Resorts at Chester River Manor Corp

In the surveyor’s words

From the most serious findings on record at Resorts at Chester River Manor Corp, in the surveyor’s own words.

• Actual harm, isolatedF690Apr 22, 2026

  Based on medical record review and interviews, the facility staff failed to 1) ensure a resident was seen timely by the Urologist as ordered and 2) reassess and intervene for a resident with urinary catheter problems. This was evident for 1 (Resident #3) of 4 residents reviewed for urinary catheters during a complaint survey. This failure led to the hospitalization of Resident #3 with diagnosis to include urinary tract infection and acute kidney injury. The findings include:Review of Resident #3's medical record on 4/20/26 revealed the Resident was admitted to the facility on [DATE] from the hospital with a urinary catheter (Foley) and a diagnosis of retention of urine. […]

• No harm, potential for more than minimal, widespreadF839Jul 17, 2026

  Based on interview and document review, the facility failed to ensure a licensed practical nurse (LPN) maintained her current credentials for 1 (LPN #1) of 8 licensed nursing staff reviewed for current credentials. This deficient practice had the potential to affect all residents who currently resided in the facility.Findings included: According to the Maryland Department of Health, LPN #1 nursing licensed expired on [DATE] and had not been renewed. LPN #1's Time Card Report for the timeframe [DATE] - [DATE], revealed LPN #1 worked 69 days in the facility. LPN #1's Employee Punch Report for the timeframe [DATE] - [DATE], revealed LPN #1 worked 67 days in the facility from [DATE] to [DATE]. […]

• No harm, potential for more than minimal, patternF641Dec 16, 2025

  Based on facility staff interviews and surveyor record reviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were coded accurately. This finding was found to be evident in 4 (Resident #1, #9, #33 and #103) out of 16 Residents reviewed for accuracy of assessments during the recertification/complaint survey.The findings include: A Minimum Data Set (MDS) assessment is a comprehensive, federally mandated clinical evaluation for Residents in Medicare/Medicaid-certified nursing homes in the United States. The purpose is to provide a standardized, uniform assessment of Resident health status, identify problems, strengths, and preferences, and inform care planning and payment. […]

• No harm, potential for more than minimal, patternF842Mar 8, 2024

  Based on the medical record review and staff interview it was determined the facility failed to keep complete and accurate medical records. This deficient practice was evident in 7 of 20 (#37, #42, #58, #5, #10, #77, #24) resident during the survey. The findings include: 1. During observation rounds on 03/05/24 at 11:21 am Resident #37 made the surveyor aware his/her wheelchair was too large and the wheelchair cushion was too small. On 03/06/24 at 9:51 am during an interview with Director of Rehabilitation #18, he/she verbalized the rehab staff measures the wheelchair to make sure it's a proper fit. When asked if the facility provided the resident with a wheelchair, he/she verbalized needing to check and follow-up. […]

• No harm, potential for more than minimal, isolatedF842Apr 22, 2026

  Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Residents #4, #3) of 9 residents reviewed during a complaint survey.The findings include: A medical record is the official documentation of a healthcare organization. As such, it must follow applicable regulations, accreditation standards, professional practice standards, and legal standards. […]