Chesapeake Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Chesapeake Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 30, 2023

  Based on a family interview, staff interviews, clinical record review, and review of documents provided by the family, the facility's staff failed to ensure Resident #2 received total assistance of two or more people during care/bed mobility and the needed assistive device (a 47-inch wide bariatric bed) was in use to prevent a fall on [DATE] which resulted in multiple blunt force injuries which contributed to the resident's death resulting in immediate jeopardy. The findings included: Resident # 2 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #2 was admitted to the facility on [DATE] and expired in the facility on [DATE]. […]

• Actual harm, isolatedF689Jan 4, 2024

  Based on family interviews, staff interviews, and a clinical record review, the facility staff failed to ensure residents received two person assistance during care and bed mobility per care plan and the bed mobility assessment binder to prevent accidents for one (1) of six (6) residents in the survey sample, Resident #1 which resulted in a fall with major injuries. The findings included: Resident #1 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The resident died in the facility on [DATE]. The diagnoses included metastatic cancer, heart failure, renal insufficiency and malnutrition. […]

• Actual harm, isolatedF686Dec 14, 2021

  Based on observations, resident interviews, staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to provide necessary care and service to prevent deterioration for 1 of 58 resident's (Resident #92) who had stage IV pressure ulcer to the coccyx. The coccyx pressure ulcer on admission to the facility measured length 9.96 centimeters by width 3.89 centimeters by depth 0.30 centimeters and on 12/2/21 the coccyx pressure ulcer measured 16.00 centimeters by 7.66 centimeters by 2.0 centimeters with a tunneling at six o'clock measuring 5.50 centimeters, and it presented malodorous with heavy drainage which constituted harm. […]

• Actual harm, isolatedF690Dec 14, 2021

  Based on staff interviews, clinical record review and facility's documentation, the facility staff failed to provide the necessary care and services to 1 of 58 residents (Resident #170) for the prevention and complication of a Urinary Tract Infection ([CONDITION(S)]) and [CONDITION(S)]. The facility staff failed to notify the physician or Physician Assistant (PA) when orders were given for a UA with C&S, and that they were never obtained, over five days. The resident became unresponsive, with oxygen saturation levels of 83% (normal=95-100%), and was transferred via 911 (emergent) to the local hospital and admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #170 was originally admitted the nursing facility on 12/13/17. […]

• No harm, potential for more than minimal, patternF677May 21, 2026

  Based on observations, resident/staff and RP (responsible party) interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for seven of 70 residents, Residents #17, #195, #66, #145, #190, #88 and #134.The findings include: 1. The facility staff failed to provide ADL (activities of daily living) specifically bathing, incontinence care, dressing, oral hygiene and personal hygiene for a dependent resident, Resident #17 (R17). R17 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DM (diabetes mellitus), CKD (chronic kidney disease) and bipolar disorder. […]