C-
57/100NORTHAMPTON MANOR NURSING AND REHABILITATION CENTE Inspection Report, Violations & Safety Grade (FREDERICK, Maryland)
200 EAST 16TH STREET, FREDERICK, Maryland 21701
Phone: 3016628700
CMS Overall:1/5
Overview & Bed Count
Certified Beds
196
Avg Residents/Day
105.9
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Frederick
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing4/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Maryland Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.48 | 0.88 | -0.40 |
| Total Nurse Hours per Resident per Day | 3.47 | 3.93 | -0.46 |
| CMS Staffing Rating | 4/5 | 3.2/5 | - |
| Nursing Staff Turnover | 31.1% | 40.2% | - |
Health Citation History
67 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-30 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-01-30 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D – Moderate Harm Potential |
| 2026-01-30 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2026-01-30 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2026-01-30 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2026-01-30 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2026-01-30 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-01-30 | Nursing and Physician Services Deficiencies | Observe each nurse aide's job performance and give regular training. | D – Moderate Harm Potential |
| 2026-01-30 | Quality of Life and Care Deficiencies | Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D – Moderate Harm Potential |
| 2026-01-30 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2026-01-30 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2026-01-30 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-01-30 | Administration Deficiencies | Have a plan that describes the process for conducting QAPI and QAA activities. | D – Moderate Harm Potential |
| 2026-01-30 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2026-01-30 | Administration Deficiencies | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | D – Moderate Harm Potential |
| 2024-08-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | F – Moderate Harm Potential |
| 2024-08-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | F – Moderate Harm Potential |
| 2024-08-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | F – Moderate Harm Potential |
| 2024-08-29 | Nursing and Physician Services Deficiencies | Observe each nurse aide's job performance and give regular training. | F – Moderate Harm Potential |
| 2024-08-29 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | F – Moderate Harm Potential |
| 2024-08-29 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | F – Moderate Harm Potential |
| 2024-08-29 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2024-08-29 | Infection Control Deficiencies | 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. | F – Moderate Harm Potential |
| 2024-08-29 | Administration Deficiencies | Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | F – Moderate Harm Potential |
| 2024-08-29 | Resident Rights Deficiencies | Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | F – Moderate Harm Potential |
| 2024-08-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | F – Moderate Harm Potential |
| 2024-08-29 | Administration Deficiencies | Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | F – Moderate Harm Potential |
| 2024-08-29 | Administration Deficiencies | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | F – Moderate Harm Potential |
| 2024-08-29 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | E – Moderate Harm Potential |
| 2024-08-29 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | E – Moderate Harm Potential |
| 2024-08-29 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E – Moderate Harm Potential |
| 2024-08-29 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | E – Moderate Harm Potential |
| 2024-08-29 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-08-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2024-08-29 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-08-29 | Quality of Life and Care Deficiencies | Provide activities to meet all resident's needs. | D – Moderate Harm Potential |
| 2024-08-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-08-29 | Quality of Life and Care Deficiencies | Assist a resident in gaining access to vision and hearing services. | D – Moderate Harm Potential |
| 2024-08-29 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-08-29 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-08-29 | Nursing and Physician Services Deficiencies | Ensure that the resident and his/her doctor meet face-to-face at all required visits. | D – Moderate Harm Potential |
| 2024-08-29 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-08-29 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-08-29 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D – Moderate Harm Potential |
| 2024-08-29 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2024-08-29 | Environmental Deficiencies | Keep all essential equipment working safely. | D – Moderate Harm Potential |
| 2024-08-29 | Administration Deficiencies | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | D – Moderate Harm Potential |
| 2024-08-29 | Infection Control Deficiencies | Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | D – Moderate Harm Potential |
| 2024-08-29 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2019-10-04 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
Showing 50 of 67 citations.
Fire Safety Citation History
18 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-30 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2026-01-30 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2026-01-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2026-01-30 | Construction Deficiencies | Meet other general requirements. | E – Moderate Harm Potential |
| 2026-01-30 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2026-01-30 | Egress Deficiencies | Install proper backup exit lighting. | E – Moderate Harm Potential |
| 2026-01-30 | Smoke Deficiencies | Construct fire resistant interior walls. | E – Moderate Harm Potential |
| 2026-01-30 | Smoke Deficiencies | Have proper openings in smoke barrier doors. | E – Moderate Harm Potential |
| 2026-01-30 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | E – Moderate Harm Potential |
| 2026-01-30 | Miscellaneous Deficiencies | Have restrictions on the use of highly flammable decorations. | E – Moderate Harm Potential |
| 2026-01-30 | Miscellaneous Deficiencies | Have restrictions on the use of portable space heaters. | E – Moderate Harm Potential |
| 2024-08-29 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2024-08-29 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | F – Moderate Harm Potential |
| 2024-08-29 | Smoke Deficiencies | Properly provide smoke detection systems in areas open to corridors. | F – Moderate Harm Potential |
| 2024-08-29 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | F – Moderate Harm Potential |
| 2024-08-29 | Gas, Vacuum, and Electrical Systems Deficiencies | Have a battery powered remote alarm panel in a location accessible by operating personnel. | F – Moderate Harm Potential |
| 2024-08-29 | Smoke Deficiencies | Install an approved automatic sprinkler system. | D – Moderate Harm Potential |
| 2024-08-29 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | D – Moderate Harm Potential |
Total Penalties & Fines
$16,562
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-08-29 | Fine | $16,562 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the FREDERICK area at no cost.
Find Safe, Vetted Facilities Near FREDERICK
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.