Calvert County Nursing CTR.

In the surveyor’s words

From the most serious findings on record at Calvert County Nursing CTR., in the surveyor’s own words.

• Immediate jeopardy, isolatedF700Feb 24, 2023

  Based on observation, staff interview, and review of medical record and complainant documentation, it was determined that prior to the installation of bed rails, the facility: 1) failed to assess resident risks for entrapment 2) failed to obtain consent for bed rail use for cognitively impaired residents, and 3) failed to attempt to use appropriate alternatives prior to installing or using bed rails. After Resident #1 was observed hanging out of the bed on 2/3/23 with his/her head on the floor and feet at or in the bed rails, staff returned him/her into the bed without addressing the bed rails and did not notify facility management of the incident. This concern was evident for 3 (#1, #8, #9) of 3 residents reviewed during a complaint survey. […]

• Actual harm, isolatedF689Jan 17, 2025

  Based 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. The findings include: 1) Based on reviews of medical records, administrative records, and staff interviews, it was determined the facility staff failed to provide a resident with a safe environment, during a transfer from the bed to the wheelchair. […]

• Actual harm, isolatedF692Feb 24, 2023

  Based on medical record review and staff interview, it was determined that: the facility failed to accurately assess nutritional needs of Resident #4, failed to effective plan for his/her nutritional needs; failed to obtain ordered weights during his/her first month of admission, failed to plan, order and implement recommendations for an added supplement after known unexplained weight loss in his/her first month of admission; and failed to assess and evaluate additional documented weight loss in his/her second month of admission. Throughout his/her entire two-month admission, the facility failed to take necessary steps to protect Resident #4 from unexplained weight loss which was an indicator of clinical decline and therefore substantiated resident harm. […]

• No harm, potential for more than minimal, widespreadF838Jun 27, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF657Feb 24, 2023

  Based on record review, observation, and staff interview it was determined that facility staff: 1) failed to update care plans when there were changes in resident needs or preferences, and 2) failed to thoroughly evaluate and revise resident plans of care after each assessment. This was evident for 2 residents ( #1 & #4) of 10 residents reviewed during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 2/9/23 at 10:00 AM, a review of Resident #1's medical record revealed Resident #1 was admitted to the facility in June 2022 with diagnoses that included spastic quadriplegic cerebral palsy, epilepsy, and muscle weakness. […]