Solomons Nursing And Rehab Center

Based on observations, interviews with facility staff, and medical record review, it was determined that the facility failed to provide respiratory care consistent with professional standards. This was evident for 2 (Residents #16 and #26) out of 2 residents reviewed for respiratory care during the recertification survey process.The findings include:On 01/22/2026 at 3:46 PM during unit rounds, the surveyor observed Resident #16 and Resident #26 receiving oxygen therapy in their rooms without an Oxygen in Use sign posted on the residents' doors.On 01/22/2026 at 4:00PM the surveyor observed an oxygen concentrator (a device that provides oxygen from room air) at the bedside of Residents #16 and #26. The oxygen concentrator humidification bottle and oxygen tubing were not labeled to indicate the date placed in use or the required replacement date.On 01/23/2026 at 7:04 AM during unit rounds, the resident#16 called the surveyor's attention and stated that the humidifier bottle contained no water and that his/her nose felt dry. The surveyor confirmed that the humidifier bottle was empty,…

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 and interviews, it was determined the facility failed to ensure medications were accurately reconciled. This was evident for 1 of 2 medication carts observed during the annual recertification survey. The findings include:On 01/28/2026 at 10:58AM, during an observation of medication cart #1 it was determined that there was a discrepancy with the narcotic count for Resident #56 liquid morphine. The narcotic book was documented as having a count of Morphine 6.5 ml (milliters) and the morphine bottle contained approximately 12 ml when observed by this surveyor. On 01/28/2026 at 11:10 AM, an interview with Licensed Practical Nurse (LPN ) #7 verified the narcotic count for Resident #56 morphine count was approximately off by 5.5ml. LPN #7 stated she goes by the narcotic book count and subtracted administered doses from the documented count in the narcotic book. LPN #7 confirmed she had not looked at the bottle to validate if the count was accurate. During an interview conducted on 01/28/26 at approximately 12:50 PM, the Director of Nursing (DON) brought 2 bottles 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 observation and interviews, it was determined the facility failed to ensure medications were properly stored and wasted. This was evident for 1of 2 medication carts and 1 of 1 medication storage rooms observed during the annual recertification survey. The findings include:A facility is required to secure all medications in a locked storage area and to limit access to authorized personnel. Storage areas may include, but are not limited to, drawers, cabinets, medication rooms, refrigerators, and carts. When medications are not stored in separately locked compartments within a storage area, only appropriately authorized staff may have access to the storage area.1/28/2026 at 11:23 AM, Surveyors observed the locked medication storage room [ROOM NUMBER] with RN Unit Manager #2 the room was observed to have multiple items that were not medications stored in there:unlabeled bag for resident that contained 2 unopened beer bottles, 1 bottle of unopened alcohol, 2 unopened soda cans , and 2 magazinestin…

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, record review and interviews it was determined that the facility failed to provide a therapeutic diet as ordered. This was found to be evident for 1 (Resident#1) out of 1 Resident reviewed for therapeutic diet during the recertification survey. The findings include: During a random observation conducted 02/02/26 at 8:00 AM, the Surveyor observed Geriatric Nurse Assistant (GNA) #21deliver Resident #1's breakfast tray. The Resident complained to the GNA that he/she did not get double portions, the extra milk and cold cereal that was requested. The GNA observed the Resident's breakfast tray and agreed with the Resident. She removed the tray and stated that she would get a new tray from the kitchen. The Resident reported to the Surveyor that this happens almost every day. The Resident reported that once the tray is taken back the wait time is about 30 minutes before the correct tray is provided. A review of the resident meal ticket revealed a therapeutic diet order for mechanical soft ground and double portions. On 02/02/2026 8:19 AM this surveyor returned and…

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 interviews it was determined that the facility failed to ensure medical records were accurate. This was evident for 1 (Resident #69) of 20 residents reviewed for accurate medical record documentation.The findings include:During a review of the Medication Administration Record for Resident #69 on 1/30/2026 at 6:38 AM it was discovered that Resident #69 had an order for: Lorazepam Oral Tablet 0.5 milligram, Give 2 tablet by mouth every 3 hours for anxiety/shortness of breath which was signed of as given on 1/30/2026 at 2:00 AM and 5:00 AM. An additional order was for Lorazepam Oral Concentrate 2 Milligram (mg) per milliliter, (mL), Give 0.5 mL by mouth every 3 hours for agitation, air hunger 0.5 mL = 1 mg which was signed off as given on 1/30/2026 at 2:00 AM and 5:00 AM. During a continued review of the orders for Resident #69 it was discovered that there was an order placed on 1/29/2026 to discontinue Lorazepam pills when liquid arrives. Do not give both the pills and liquid. It was revealed that the order for the Lorazepam pills was not…

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 record reviews and interviews it was determined that the facility failed to have a designated Interdisciplinary Team (IDT) member for their hospice services. This was found to be evident for 1 (Resident #7) out of 1 Resident reviewed for hospice services during the recertification survey. The findings include: Hospice is a specialized, holistic, and palliative care approach for individuals with terminal illnesses typically with a prognosis of 6 months or less to live, designed to provide comfort, dignity, and pain management rather than curative treatment. It focuses on the patient's quality of life, offering physical, emotional, and spiritual support to both patients and their families, often in the comfort of home. During an interview conducted on 01/22/26 at 11:07 AM, Resident #7 advised that he/she received hospice services. During a record review conducted on 02/01/2026 at 3:19 PM, Resident #7's medical records revealed that the resident was placed on hospice on 02/17/25 with Chesapeake Hospice for heart failure. According to the Resident's medical records, 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.

Based on observation, interviews and record review it was determined that the facility failed to ensure staff practiced infection control. This was found to be evident for 2 (Resident #9 and #69) out of 2 Residents observed for infection control during the recertification survey. The findings include: 1. During a random observation conducted on 01/22/26 at 11:39 AM, the Surveyor observed Activities Aide #25 push Resident #9 in a wheelchair down the hallway from the activities room. The Surveyor heard a dragging sound and observed the Resident's foley catheter bag dragging across the floor as the Activities Aide pushed the resident in the wheelchair down the hallway past the nursing station and to the resident's room. During an interview conducted on 01/22/26 at 11:40 AM, Activities Aide #25 reported that he had not noticed that the foley catheter bag was dragging on the floor. The Activities Aide looked at the foley catheter bag and stated oh it's on the floor, they usually hang it higher, so it does not touch the floor. During an interview conducted on 01/22/26 at 11:49 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.

Based on interview and record review it was determined that the facility failed to ensure education was provided to staff for the current Covid-19 vaccinations. This was found to be evident for 110 out of 110 staff employed at the facility reviewed for infection control during the recertification survey. The findings include: During a review of the staff Covid-19 vaccinations status with the Infection Control Preventionist conducted on 01/30/26 at 11:30 AM, the Surveyor was unable to locate the education for the current Covid-19 status. During an interview conducted on 01/30/26 at 11:33 AM, the Infection Control Preventionist (ICP) reported that there were only 2 staff members who had received the current Covid-19 vaccination. The ICP explained that she conducts a flu clinic for the staff that included an option for the staff to go to Walgreens to receive the current Covid-19 vaccination. When asked if the staff were provided education for the current Covid-19 vaccination, the ICP replied no, she had not provided education but going forward she would make sure she offered education…

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, record review, facility document review, and facility policy review, the facility failed to assess, document, and notify the physician, oncoming staff, and the responsible party of a fall for 1 (Resident #2) of 3 sampled residents reviewed for falls.Findings included: A facility policy titled, Fall Prevention Program, revised 12/2025 indicated 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. An admission Record revealed the facility admitted Resident #2 on 09/19/2025. According to the admission Record, the resident had a medical history that included heart failure, polyneuropathy disorders of the bone density, protein-calorie malnutrition, and anemia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/21/2025, revealed Resident #2 had a Brief…

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 observation and interview with facility staff, it was determined that the facility failed to maintain a homelike environment in resident rooms. This was evident for 7 of 7 resident rooms reviewed during the environmental survey. The findings include: On 3/4/25 at 9:20 AM, a tour was conducted of rooms 79, 10, 18, 17, 32, 33, and 16, all of which were being reviewed for an increase in occupancy. The tour was conducted with the Administrator and the Director of Maintenance. The tour revealed the following concerns: - room [ROOM NUMBER]: no towel hanger in the bathroom - room [ROOM NUMBER]: no towel hanger in the bathroom. Damage noted to the footboard of the bed - the protective outer layer of the footboard was damaged and peeling away, exposing the inner particle board. - room [ROOM NUMBER]: no towel hanger in the bathroom. Damage noted to the footboard of the bed nearer the door - the protective outer layer of the footboard was damaged and peeling away, exposing the inner particle board. - room [ROOM…

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 observation and interview with facility staff, it was determined that the facility failed to ensure that resident bathrooms had effective mechanical ventilation. This was evident for 5 of 7 resident rooms reviewed during the environmental survey. The findings include: On 3/4/25 at 9:20 AM, a tour was conducted of rooms 79, 10, 18, 17, 32, 33, and 16, all of which were being reviewed for an increase in occupancy. The tour was conducted with the Administrator and the Director of Maintenance. All rooms included a bathroom attached to the room that included a sink and a commode. As part of the tour, effective mechanical ventilation in the bathroom was tested by observing if a thin piece of paper was drawn towards and held against the ventilation intake on the ceiling. This test was performed by the Director of Maintenance. This test showed effective ventilation in the bathrooms of rooms [ROOM NUMBERS], but failed to show effective ventilation in the bathrooms of rooms 18, 17, 32, 33, and 16. The Director 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, and interviews it was determined that the facility failed to make an effort to resolve residents' grievances. This was found to be true for 2 of 2 grievances for Resident #58, 1 of 1 grievance for Resident #18, and 6 out of 8 grievances for Resident #291. The findings include: 1a) Review of Resident #58's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses including a cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, conversion disorder with seizures or convulsions, heart failure, chronic obstructive kidney disease, and stage 3 chronic kidney disease. Additional review of Resident #58's medical record showed a care plan created on 1/11/23 that stated Resident #58 has activities of daily living (ADL) limitations/deficits requiring staff assistance of 1 person for toilet use and transfers between surfaces. On 8/19/23 12: 45 PM Surveyors reviewed the grievance logs from 2023 through 2024. During review of the 2023 grievance…

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, resident interview and staff interview it was determined that facility staff failed to: 1) ensure that residents' allegations of theft were reported to in a timely manner and 2) respond to and report allegations of abuse. This was evident for 5 (Resident #68, Resident #42 and Resident #291, Resident #58, and Resident #18) of 10 residents reviewed for timely reporting and abuse. The findings: 1a) On 08/19/24 at 10:27 AM the surveyor reviewed a facility reported incident (FRI), #MD00206250, sent to the Office of Health Care Quality (OHCQ) on 6/3/24 which stated that Resident #68 reported $100 was taken from his/her wallet. The surveyor observed that the report was submitted on 6/3/24 and the date of the incident documented as 6/26/24. The discrepancy was pointed out to the Director of Nursing (DON) who confirmed it was an error and that the incident was reported to the facility by the resident on 5/25/24 and not 6/26/24. Additional review of the FRI investigation revealed 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 Based on record review, review of the facility's investigation files, and interviews it was determined that the facility failed to complete a thorough investigation and maintain the records of their investigation. This was found evident for 6 (Resident #291, #283, #58, #18, #28 and #38) out of 10 residents investigated for abuse. The findings include: 1a) On 8/22/24 at 9 AM, the surveyor reviewed the investigation the facility conducted into the allegation that GNA #11 hit Resident #283 on the head three times while providing care. The summary of the investigation described that an interview was conducted with Resident #291 and Resident #291's roommate, a witness. It also described a statement was taken from GNA #11, the alleged perpetrator, who denied the allegation. The reports stated that 4 other Residents that GNA #11 was assigned to were interviewed, however it did not state the results of the interviews or have copies of the interviews that were conducted. No GNA assignment documentation was in the file to…

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 record review and interviews it was determined that the facility failed to provide routine administration of medications timely. This was found evident in 1 (Resident # 298) of 5 residents reviewed for medication administration. The finding include: On 8/15/24 at 1:16 PM, the surveyor reviewed Resident #298's medical record. The review revealed that Resident #298 was admitted to the facility early April of 2021 with a past medical history that included, but is not limited to, type 2 diabetes, disorientation, epilepsy (a brain disorder that causes seizures), and acute cystitis (infection/inflammation of the urinary tract system). The surveyor reviewed a progress note written on 4/17/21 by Licensed Practical Nurse (LPN) #29 that stated at 10:40 AM, upon initial assessment, Resident #298 was found nearly unresponsive and per report from the aide was not responsive enough to eat breakfast this morning. The surveyor next reviewed the Medication Administration Record (MAR) for April of 2021. The record revealed that Resident # 289 was given a scheduled 6 AM medication at 6:18 AM…

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 and interview with residents and facility staff, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures. This practice has the potential to affect all residents who eat food prepared by the facility. The findings include: On 8/08/24 at 10:00 AM, the Surveyor conducted an interview with Resident #74. During the interview, the resident stated that the food is lukewarm and not palatable. In addition, the Surveyors received complaints from resident families stating that the food is cold by the time it reaches their loved one. On 8/15/24 at 11:40 AM, the Surveyor observed preparation for the lunch tray line. The Certified Dietary Manager (CDM) #6 was present during the Surveyor's observation of the tray line. The first tray was prepared at 12:00 PM. Trays were prepared accordingly, placed in a meal cart, and immediately taken to the appropriate unit. The Surveyor was informed that the meal trays are delivered to each…

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 observation and interview with facility staff, it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents who eat the food prepared in the facility's kitchen. The findings include: During a tour of the facility's kitchen conducted on 8/13/24 at 8:30 AM, the Surveyor inspected the main walk-in refrigerator. The Surveyor observed a shelf containing an opened and unlabeled 1-gallon tub of Sysco mayo, a 1-gallon tub of Sysco mustard with a received date of 3/1 on the lid, and 1 gallon tub of Kens Homestyle Ranch with a received date of 7/29. During a continued tour of the kitchen, the Surveyor observed the dry goods storage pantry. The Surveyor noted an opened and unlabeled 28 oz box of Quaker Cream Of Wheat with a use first label, Ralson Foods Quick oats with a use first label, tub of Goldmetal Chocolate Fudge icing with a use first label, 26 oz pack of Idahoan classic mashed…

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 with staff, it was determined that the facility failed to maintain complete and accurate medical records in accordance with acceptable professional standards. This was evident for 3 (Resident #64, Resident #34, and Resident #44) out of 56 resident records reviewed during the annual survey. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Cardiopulmonary resuscitation (CPR) is a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped. Do Not Resuscitate (DNR) is an order placed in a person's medical record by a doctor informs the medical staff that CPR should not be attempted. Do Not Intubate (DNI) is an order placed in a person's medical record by a doctor informs the medical staff that chest compressions and cardiac…

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 record review, and interview it was determined that the facility failed to notify the Resident's health care Responsible Party (RP) of a change to the Resident's plan of care. This was found evident in 1 (Resident #290) of 4 Residents reviewed for care planning. The findings include: On 8/14/24 at 9:52 AM, the surveyor reviewed Resident #290's medical record. The review revealed that Resident #290 was admitted to the facility in mid 2013. Further review revealed admitting paperwork dated 6/24/23 for Resident #290 that has a spouse/friend listed first and next a Responsible Party (RP) with a comment (representative payee). Additionally in the paper record, there was a typed note from the spouse/friend RP that stated, this RP makes medical decision for Resident #290 and to please see Maryland Health Care Decision Act paper signed on 12/15/04. On further review the surveyor noted that the designated financial RP (representative payee) was in attendance at the care plan meeting dated 2/21/19 and 2/27/20. On review of all the other care plan meeting held for Resident #290 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.

Based on record review, and interview it was determined that the facility failed to inform a Resident's Responsible Party (RP) in advance of a change in the residents' plan of care. This was found evident in 1 (Resident #285) of 10 residents reviewed for Resident Rights. The findings include: On 8/27/24 at 1 PM, the surveyor reviewed Resident #285's medical record. The review revealed that Resident #285 had a past medical history that included, but not limited to, muscle weakness, malnutrition, dementia and dysphagia (difficulty swallowing). On further review of the record on a progress note dated 9/21/23 written at 7:17 PM by Licensed Practical Nurse (LPN) #18 described an incident where LPN #18 found Resident #285 on the floor. No injuries were noted after assessment and Resident #285's Responsible Party (RP) was notified. The surveyor next reviewed Resident #285's orders. An order was placed on 9/21/23 for Resident #285 to be changed from mechanical soft diet to pureed texture and chopped meats. No where in the medical record was a reason given for the diet change or that the RP…

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, interview with staff, and record review it was determined that the facility failed to: 1) ensure a resident has a call bell within reach and is able to use it if desired and, 2) provide reasonable accommodations for a resident to assist with mobility. This was evident for 1 (Resident #44) observed during a tour of the facility and 1 (Resident #300) out of 2 residents reviewed for accommodations. The findings include: 1) On 8/8/2024 at 8:14 AM, the Surveyor observed Resident #44 laying in their bed and the call bell on the floor at the foot of the bed. The Surveyor expressed this concern with Licensed Practical Nurse (LPN) #16, who stated she would take care of it. On 8/9/2024 at 8:00 AM, the Surveyor observed Resident #44 laying in their bed. The Surveyor asked Resident #44 where his/her call bell was in case he/she needed to call for assistance. The resident stated he/she did not know. The Surveyor observed the call bell on the floor at the foot of the bed. On 8/9/2024 at 8:10 AM, the Surveyor informed LPN #16 of the second observation. The Surveyor observed…

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 interviews and family council meeting minutes, it was determined that the facility failed to demonstrate their prompt response and rationale on concerns from the family council group. This was evident for 5 of the 7 months of family council meeting minute notes reviewed. The findings include: The surveyor reviewed a complaint received at the Office of Health Care Quality (OHCQ) on 10/27/2023. The complaint stated that the Nursing Home Administrator did not respond to the family council group's (FCG) concerns for the months of July, August, and September of 2023. During an interview on 08/21/24 at 10:05 AM with the Nursing Home Administrator (NHA) the surveyor asked what the process in place regarding family council meetings is. The NHA stated the family council group meets monthly and then sends the meeting minute notes to him monthly by email. The NHA also stated that he responds to monthly meeting minutes every month before the next meeting occurs. The surveyor requested a copy of all monthly meeting minutes from April 2023 to October 2023. In an interview with 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.

Based on observations and interviews it was determined that the facility failed to ensure information related to the Resident's [NAME] of Rights, including but not limited to the name and contact information of the Maryland's Long-Term Care Ombudsman program and a statement informing residents that they may file a complaint with Maryland's Survey Agency concerning any suspected violation of state or federal nursing facility regulation, was posted in easily viewed and accessible locations. This was found to be evident on all units/halls with resident care areas. The findings include: On 08/20/24 at 12:05 PM the surveyor toured all units with resident care areas in the facility. Observation of the Chesapeake, Patuxent, The Lodge, and Rehab area revealed that there were no signs posted showing the Residents [NAME] of Rights, information on how to contact and/or make a complaint to the state survey agency and the ombudsman office at the Department of Aging. During an interview with Staff #10 on 08/20/24 01:10 PM, the surveyor asked Staff #10 if there were any Resident Rights 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 observation and interview, it was determined that the facility staff failed to display the results of the annual recertification survey and plan of correction in a place readily accessible to residents, family members, and legal representatives. This was evident in 1 of 1 survey results book posted in the facility. The findings include: Surveyor observation of the lobby on 8/6/24 at 9 AM and 8/7/24 at 7:15 AM revealed no evidence of the survey inspection results in an open and readily accessible area for residents, staff, and visitors to review and a tour of the facility did not reveal any signs posted telling residents where the state survey results were located. On 8/7/24 at 7:30 AM an interview with the Director of Nursing (DON) revealed the Survey Results binder was located in the Nursing Home Administrator's (NHA) office. The DON confirmed the book would be provided to the survey team upon the NHA's arrival to the facility. On 8/7/24 at 8: 00 AM, the Nursing Home Administrator provided the survey team with the Survey Results binder. The NHA stated the book may 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to have a system in place to ensure that copies of the resident's Advanced Directives have been obtained and maintained in the resident's medical record. This was evident for 3 (Resident # 8, #70 and #291) out of 4 residents reviewed for Advanced Directives. The findings include: An Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. 1) On 8/8/2024 at 12:05 PM, a review of Resident #70's electronic and paper medical record, revealed no documents that indicated the resident's written Advanced Directive. On 8/13/2024 at 11:31 AM, the Surveyor conducted an interview with the Director of Social Services, Social Worker (SW) #17. SW #17 informed the Surveyor that she interviews the resident and/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to provide written transfer notice to the resident and/or the responsible representative. This was found to be evident for 2 (Resident #8 and #20) of 2 residents reviewed for Hospitalizations. The findings include: 1) On 08/15/24 at 10:00 AM a review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. On 01/06/24, Resident #8 was transferred to the hospital and returned 1/10/24, then transferred again to the hospital on [DATE] and returned on 06/28/24. On both occasions, there was no documentation and/or evidence in the medical record to indicate that the facility staff notified Resident#8 /Resident #8's representative (RP) in writing of the reason for the transfers to the hosptal. 08/16/24 at 11:25 AM the Administrator gave surveyor documents which revealed that the Ombudsman was notified of Resident #8's transfers to the hospital. No document was given to verify that the resident…

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 it was determined that the facility failed to: 1) conduct care plan meetings after each Resident Assessment, 2) hold quarterly care plan meetings for residents, and 3) failed to include interventions for a resident's activity care plan. This was found evident in 3 (Resident #290, #8, and #72) out of 4 residents reviewed for care planning. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). 1) On 8/14/24 at 9:52 AM, the surveyor reviewed Resident…

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 record review, interview, and observation it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent Residents. This was found evident in 2 (#291 & #45) out of 8 Residents reviewed for Activity of Daily Living (ADL) cares. The findings include: 1a) On 8/20/24 at 12:18 PM, the surveyor reviewed Resident # 291's medical record. The review revealed that Resident #291 was admitted in late January 2023. Further review revealed that Resident #291 had a past medical history that included, but not limited to, dysphagia (difficulty swallowing), dysphonia (disorder of the voice), muscle weakness, unsteadiness of feet and need for assistance with personal cares. On further review a progress note written by Licensed Practical Nurse (LPN) #13 stated Resident #291 requires extensive assistance with ADLs and uses a wheelchair and walker while in the facility. On 8/21/24 at 12:20 the surveyor requested shower records for Resident #291 from the Director of Nursing (DON). On 8/22/24 at 7:16 AM, the surveyor reviewed the shower and…

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 facility policy review, and interviews, it was determined that the facility failed to: 1) adequately document responses to treatment of skin conditions and 2) provide 2-person assistance to ensure resident safety during transfers. This was found evident for 2 (Resident #291 an #29) of 4 residents reviewed for wounds and resident- assisted transfers. The findings include: 1) On 8/20/24 at 12:18 PM, the surveyor reviewed Resident # 291's medical record. The review revealed that Resident #291 was admitted in late January 2023. Further review revealed that Resident #291 had a past medical history that included, but not limited to, dysphagia, dysphonia, muscle weakness, unsteadiness of feet and need for assistance with personal cares. The surveyor reviewed the progress notes for Resident #291 and discovered on 2/20/23 that Licensed Practical Nurse (LPN) #16 documented that Resident #291 had an open area to the coccyx and that the area was cleaned, a foam dressing was applied and the doctor and…

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 surveyor observation, review of medical records and interview of facility staff, it was determined that the facility failed to provide appropriate treatment to maintain an individual's limited range of motion. This finding was evident for 1 (Resident# 6) of 1 resident reviewed for range of motion. The findings include: On 8/8/24 at 8:15 AM the surveyor observed Resident #6 sitting in a wheelchair in his/her room using the left hand to stabilize the right arm which was flaccid. On 8/13/24 at 9:31 AM while in the hallway, the surveyor again observed Resident #6 sitting in a wheelchair using her/his left hand to support the right arm which was pressed against the inside of the wheelchair. The surveyor enquired from Staff #18 whether Resident # 6 should have an arm support. Staff # 18 replied yes and proceeded to the resident's room, retrieved a splint and placed it on Resident #6's right arm. A review of Resident #6's medical record on 08/13/24 at 08:31AM revealed that the resident was admitted to 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.

Based on review of the daily staffing sheets and interviews with staff, it was determined that the facility failed to have a Registered Nurse (RN) providing services for at least 8 consecutive hours a day, 7 days a week. This was found to be evident 4 out of 19 days reviewed for sufficient and competent nursing staff during the annual survey. The findings include: During the entrance conference on 8/6/24, the Director of Nursing (DON) confirmed that the facility did not have any Federal or State nursing staffing waivers. On 8/22/24 at 8:34 AM, the Surveyor reviewed the daily staffing sheets from 7/22/24 through 8/5/24. On 7/28/2024, there was no RN coverage for 24 hours. On 8/27/24 at 11:05 AM, the Surveyor conducted an interview with Staff Scheduler #30. During the interview, the Surveyor was informed that finding RN coverage for the weekend shifts are a challenge and that most of the time there is no RN coverage on the weekends. Staff Scheduler #30 also informed the Surveyor that there is a weekend supervisor that will start soon, and that person is an RN. During additional 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 medical record review, observation and interview, it was determined that the facility failed to provide a safe, sanitary environment to prevent the development and transmission of disease and infection. This was evident for 2 (Resident #72 and Resident # 22) out of 56 residents observed for Infection Control. The findings include: Droplet precautions are a set of measures used to prevent the spread of infections caused by germs that spread through coughing, sneezing or talking. 1) Review of record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Major Depressive Disorder, Muscle Weakness, Unsteadiness on Feet. Resident #72 had a history of falls, and his/her plan of care included an intervention dated 08/05/24 which stated - during periods of significant restlessness and attempting to get out of chair without assistance, offer period of mats on the floor for (NAME) to rest on or engage in activities with supervision. On 7/27/24 Resident #72…

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 and interview with staff, it was determined that the facility failed to ensure that the walk-in freezer was in safe operating condition that prevented ice build-up including ice frozen to the floor. This was found to be evident for the walk-in freezer in the kitchen. The findings include: On 8/13/24 at 8:30 AM, the Surveyor conducted a follow up tour of the kitchen. During the tour, the Surveyor observed the walk-in freezer. Located at the back of the freezer, just below the ceiling, was a two-condenser fan unit. There were tiny mounds of ice on the ceiling of the freezer in front of the left condenser fan. Behind the right condenser fan, was a pipe with ice buildup and icicles. At the back of the freezer, directly below the condenser fan unit and the pipe, was several large mounds of ice across the floor which made that area slippery. On 8/13/24 at 9:45 AM, Certified Dietary Manager (CDM) #6 confirmed the Surveyors findings in the walk-in freezer. CDM #6 stated that, he has to remove the ice buildup a couple times a week. He informed the Surveyor that a repair…

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 review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that drug regimen reviews performed by a consulting pharmacist identified irregularities in residents' medication regimens. This was evidenced by a resident with an order for an as-needed psychotropic medication that was not time-limited being cleared without medication irregularities for the four reviews that took place since the psychotropic was prescribed. This was evident for 1 (Resident #56) of 5 residents reviewed for unnecessary medications. Psychotropic medications affect a person's mental state or mood, and include antipsychotics and antianxiety medication, as well as, other categories of medication. Because elders are particularly susceptible to the effects of psychotropic medicaiton, federal regulation prohibits the use of psychotropic medication in nursing homes that is deemed unnecessary. This includes the use of psychotropic medication used on an as-needed basis for longer than a 14-day trial period without due explanation for such use.…

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 review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that residents' drug regimens remained free of unnecessary psychotropic medication. This was evident for 1 (Resident #56) of 5 residents reviewed for unnecessary medications. Psychotropic medications affect a person's mental state or mood, and include antipsychotics and antianxiety medication, as well as other categories of medication. Because elders are particularly susceptible to the effects of psychotropic medicaiton, federal regulation prohibits the use of psychotropic medication in nursing homes that is deemed unnecessary. This includes the use of psychotropic medication used on an as-needed basis for longer than a 14-day trial period without due explanation for such use. The findings include: Resident #56's medical record was reviewed on 9/11/19 at 1:53 PM. During the review, it was noted that Resident #56 was written for an antianxiety medication with a start date of 5/6/2019. The text of the order read, Give 1 tablet by mouth every 8 hours as…

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.