Calvert County Nursing Ctr.

Inspectors wroteBased on medical observations and staff interviews, it was determined the facility staff failed to provide nursing care within the standards of practice. This was evident for 4 (Residents #78, # 43, #83, and #15) out of 6 residents reviewed during the recertification and complaint survey process.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure 1) Residents' immunization status was verified and 2) current vaccinations were offered. This was found to be evident for 4 (Resident #30, #45, #2, and #49) out of 5 Residents reviewed for infection control during the recertification and complaint survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure that geriatric nursing assistants (GNA) received at least 12 hours of in-service training annually. This was found to be evident for 5 (GNA #18. #19, #20, #21 & #22) out of 5 GNA's reviewed for training.

Inspectors wroteBased on a review of a complaint, staff interviews, and record reviews, it was determined that the facility failed to ensure the provision and use of a motorized wheelchair to promote and maintain the resident's independence and freedom of movement. This was evident for 1 (Resident #65) out of 1 resident reviewed during the recertification and complaint survey process.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were offered written information regarding advance directives. This was evident for 4 (Resident#6, # 10, 89, and #90) out of 6 residents reviewed for advance directives during the recertification and complaint survey process.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to ensure a Resident was free from abuse. This was found to be evident for 1 (Resident #6) out of 4 Residents reviewed for abuse during the recertification and complaint survey.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was evident for 1 of 1 resident (Resident #118) reviewed for ADL care.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to ensure a Resident was free of accidents. This was found to be evident for 1 (Resident #2) out of 1 Resident reviewed for accidents during the recertification and complaint survey.

Inspectors wroteBased on observations, interviews and record reviews it was determined that the facility failed to store medications to ensure medications remained safe and effective. This was evident for 1 (Western [NAME] Unit) out of 3 Refrigerators used for medication storage.

Inspectors wroteBased on observations, record reviews and interviews it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 2 medication errors out of 37 opportunities which resulted in a medication error rate of 5.41%.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to transfer Resident #417 using a sit to stand transfer device that resulted in the resident sustaining a fracture to their right arm. This was identified a G of past non-compliance for facility reported incident MD00210322 for F689. This was true for 1 out of the 29 residents reviewed during this survey.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote2) 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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) .

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]