Calvert County Nursing Ctr.

During an interview on 01/16/25 at 6:00 PM, Licensed Practical Nurse (LPN) 11 stated, I don't remember the specifics on this, but I remember she [R13] had a bruise on her inner thigh. I reported this to the Supervisor .

During an interview on 01/17/25 at 8:49 AM, Registered Nurse (RN) 1 stated, The nurse [LPN 11] reported this to me. I told her to fill out a Change in Condition, call the MD [medical doctor] and call the [resident's] family.

She [LPN 11] also put in a progress note.

There were no reports of this from the off-going shift. I put this in the Supervisor's report and then at the end of my shift, I faxed it to the DON. I think this was an injury of unknown origin because no one knows how it got there.

When RN 1 was asked what the time frame was to report an injury of unknown origin to the state agency, RN1 replied I have 24 hours to report this.

During an interview on 01/17/25 at 9:04 AM, the DON was asked what the Supervisor's reports were used for.

The DON stated, It is used so the Supervisors can let us know what is going on in there shift.

For example, call outs and any issues out of the ordinary.

When asked what the time frame was to report an injury of unknown origin to the SSA after it was identified, the DON stated, From the time you see it, or it is reported, that person is supposed to notify the Administrator and myself, and this has to be reported to the state agency within two hours.

When asked if R13's bruising/injury of unknown origin was reported to the state agency, the DON stated, I don't know.

During an interview on 01/17/25 at 11:24 AM, the Administrator stated, If we are not here, the Supervisors are to call me and the DON to report suspicious bruising.

The nurses will attempt to find out how.

For example, how the bruising occurred and if they cannot find the etiology of the bruise, then I will do a Self-Report.

When the Administrator was asked what the time frame was for reporting this to the SSA, the Administrator stated, They have to investigate this immediately so I can report this within two hours.

The Administrator was notified of the nursing note dated 11/30/24 and the Administrator stated, Should have been the same thing. I should have been notified so that it could have been reported within two hours if they did not know the cause of the bruise.

When the Administrator was asked if the bruise was reported to the SSA, the Administrator stated, I don't believe so.

215188 01/17/2025

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

During an interview on 01/15/25 at 2:47 PM, Licensed Practical Nurse (LPN)7 said a Geriatric Nursing Assistant (GNA) reported the bruise to her, and she reported it to her unit manager.

They were never able to determine how the bruise occurred.

Review of Progress Notes located in the EMR under the Notes tab dated 12/16/2024 at 10:46 AM revealed, Change in condition, bruise to right eye socket started on 12/16/2024.

The bruise is located where her helmet sits on her head.

During an interview on 01/17/25 at 10:16 AM, LPN8 stated she reported the bruise to her unit manager.

During an interview on 01/17/25 at 10:35 AM, the Unit Manager (UM)2 stated the bruise to the residents left flank area was reported to her, and she reported it to the prior DON, and it was discussed during their clinical at-risk meetings. UM2 said she did not report the bruised eye socket immediately because she didn't think it was so severe that it needed to be reported immediately.

Review of of a document entitled Customer at risk, provided by the facility, dated 06/27/24 revealed discoloration to flank.

This document further revealed meeting notes dated 12/19/24 bruise (yellow) right eyebrow-wears soft helmet-remove at bedtime.

During an interview on 01/17/25 at 10:51 AM, the DON stated she was not the DON at the time the bruise was found on R342 on 06/20/24.

The DON stated she did not think this was investigated.

The DON stated any suspicious bruise, or mark should be reported to the DON or Administrator as soon as staff become aware and investigated.

During an interview on 01/17/25 at 11:24 AM, the Administrator said injuries of unknown origin must be reported to a supervisor immediately if the nurse does not know how the injury occurred.

She said they determined that the bruise to R342's right was the result sleeping with the helmet on.

She confirmed this was not investigated and she was not sure if she had documentation of how and when they determined it was the result of sleeping with the helmet on, but she would provide that if she was able to do it. (This information was not provided prior to the end of the survey.

The Administrator stated that any incident where a resident has an injury of unknown origin should be investigated to try and figure out how the injury occurred.

215188 01/17/2025

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

resident the sit-to-stand device but, GNA 2 was in a hurry and lifted the resident.

They said that they

comfort them On 1/15/25 at 12 PM, an interview with the Director of Nursing revealed that resident had a sit-to-stand lift transfer initiated on 2/4/22 and it was continued to this day. GNA 2 did not follow the GNA transferring [NAME].

The resident was sent to the emergency room for treatment of the right fractured arm.

Education to staff on the protocol for safe lifting and movement of resident requiring a sit-to stand lift transferwas completed on 9/27/24.

On 1/15/25 at 2:30PM, an interview with the Director of Nursing stated the delay in education was that the resident failed to inform staff at the time of the incident that the sit-to-stand device was not used in the transfer.

On 1/16/25 at 8:55 AM, an interview with the Administrator revealed a Quality Assurance Performance Improvement (QAPI) action plan, completed 9/27/24, that identified what occurred i.e. full house education including agency staff and the suspension of GNA2. GNA2 was not allowed to return to the facility.

There have been no new agency staff since this occurred. If new agency staff are to start work in the facility, they are educated on the transfer procedures for the residents.

The plan of correction to address the facility's failure to be in compliance was completed by 9/27/24 and training is ongoing as needed for agency staff

215188 01/17/2025

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

Review of R245's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R245 was admitted to the facility on [DATE] with the diagnosis of complete intestinal obstruction, encounter for surgical aftercare following surgery on the digestive system, and hypertension.

Review of R245's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/04/24 revealed the facility that the resident assessed to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact.

Review of R245's Physician Orders located under the Orders tab in the EMR revealed orders dated 10/30/24 for Pramipexole Dihydrochloride ER (extended release) 24 hour 0.375 mg (milligram), Give one tablet by mouth at bedtime for restless leg syndrome, and carvedilol 12.5 mg, Give 12.5 mg two times a day for HTN (hypertension) Hold for SBP (systolic blood pressure) less than 110 and HR (heart rate) less than 60.

Review of R245's Medication Administration Record (MAR) located under the Orders tab in the EMR and dated October 2024 and November 2024, revealed on 10/30/24, 10/31/24, 11/01/24, and 11/02/24 at 9:00 PM, it was documented Pramipexole Dihydrochloride ER was coded as being on Hold as represented as a 5 documented for these dates and time.

Carvedilol was documented as on Hold on 10/31/24 at 9:00 PM as represented as a 5 documented for this date and time for this mediation.

During an interview on 01/17/25 at 5:15 PM, Licensed Practical Nurse (LPN) 12 stated, I don't know why I have documented this except that the medication possibly wasn't here from the pharmacy yet.

Review of the documentation that LPN12 documented in the progress notes for these dates, and it stated, Awaiting from Pharmacy.

Asked if LPN12 checked the stock of medications that were available to be used for residents in the event that this happens, LPN12 stated, I don't believe that I checked that.

During an interview on 01/17/25 at 5:25 PM, the Director of Nursing stated, I can't confirm that he [LPN12] gave the medications. If they were not here from pharmacy, then the nurse should call the MD [medical doctor] and make them aware of this.

215188 01/17/2025

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

Review of R8's Behavioral Monitoring, dated January 2025 and located under the Orders tab in the EMR revealed [Behaviors] Monitor for: anxiety/anxious mood every shift . and [Behaviors] Monitor for: depressed mood every shift .

There was no documented evidence that the resident's behaviors were being monitored.

During an interview on 01/16/25 at 11:59 AM, Registered Nurse (RN) 2 stated, I don't know what the targeted behaviors are.

During an interview on 01/16/25 at 12:56 PM, the Director of Nursing (DON) stated, There aren't any targeted behaviors listed on the behavioral monitoring sheets. It just says to monitor anxiety and depressed mood.

215188 01/17/2025

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

Based on observations, interviews, and policy review the facility failed to ensure that one of seven

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.

Findings include: Review of the facility's policy titled Security of Medication Cart revised 04/07, revealed The nurse must secure the medication cart during the medication pass to prevent unauthorized entry .Medication carts must be securely locked at all times when out of the nurse's view.

Review of the facility's policy titled Storage of Medications revised 04/07 revealed The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

During an observation on 01/16/25 at 11:03 AM, Registered Nurse (RN)4 went into Resident (R)38's room to conduct his blood sugar check. RN4 left the medication cart outside of R38's room door, the medication cart was facing inside of R38's room. RN4 left the medication cart unlocked, with an insulin pen on top of the medication cart.

After conducting the blood sugar check, RN4 went into R38's bathroom to wash her hands.

The medication, and medication cart were out of RN4's sight while she was in the bathroom.

During an interview with RN4 on 01/16/25 at 11:08AM, RN4 confirmed she had left the medication cart unlocked with the insulin pen on top of the cart. RN4 stated she should have put the insulin pen in the cart and locked it while she was in the room.

During an interview with the Director of Nursing (DON) on 01/17/25 at 11:08 AM, the DON stated she expected that medications are securely stored, and the medication carts to be locked when the staff are not within sight of the cart.

215188 01/17/2025

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

During an observation on 01/13/25 at 9:40 AM, the kitchen ice machine, located in the food service area inside the double doors leading to the dining room, clear and brownish colored smears with debris on the top, sides, and front of the ice machine.

The interior front portion of the ice machine had an orangish film on the surface.

During an observation on 01/13/25 at 10:30 AM, in the Southern Shore unit nourishment room, the ice machine had clear and brownish colored smears with debris.

During an interview on 01/14/25 at 8:40 AM, the Assistant Dietary Manager (ADM) verified both ice machines had brown colored smears and debris, and the kitchen ice machine had an orangish film on the surface.

During an interview on 01/16/25 at 2:45 PM, the Maintenance Director (MTD) stated the maintenance department cleaned the inside of the ice machines and the kitchen cleaned the front and sides.

Review of Ice Machine Log dated 2024 provided by the MTD shows quarterly clean-out and filter change [as needed].

The form does not indicate if the entire ice machine is cleaned inside and out.

During an interview on 01/17/25 at 12:20 PM, the Director of Nursing (DON) stated she was unsure who the responsibility for keeping the ice machines in the facility clean fell upon. We discussed the interview with the MTD and the interview with the ADM.

The DON stated it has been a group effort and housekeeping is also to clean the outside of the ice machines on the units.

Policies were requested but were not provided prior to the end of the survey.

215188 01/17/2025

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

Review of the facility's policy titled Electronic Medical Records dated 03/14, revealed The facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of use or disclosure.

During an observation of Registered Nurse (RN)4, on 01/16/25 at 11:03 AM, during a blood sugar check, RN4 left the computer unlocked, and unattended on top of the medication cart, exposing the resident's information, while she was washing her hands in the resident's bathroom. RN4 confirmed she had left the computer open, and stated she should not have left the computer unlocked.

During observation conducted during the medication pass task on 01/17/25 at 8:17 AM, with Unit Manager (UM)2, UM2 left the computer on top of the medication cart opened with resident information exposed, while she went to obtain cups for the cart.

The computer was not within reach or sight of UM2.

During an interview at 8:31 AM, the UM2 stated she should have locked the computer.

During an interview with the Director of Nursing (DON) on 01/17/25 at 11:08 AM, the DON stated that exposing protected health information was an unacceptable practice.

215188 01/17/2025

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

shared with the DON.

The DON stated that all staff are expected to follow all isolation precautions,

Review of the facility's policy titled, Antibiotic Stewardship dated 09/25/24 stated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program .

The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents .

When a nurse calls the physician/prescriber to communicate a suspected infection, he or she will have the following information available: a.

Signs and symptoms .

Review of R28's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R28 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus and morbid obesity.

Review of R28's Physician Orders located under the Orders tab in the EMR revealed an order dated 11/05/24 for Ciprofloxacin (an antibiotic medication) 500 mg, give one tablet by mouth every 24 hours for UTI (Urinary Tract Infection) for five days.

Review of R28's Nursing Progress Note, dated 11/01/24 and located under the Progress Note tab in the EMR revealed Urine specimen collected.

There was no documentation prior to this date of R28 having a change in condition that warranted a urine specimen nor of the physician giving an order for the urine specimen to be collected.

During an interview on 01/16/25 at 10:10 AM, the Infection Preventionist (IP) stated, The only entry I see is the 11/1 [11/01/24] that says a urine specimen was collected.

When asked if the resident met question #1 on the McGeer's Surveillance Form which stated, .must fulfill both 1 and 2, with at least one of the following signs or symptoms acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate, The IP stated, I don't know the sign and symptoms the resident was having because the nurse did not document them.

During an interview on 01/17/25 at 5:20 PM, the Director of Nursing (DON) stated, It is the responsibility of the IP nurse to review each resident's chart to make sure that each antibiotic ordered meets McGeer's criteria. If it does not, then education needs to be provided to staff.

215188 01/17/2025

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

Review of R13's Immunizations located under the Immunization tab in the EMR revealed R13 was administered a flu vaccine on 11/01/24; however, there was no documented evidence the resident and/or the resident representative received education on the flu vaccine Continued review revealed no documented evidence the resident and/or the resident representative received education on the pneumococcal vaccination or was offered the pneumococcal vaccination.

• Review of R66's undated Face Sheet located under the Profile tab in the EMR revealed R66 was

admitted to the facility on [DATE] with the diagnosis of atrial fibrillation, stage four pressure ulcer, and hypertension.

Review of R66's Immunizations located under the Immunization tab in the EMR revealed R66 was administered a flu vaccine on 11/01/24; however, there was no documented evidence the resident and/or the resident representative received education on the flu vaccine.

Continued review revealed R66 received a PPSV 23 pneumococcal vaccination on 06/09/17; however, there was no documented evidence the resident and/or the resident representative received education on the pneumococcal vaccination or was offered a pneumococcal vaccination since being admitted to the facility.

• Review of R8's undated Face Sheet located under the Profile tab in the EMR revealed R8 was

readmitted to the facility on [DATE] with the diagnosis of heart failure, atrial fibrillation, and vascular dementia.

Review of R8's Immunizations located under the Immunization tab in the EMR revealed R8 was administered a flu vaccine on 11/01/24; however, there was no documented evidence the resident and/or the resident representative received education on the flu vaccine.

Continued review revealed R8 received a Pneumovax Dose 1 on 06/06/19 and a PCV 13 on 12/27/21; however, there was no documented evidence the resident and/or the resident representative received education on the pneumococcal vaccination or was offered a pneumococcal vaccination since being admitted to the facility.

During an interview on 01/17/25 at 3:20 PM, the Infection Preventionist (IP) and the Director of Nursing (DON) were asked who was responsible for collecting information and giving the residents the vaccine they were eligible for.

The IP replied, The nurses when they do the admissions get a consent for the vaccines signed that the resident is needing .they get the doctor's order for which particular vaccine is needed and then [the vaccine] is ordered from the pharmacy.

Once it is received from pharmacy, I don't know what the process is for nursing.

The DON stated, It is the responsibility of the IP nurse to review the vaccinations of each resident to make sure the vaccines are up to date, and they are being offered.

The IP stated she did provide education and consents for both the flu and pneumococcal vaccinations; however, she erroneously marked No on the forms which indicated she did not provide education or offered the vaccinations.

215188 01/17/2025

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678

Review of Resident #417's fall prevention care plan initiated on 8/11/2024 revealed Resident #417 was at high risk for falls.

A review of Resident #417's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date of 4/20/24 Quarterly, was conducted.

The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provides the appropriate care and services to the resident and to modify the care plan based on the resident's status.

MDS Section GG: Functional Abilities is coded to reflect that Resident #417 depends on staff for transfers (how the resident moved between surfaces including to or from the bed, chair and wheelchair and required the support of two or more individuals to transfer.

Review of the facility reported incident MD00210322 on 8/23/24 at 9:59 AM, the date of the incident, revealed that the resident reported to the Director of Nursing that the Aide did not transfer her correctly.

The resident explained that the GNA2 bear hugged her/him, and the arms were around the GNA2 neck when he/she lifted her.

On 1/15/25 at 9:30AM, an interview with the resident revealed that the resident was getting ready to attend an activity and her Geriatric Nursing Assistant (GNA) was helping another resident. GNA 2 and GNA 3 came into the room to help her transfer from the side of the bed to the wheelchair. GNA 2 said they could lift the resident to the wheelchair, the resident and GNA 3 said that the resident was to be transferred via a sit to stand. A sit-to-stand device is meant to replace the manual stand-and-pivot transfer that's performed frequently by caregivers when transferring a weight-bearing resident/patient from a seated posture to a standing posture or different seated surface.

The resident stated that's she felt the pain in her arm and heard the snap when she lifted her arms around the GNA's neck.

215188

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 215188 B.

Wing 01/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Calvert County Nursing Ctr. 85 Hospital Road Prince Frederick, MD 20678