased on observation, review of resident medical records, and interview with facility staff, it was determined that the facility failed to assess residents for the safe use of bedrails prior to placing them on resident beds. This was evident for 3 (Residents #5, #43, and #84) of 49 residents reviewed during the annual survey.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that nurse practitioner notes were written and entered into a resident's medical record at the time of the nurse practitioner's visit. This was evident for 1 (Resident #84) of 49 residents reviewed during the survey.

Inspectors wroteBased on review of employee files and interview with facility staff, it was determined that the facility failed to ensure that all staff working as geriatric nursing aides (GNAs) were certified and competent to work in that position. This was evident for 1 (Staff #26) of 3 staff reviewed for working as GNAs.

Inspectors wroteBased on review of employee files and interview with facility staff, it was determined that the facility failed to verify that employees hired as geriatric nursing assistants (GNAs) were registered with Maryland or a compact state as having met competency evaluation requirements. This was evident for 1 (Staff #26) of 3 staff reviewed for working as GNAs.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to complete a thorough annual performance review and provide regular in-service training based off of the annual performance review for geriatric nursing assistants (GNAs). This was evident for 1 (staff # 51) out of 1 geriatric nursing assistant reviewed for annual performance and training reviews.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to provide medically related social services due to the absence of licensed, masters prepared social workers. This was evident for 1 (#88) out of 2 residents reviewed for behavioral/emotional issues and dialysis treatment

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to assess a resident for food preferences. This was evident in 1 (Resident #84) out of 11 residents reviewed for nutrition.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to a) properly store prepared food stored in the refrigerator and in dry storage, b) have a process to maintain nourishment refrigerators at proper temperatures and, c) maintain the cleanliness of kitchen equipment. This was evident during a tour of the kitchen and nourishment rooms on 1 of 3 nursing units.

Inspectors wroteBased on record review and interview it was determined that the facility's administration had failed to use their resources to ensure that their residents had optimal supervision of care and services. This was evident during the survey and had the potential to affect all residents.

Inspectors wroteBased on interview and record review, it was determined that the facility employed staff in positions that were outside their scope of practice in accordance with state laws and failed to have an effective process in place to ensure that individuals hired to licensed positions had the appropriate license at time of hire and maintained that license as active while employed. This was evident for 5 of 5 staff reviewed for job duties and 2 (Staff #26 and #25) of 5 staff reviewed for working in a licensed position.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (#110) of 13 residents reviewed for abuse and for 2 (Residents #84 and #76) of 49 residents reviewed during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan to monitor the quality and safety of the care provided to their residents. This was evident for 1 of 1 plan reviewed and has the potential to affect all the residents residing in the facility.

Inspectors wroteBased on record review and staff interview, it was determined that the facility staff failed to develop and implement polices and procedures for a QAPI (Quality Assurance and Performance Improvement) program to ensure that residents received quality care that was safe and effective. This was evident throughout the survey and has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to develop and implement polices and procedures to ensure infection control prevention measures were used by staff while 1) emptying a urinary catheter bag and 2) while folding and storing clean linens in the laundry area and storage of boxes and totes. This evident for 1 of 1 observation of staff emptying a urinary catheter collection bag and 1 of 1 laundry rooms observed.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined that the facility failed to develop and implement policies and procedures to 1) maintain a record that residents were evaluated for contraindications in regards to the COVID-19 vaccination 2) failed to ensure that resident representatives were educated and that the education was documented in the resident's medical record 2) failed to ensure that staff were offered the vaccination and educated regarding the vaccine and failed to maintain records that education was provided. This was evident for 2 (#1 and #91) of 5 residents and 10 (#34, #35, #45, #22, #48, #47, #36, #46, #39, and #49) of 10 staff reviewed for COVID 19 vaccinations.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to develop and implement policies and procedures to ensure that 100% of staff were fully vaccinated, had an approved exemption, or had a temporary delay to receive the vaccination and/or was not eligible for the required second dose of COVID 19. This was evidenced by a 97.6% vaccination rate with 3 (#34, #35, and #22) of 85 direct hire staff and 1 (#36) of 4 contracted staff.

Inspectors wroteBased on review of employee training files and interview with facility staff, it was determined that the facility failed to ensure that Nurse Aides received 12 hours of training annually that addressed their areas of weakness as determined by nurse aide performance reviews. This was evident for 1 of 1 Geriatric Nursing Aide (GNA#51) reviewed for annual training.