Calvert County Nursing Ctr.

Based on observations and interviews it was determined that the facility failed to ensure food was prepared and served on sanitary pans, dishes and utensils. This was found to be evident for 1 out of 1 commercial dishwasher observed during the recertification and complaint survey. The deficient practice has the potential to affect all residents who consume liquids and food. The findings include: 3-bay Compartment Sinks maintains proper sanitization. Each sink bowl (bay) serves a different role, one for rinsing, washing, and sanitizing. During an observation conducted on 03/22/26 at 8:49 AM, the Surveyor observed Dietary Aide #13 rinsing silver metal pans in the 3-bay compartment sink. The Surveyor observed one bay with water, the bay for washing and sanitizing was empty. The Surveyor asked why the other 2 bays weren't filled, the Dietary Aide replied that he was rinsing the pans before placing them in the dishwasher so there was no need to fill the other 2 bays. Center of Medicaid and Medicare Services (CMS) requirements for hot water dishwashers in facilities like nursing homes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee consisted of the minimum required members. This deficient practice had the potential to affect all residents. This was identified during the QAPI/QAA facility task during the annual/complaint survey.The findings include:On 03/26/2026 at 10:11 AM, the Administrator provided the QAPI (Quality Assurance and Performance Improvement) binder for review. The Administrator reported that there were impacts to QAPI meetings due to unfilled clinical staff positions. On 03/26/2026 at approximately 11:00 AM, this surveyor conducted a record review of the QAPI binder, including QAA committee meeting attendance and signatures. Record review revealed that for the QAPI meeting dated 10/23/2025, there was no documented attendance or signature for the Administrator or Infection Preventionist. For the meeting dated 11/17/2025, there was no documented attendance or signature for the Infection Preventionist. For the meeting dated 12/19/2025, there was no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, it was determined that the facility failed to provide a safe and sanitary environment. This was found to be evident for 2 (Resident #2 & #130) out of 20 Residents observed for Infection Control during the recertification and complaint survey. The findings include: 1) A Foley catheter bag collects urine from a flexible tube (catheter) inserted into the bladder, typically holding 600–900 mL (leg bags) or up to 2000 mL (bedside bags). Always keep the bag below waist level to use gravity for draining and prevent infection. Empty the bag every 3-4 hours or when it is 1/2 to 2/3 full. During an interview conducted on 03/22/2026 at 8:42 AM, the Surveyor observed Resident #2's bed in the lowest position with the foley catheter bag attached to the right side of the bed and lying on the floor. On 03/22/26 at 9:17 AM the Surveyor reported the observation to the assigned License Practical Nurse (LPN) #3. The Surveyor observed the LPN raise the resident's bed from the lowest position to a position that allowed the foley bag to no longer touch the floor.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews it was determined that the facility failed to maintain an antibiotic stewardship program. This was found to be evident for 5 out of 5 Antibiotic stewardship line listings during the recertification and complaint survey. This deficient practice has the potential to affect all residents.The findings include:Antibiotic Stewardship Program (ASP) requires a facility to develop and implement policies, procedures and/or protocols to optimize the selection, dosage, route and duration of antibiotic therapy. This is to improve Resident outcomes, reduce the risk of residents having adverse reactions to antibiotics, receiving them unnecessarily and/or developing antibiotic-resistant organisms.An Infection Preventionist (IP) is responsible for the facility's Infection Prevention and Control Program. This position requires specialized training in infection control.Based on a review of a certificate of completion from the Centers for Disease Control and Prevention on 3/24/2026 at 1:27 PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews of the facility records, it was determined that the facility failed to designate an Infection Preventionist at least part time to be responsible for managing its Infection Prevention and Control Program. This was evident during the recertification survey. This deficient practice has the potential to impact all residents in the building. The findings include:An Infection Preventionist (IP) is responsible for the facility's Infection Prevention and Control Program. This position requires specialized training in infection control.Based on a review of a certificate from the Centers for Disease Control and Prevention on 3/24/2026 at 1:27 PM it reported the Unit Manager for the Western [NAME] Unit had completed the Nursing Home Infection Preventionist Training Course on 3/06/2026.During an interview with the Unit Manager of the Western [NAME] Unit on 3/25/2026 at 12:33 PM she reported she was the full time Unit Manager of the Western [NAME] Unit and was assigned the role of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews it was determined that the facility failed to maintain a safe, functional and sanitary environment. This was evident in the Laundry Washer Room and the Laundry Folding Room during the recertification survey. This practice has the potential to affect all Residents.The findings include:1. During an observation of the Laundry Washer Room on 3/23/2026 at 1:56 PM a leak was discovered dripping from a pipe in the ceiling and running down the wall in the corner near the dryer room. Additional observation revealed a large area of black staining along the wall and on top of the Ecolab dispensing system box where the water was leaking. Further observation showed a red bucket below the pipe that collected the dripping water.During an interview with Laundry Aide #14 on 3/23/2026 at 1:58 PM she reported the leak from the ceiling had been leaking off and on for a couple of months. She advised maintenance was aware and had worked on the leak.During an interview with the Maintenance Director on 3/23/2026 at 2:09 PM he reported he didn't know the Laundry Washer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, the facility failed to provide psychiatric evaluation for a resident (resident #1) who had a history of trauma from physical abuse. This is evident in 1 of 4 residents reviewed during a complaint survey. Findings includes: On 3/18/25 at 2:10pm, surveyor review of resident #1's medical records revealed that the resident reported an allegation of abuse from LPN # 4 on 1/17/25 at approximately 8:30am. Resident #1 reported that LPN #4 threw a cup filled with the resident's medication at the resident. Review of the facility investigation on 3/18/25 at 2:20pm revealed that the facility was unable to substantiate the abuse but recommended that the resident receive psychiatric assessment after the alleged abuse incident. Continued review of resident #1's medical record on 3/18/25 at 2:40pm revealed that the resident received a trauma informed care assessment that revealed that the resident had a history of physical abuse and required psychiatric assessment. Further review of resident #1's medical records on 3/18/25 at 2:50pm found no evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to report an allegation of staff to resident abuse and injuries of an unknown origin for four residents (Resident (R) 342, R295, R296 and R13) reviewed for abuse out of 29 sample residents. This had the potential to affect all the residents in the facility who were at risk of abuse. Findings include: Review of the facility's policy titled Abuse and Neglect-Clinical Protocol revised July 2017 revealed, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown origin shall be promptly reported to local, state, and federal agencies. 1. Review of R295's undated admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including cellulitis, chronic pain, chronic obstructive pulmonary disease, and hypertension. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon observation and interview, the facility failed to ensure the ice machine in the kitchen and on the Southern Shore unit remained clean. This failure has the potential for food-borne illness affecting 97 of 98 residents in the facility. Findings include: During an observation on 01/13/25 at 9:40 AM, the kitchen ice machine, located in the food service area inside the double doors leading to the dining room, clear and brownish colored smears with debris on the top, sides, and front of the ice machine. The interior front portion of the ice machine had an orangish film on the surface. During an observation on 01/13/25 at 10:30 AM, in the Southern Shore unit nourishment room, the ice machine had clear and brownish colored smears with debris. During an interview on 01/14/25 at 8:40 AM, the Assistant Dietary Manager (ADM) verified both ice machines had brown colored smears and debris, and the kitchen ice machine had an orangish film on the surface. During an interview on 01/16/25 at 2:45 PM, the Maintenance Director (MTD) stated the maintenance department cleaned the inside of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility document review, the facility failed to have a functional Antibiotic Stewardship Program that followed the McGeer Criteria for an antibiotic prescribed for one of three residents reviewed for antibiotic usage (Resident (R) 28) out of 29 sampled residents. This failure had the potential to affect residents being prescribed antibiotics that were potentially unnecessary. Findings include: Review of the facility's policy titled, Antibiotic Stewardship dated 09/25/24 stated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program . The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents . When a nurse calls the physician/prescriber to communicate a suspected infection, he or she will have the following information available: a. Signs and symptoms . Review of R28's undated Face Sheet located under the Profile tab in the electronic medical record (EMR)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, facility document review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to provide education for the residents to receive flu and/or pneumococcal vaccines; and failed to obtained a consent/declination for the flu and pneumococcal vaccinations for four of five residents (Resident (R) 11, R13, R66, and R8) out of 29 sample residents. This failure had the potential to put these residents at more risk of developing flu and pneumonia. Findings include: Review of CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed 09/12/24, indicated .CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you .Give one dose of PCV20 [pneumococcal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of three residents (Resident (R) 58) reviewed for abuse out of 29 sample residents. This had the potential to affect all the residents in the facility who were at risk of abuse. Findings include: Review of R57's Face Sheet, located in resident's electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's, major depressive disorder and restlessness and agitation. Review of R57's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/08/24 and located in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated the resident was severely cognitively impaired. Review of R57's Care Plan, dated 10/31/21 and located in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to investigate an injury of an unknown origin for two residents (Resident (R) 342, and R13) reviewed for abuse out of 29 sample residents. This had the potential to affect all the residents in the facility who were at risk of abuse. Findings include: Review of the facility's policy titled Abuse and Neglect-Clinical Protocol revised July 2017 revealed, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown origin shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. 1. Review of R13's undated Face Sheet located under the Profile tab in the EMR revealed R13 was admitted to the facility on [DATE]. Review of R13's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 12/13/24 revealed the facility assessed the resident to have a Brief Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, the facility failed to update residents (#406 & #407) care plan after a change in condition. This was evident for 2 of 30 residents reviewed during a complaint survey. Findings include: 1. On 1/5/23, the State of Maryland's Office of Health Care Quality received a facility reported incident which reported that Resident #406 alleged that a male staff member touched the resident inappropriately. Review of Resident #406's medical record on 1/16/25 at 11:25 AM revealed a written statement by hospice volunteer #12 which reported that Resident #406 told hospice volunteer #12 that a male GNA touched the resident inappropriately. An additional review of the resident's medical record on 1/16/23 at 11:50 AM revealed no evidence that a change in care plan was made after the resident's allegation. On 1/16/25 at 1:30 PM, the survey team reviewed interviews with the Social Work Director and nursing staff regarding the facility's policies on making appropriate changes to a resident's care plan after a change in condition. The review determined that a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) On 1/5/23, the State of Maryland's Office of Health Care Quality received a facility reported incident which reported that Resident #406 alleged that a male staff member touched the resident inappropriately. Review of Resident #406's medical record on 1/16/25 at 11:25 AM revealed a written statement by hospice volunteer #12 which reported that Resident #406 told hospice volunteer #12 that a male GNA touched the resident inappropriately. An additional review of the resident's medical record on 1/16/23 at 11:50 AM revealed no evidence that a trauma informed assessment was performed to ensure the resident's care was appropriate. On 1/16/25 at 1:30 PM, the survey team reviewed interviews with the Social Work Director and nursing staff regarding the facility's policies on trauma informed care. The review determined that trauma informed care assessments are completed when a resident is admitted and at a change of condition to ensure that the resident is receiving appropriate care. On 1/17/25 at 10:00 AM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents' medications were on hand at the facility to be administered per the physician's order for one of 29 sampled residents (Resident (R) 245). This failure placed the resident at risk of not receiving therapeutic pharmacological interventions for ordered medication's indication of use. Findings include: Review of R245's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R245 was admitted to the facility on [DATE] with the diagnosis of complete intestinal obstruction, encounter for surgical aftercare following surgery on the digestive system, and hypertension. Review of R245's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/04/24 revealed the facility that the resident assessed to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact. Review of R245's Physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to monitor targeted behaviors for an anxiety medication and antidepressant for two of five residents reviewed for unnecessary medications (Resident (R) 34 and R8) out of 29 sampled residents. This failure had the potential for residents to receive unnecessary medications. Findings include: 1. Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring dated December 2016 revealed .When medications are prescribed for behavioral symptoms, documentation will include: .Specific target behaviors . Review of R34's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R34 was admitted to the facility on [DATE] with the diagnosis of anxiety disorder. Review of R34's Physician Orders located under the Orders tab in the EMR revealed an order dated 12/20/24 for Buspar (an antianxiety medication) 10 mg (milligrams); give one tablet by mouth three times a day for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and policy review the facility failed to ensure that one of seven medication carts were kept locked, and medications were kept secured during medication pass. Specifically, medication was left on top of the medication cart, and the medication cart was left unlocked and unattended while the nurse went into the resident's bathroom out of site of the medication cart. This has the potential for other residents or visitors to have access to the medications in the cart. Findings include: Review of the facility's policy titled Security of Medication Cart revised 04/07, revealed The nurse must secure the medication cart during the medication pass to prevent unauthorized entry .Medication carts must be securely locked at all times when out of the nurse's view. Review of the facility's policy titled Storage of Medications revised 04/07 revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. During an observation on 01/16/25 at 11:03 AM, Registered Nurse (RN)4 went into Resident (R)38's room to conduct his blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and policy review the facility failed to ensure that resident information was protected specifically related to electronic medical records. This failure had the potential to cause residents' information to not be safeguarded. Findings include: Review of the facility's policy titled Electronic Medical Records dated 03/14, revealed The facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of use or disclosure. During an observation of Registered Nurse (RN)4, on 01/16/25 at 11:03 AM, during a blood sugar check, RN4 left the computer unlocked, and unattended on top of the medication cart, exposing the resident's information, while she was washing her hands in the resident's bathroom. RN4 confirmed she had left the computer open, and stated she should not have left the computer unlocked. During observation conducted during the medication pass task on 01/17/25 at 8:17 AM, with Unit Manager (UM)2, UM2 left the computer on top of the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review the facility failed to ensure that staff donned appropriate Personal Protective Equipment (PPE) for one Resident(R)293) of one resident that was on contact precautions. Additionally, the facility failed to ensure staff protected medications from becoming contaminated. These failed practices could result in increased spread of infections among residents. Findings include: Review of the facility's undated policy titled Isolation-Categories of Transmission-Based Precautions revealed Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .Contact Precautions-1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on complaints, reviews of facility administrative records, and an staff interviews, it was determined that the facility failed to revise and document an accurate up-to-date facility-wide assessment. This was identified during the review of the facility emergency preparedness plan during a complaint survey. This has the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. Review of complaints MD00206987 and MD00206855 on 06/26/24 revealed allegations that the facility has not had any ice cubes available for beverages and that there may be a water borne illness in the facility. A review of the Facility Assessment occurred on 06/26/24. The review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaints, reviews of facility administrative records, and staff interviews, it was determined that the facility failed to maintain an effective infection control program by failure by 1) not informing the residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other. (This was evident for 3 different days in June 2024) and 2) ensure consistent infection prevention monitoring for waterborne infections, which was evident by not taking steps to address low resident hand sink water temperatures. This has the potential to affect all residents within the facility. The findings include: 1) Review of complaints MD00206987 and MD00206855 on 06/26/24 revealed allegations that the facility has not had any ice cubes available for beverages and that there may be a water borne illness in the facility. Review of the facility June…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the review of Resident Council minutes and interviews, it was determined the facility failed to provide residents' with a written response and rationale to the Resident Council to grievances. This practice has the potential to affect all residents. The findings include: On 7/25/19 at 10:26 AM the Resident Council President was interviewed. He/she stated the Resident Council meets once a month and the Recreation Director (RD) helps make the meeting arrangements and records the minutes. When asked, the President stated the RD keeps track of grievances brought up during the meeting and gets back with the council members. On 7/25/19 the review of Resident Council minutes for April, May, and June 2019 were requested the following: On 4/23/19 the Resident Council documented a minimum of 10 grievances. On 5/31/19 the Resident Council documented seven (7) written grievances. On 6/24/19 the Resident Council Documented three (3) grievances. There was no documentation to indicate that the appropriate staff members from each department ( such as nursing or dietary) investigated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to ensure physicians completed the Medical Orders for Life-Sustaining Treatment (MOLST) form with clear non-conflicting orders. This was evident for 1 of 76 residents reviewed for MOLST forms during the survey (Resident #16). According to Maryland's MOLST website (https://marylandmolst.org/), the Maryland MOLST is a portable and enduring form that provides healthcare providers with orders about cardiopulmonary resuscitation and other life-sustaining treatments. The Maryland MOLST form makes your treatment wishes known to health care professionals. The findings include: 1. On [DATE] at 11:03 AM the review of Resident #16's medical record revealed a MOLST, signed and dated on [DATE], by Physician #10. Two options, Attempt CPR and No CPR, were indicated for Resident #16 wishes for cardiopulmonary resuscitation (CPR). On [DATE] at 9:03 AM Physician #10 was interviewed by phone. Physician #10 stated that she had intended to mark…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, it was determined that the facility failed to follow-up on a physician's order to obtain a behavioral service for 1 of 47 residents (Resident #95). The findings include: On 7/25/19 at 2:30 PM the review of Resident #95's medical record revealed a physician's order, dated 5/23/19, for a behavioral health consultation for an anxiety disorder. Further review of the medical record revealed no notes or documentation to show that Resident #95 received the behavioral health consultation as ordered. On 7/27/19 at about 1:30 PM the Director of Nursing (DON) was informed of the physicians order for Resident #95 to have a behavioral health consultation. At 2:30 PM the DON confirmed the behavioral health consultation had not been obtained for Resident #95.

Based on record review and interview with residents and staff, it was determined the facility failed to ensure staff treated 1 of 46 sampled residents with dignity and respect (Resident #11). The findings include: On 7/22/19 at 3:24 PM Resident #11 was interviewed. Resident #11 described an incident that occurred between him/her and Nurse #9 in June 2019. The resident stated Nurse #9 came into the television (TV) room where he/she was watching a program and changed the channel before providing Resident #11 an explanation as to why the channel was changed. The resident stated when he/she told the Nurse #9 to turn the TV back to the program he/she was watching, Nurse #9 said that he was checking a program for another resident. Resident #11 stated he/she was angry because Nurse #9 did not provide an explanation prior to turning the channel and changed it with no regard for the fact that he/she was watching it. On 07/25/2019 a review of the facility's documents about the incident between Nurse #9 and Resident #11 revealed a written statement by Unit Manager #12 (UM #12), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, and interviews, it was determined the facility failed to ensure 1 of 46 residents observed for personal hygiene received the appropriate amount of assistance with activities of daily to accommodate the resident's needs and preferences (Resident #49). Activities of Daily Living (ADL) is a term used to describe a people's ability to complete daily self-care task or the level of assistance required to complete daily self-care task. ADLs self- care task include, but is not limited to: bathing, grooming, dressing, eating, and toileting). The findings include: On 7/24/19 at approximately 11:00 AM Resident #49 was observed dressed in his/her pajamas and sitting in a wheelchair. During an interview with Resident #49 he/she expressed a concern that he/she was still in night clothes and therefore unable to participate in a planned activity. The resident went on to say that the facility's staff knows he/she likes to attend activities, and will not go to activities until he/she is dressed. On 7/26/19 at approximately 11:07 AM Unit Manager (UM) #12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the review of facility incident reports, resident medical records, and interviews with residents and the facility's staff, it was determined that the facility failed to ensure staff reported allegations of sexual abuse between residents to facility administration immediately upon learning of the abuse. This was evident for 1 of 1 resident reviewed for abuse (Resident #26). The findings include: A review of a Facility Reported Incident (FRI) MD00143009 was performed on 7/25/19 at 9:05 AM. During the review, it was found that Resident #109 had reported a concern of possibly unwanted sexual contact between Resident #26 and Resident #37 on 7/12/2019 to recreational staff. However, the report indicates that the Director of Therapeutic Recreation did not make the Administrator aware of the allegation until 7/17/19. The allegation was that Resident #37 put his/her hand under the shirt of Resident #26 and on Resident #26's thigh. Resident #37 was reported to have diagnoses of traumatic brain injury, schizoaffective disorder, and anxiety disorder. Resident #26 was reported to have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the medical record reviews and staff interview, it was determined that the facility staff failed to send a copy of residents' comprehensive care plan to the receiving health care provider for 2 out of 2 residents investigated for hospitalization (Residents #25 and #216's). The findings include: a). On 7/26/19 at approximately 9:30 am, the review of Resident #25's medical record revealed that on 4/4/19 the resident was assessed by nursing to have acute altered mental status. Resident #25 was sent out to the hospital. The resident was admitted to the hospital with a diagnosis of Hypokalemia and Encephalopathy. Further review of the medical records, revealed there was no documentation that showed the information that the facility provided to the receiving medical provider regarding Resident #25's on going care. b). On 07/26/19 the review of Resident #216's medical record revealed that on 7/10/19 the resident was noted to to be lethargic and was difficult to arouse. A physician ordered the resident to be sent to the emergency room via 911 for an evaluation for change in his/her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record reviews and staff interviews, it was determined that the facility's staff failed to provide residents or their responsible party (RP) with a bed hold policy prior to the residents' transfer to a hospital. This was evident for 3 out of 3 residents investigated for hospitalization during the survey process (Residents #25, #116, and #216) . The findings include: 1 a). On 7/26/19 at approximately 9:30 am, the review of Resident #25's medical record revealed that on 4/4/19 the resident was assessed by nursing to have acute altered mental status. Resident #25 was sent out to the hospital. The resident was admitted to the hospital with a diagnosis of Hypokalemia and Encephalopathy. Further review of the medical records, revealed there was no documentation that the facility provided Resident #25 or his/her RP with the facility's bed hold police prior to or after the resident's transfer to the hospital. b). On 07/26/19 the review of Resident #216's medical record revealed that on 7/10/19 the resident was noted to to be lethargic and was difficult to arouse. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review and staff interview, it was determined the facility failed to ensure an environment that remained free of hazards. This was evident for 1 of 34 residents rooms reviewed for the environment during the investigation (Resident #166). It is a minimum standard of nursing practice to not leave medications at bedside without a physician order. This is to prevent residents from erroneously taking the medication at the wrong time or with the wrong dose. This standard also prevents other residents who may be confused from wandering into a room and taking medications not meant for them. The findings include: On 7/23/19 at 9:00 AM during an interview, a visitor of Resident #166 stated he/she had given a nurse pre-filled syringes the previous night for Resident #166, and the syringes were still in the resident's room. The visitor stated the resident has Muscular Sclerosis (MD) and the injections are to treat MS. On 07/23/19 at approximately 9:00 AM observations of Resident #166's room revealed a bag containing a box with six (6) pre-filled syringes.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, the review of resident medical records, and interviews, it was determined that the facility failed to ensure oxygen therapy was administered as ordered by the resident's physician. This was evident for 1 of 1 resident reviewed for Respiratory Care (Resident #101). The findings include: Resident #101 was observed in his/her room on 7/22/19 at 12:39 PM. During the observation, it was noted that the resident was receiving oxygen via nasal cannula at a rate of 3 Liters per minute (L/min). In an interview conducted with Resident #101 on 7/22/19 at 12:39 PM, the resident stated that s/he is accustomed to receiving oxygen therapy at home, and receives it at a rate of 2 L/min. Resident #101's medical record was reviewed on 7/22/19 at 1:00 PM. The review revealed that Resident #101 did not have a current and active order to receive oxygen. During a second observation of Resident #101 on 7/23/19 at 11:30 AM, it was found that the resident was still receiving oxygen at a rate of 3 L/min. This concern was brought to the attention of the Director of Nursing on 7/25/19 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on meal service observations and staff interviews, it was determined that the facility staff failed to demonstrate the appropriate hand hygiene to prevent the spread of infection while preparing lunch. This was evident for 3 of 3 staff observed preparing the meal tray-line (Dietary Aides #4, #5, and #6). The findings include: On 7/22/19 at 9:54 AM observations of lunch service, with the Dietary Manager, the surveyor observed Dietary Aides (DA) #4, #5, and #6 touching their clothing with their hands. Further observations revealed that DA #4, #5, and #6 did not wash or sanitize their hands before touching and plating residents' lunch trays. On 7/22/19 at 10:10 AM in an interview, the DM. The DM stated that all staff are aware of infection control hand washing policy and these staff members will be in-service again. The Administrator, Director of Nursing with other leadership members were made aware of finding prior to survey exit.

Based on observation, medical record review and interviews with staff and a visitor, it was determined the facility failed to ensure visitor wore the appropriate protective equipment when entering the room of a resident on contact isolation. This was evident for 1 of 1 resident reviewed for isolation precautions during the survey (Resident #166). According to a C. diff fact sheet published by the CDC (Center for Disease Control, https://www.cdc.gov/cdiff/pdf/Cdiff-Factsheet-508.pdf ) Clostridioides difficile (formerly known as Clostridium difficile ) is a bacterium that causes diarrhea and colitis (an inflammation of the colon). C. diff infections can be deadly The factsheet explains that C. diff spreads, when people touch surfaces that are contaminated with poop from an infected person or when people don't wash their hands with soap and water. The CDC recommends that staff and visitors wear gowns and gloves while in the room of a resident with C. diff to help prevent the spread of infection to themselves and others. The findings include: On 7/22/19 at 3:03 PM Resident #166's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.