Calvert County Nursing Ctr.

F-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.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 1/15/25 at 11AM, GNA 3 revealed the resident was a sit-to-stand transfer and offered to get the resident

the sit-to-stand device but, GNA 2 was in a hurry and lifted the resident. They said that they did hear the Level of Harm - Actual harm snap of the resident's arm. I immediately got the RN and then stayed with the resident to comfort them

Residents Affected - Few 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 Kardex. 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306

Residents Affected - Few Based 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.

Findings include:

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

Review of Resident 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 Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 29015 Residents Affected - Few Based 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.

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 Resident R38's room door, the medication cart was facing inside of Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 46592

Residents Affected - Some Based 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.

Findings include:

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 29015

Residents Affected - Few Based 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.

Findings include:

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29015 potential for actual harm Based on observations, interviews, record review, and policy review the facility failed to ensure that staff Residents Affected - Few 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.

Findings include:

Review of the facility's undated policy titled Isolation-Categories of Transmission-Based Precautions revealed Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .Contact Precautions-1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.

According to CDC recommendations, when caring for a patient with MSSA (Methicillin-susceptible Staphylococcus aureus) infection and an intravenous catheter, contact isolation PPE would include a gown and gloves that should be worn for all interactions involving contact with the patient and their environment;

this is because the primary transmission route for MSSA is through direct contact with contaminated surfaces or body fluids. Key points about contact isolation for MSSA with a catheter:

PPE required: Gown and gloves are mandatory for all patient interactions.

Rationale: A gown protects clothing from potential contamination, while gloves prevent hand contamination with bacteria that could be transferred to other surfaces or patients.

When to wear: [NAME] PPE upon entering the patient's room and remove it before exiting.

Other considerations:

Dedicated equipment: Use dedicated patient care equipment (like blood pressure cuffs) whenever possible to minimize cross-contamination.

Hand hygiene: Perform thorough hand hygiene before and after patient contact, even when wearing gloves.

Environmental cleaning: Regularly disinfect frequently touched surfaces in the patient's room.

1. Review of Resident R293's undated Admission Record located in the electric medical record (EMR) under the Profile tab, indicated Resident R293 was admitted on [DATE REDACTED], with diagnoses including methicillin susceptible staphylococcus aureus (MSSA) infections, pneumonia, and congestive heart failure.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of Resident R293's Orders located in the EMR under the Order tab, revealed an order for resident on contact precautions due to MSSA infection. Level of Harm - Minimal harm or potential for actual harm Review of Resident R293's Care Plan located in the EMR under Care Plan tab, dated 01/08/25, revealed Resident R293 has MSSA- colonization .Interventions: Contact Isolation: Wear gowns and masks when changing contaminated Residents Affected - Few linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry . Resident care equipment to be appropriately cleaned, disinfected or sterilized according to facility protocol.

Review of Resident R293's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/10/25, located in the EMR under the MDS tab, Brief Interview of Mental Status (BIMS) score is a 15 out of 15, indicating the resident was cognitively intact. Additionally, this MDS indicated the resident is on isolation or quarantine for active infectious disease.

During an observation conducted on 01/15/25 at 12:08 PM of Resident R293's room, there was a sign on room door documenting Contact Precautions: clean hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before the room is exited. Put

on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person.

During an observation on 01/15/25 at 12:42 PM of Registered Nurse (RN)2, RN2 was observed entering Resident R293's room and connecting Resident R293's intravenous antibiotic to the residents peripherally inserted central catheter (PICC) line. RN2 was observed not wearing any PPE while he was in the resident's room and conducting resident care. Upon exiting Resident R293's room, RN2 was questioned if he should have been wearing PPE while in the resident's room since Resident R293 was in contact isolation. RN2 stated doesn't believe he needed to wear PPE, because the resident only has pneumonia in his lungs.

During an interview on 01/15/25 at 12:59 PM, Infection Control Preventionist (ICP) stated Resident R293 was on contact isolation because Resident R293's blood cultures came back positive for having MSSA bacteremia in his blood. The ICP stated the contact isolation sign is on the door, it instructs the staff of what is expected to do, and that there is no exception.

During an interview on 01/15/25 at 1:11PM, Unit Manager (UM)2, stated it is expected that staff providing care to don PPE upon entering room and doff PPE when they exited the room.

2. Review of the facility's policy titled Administering Medications dated 12/12, revealed Medications shall be administered in a safe and timely manner, and as prescribed Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

During medication pass observation on 01/16/25 at 9:20AM, Medication Technician (MT)1 dropped the medication Atenolol (blood pressure medication) on top of the medication cart, picked the pill up with bare hands and put back into the medication cup, with the intent to administer the medication. Upon interviewing MT1 during this observation, MT1 stated she should have disposed of the medication after dropping it and should not have touched the pill with her hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During medication pass observation conducted on 01/17/25 at 8:26AM, UM2 was observed dropping a Clonidine (blood pressure) pill on top of a piece of paper on top of the medication cart. UM2 proceeded to Level of Harm - Minimal harm or scoop it up in medication cup with the intention of administering it to the resident. Upon interviewing UM2 potential for actual harm during the observation, UM2 stated at least I didn't touch it with my hands. UM2 stated she wasn't sure if the paper was clean or not. Residents Affected - Few

During an interview with the Director of Nursing (DON) on 01/17/25 at 11:08AM, observations were shared with the DON. The DON stated that all staff are expected to follow all isolation precautions, and that when medication is dropped, it should have been disposed of appropriately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306 potential for actual harm Based on record review, interview, and facility document review, the facility failed to have a functional Residents Affected - Some 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.

Findings include:

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

Review of Resident 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 Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306 potential for actual harm Based on record review, interview, facility document review, and review of the Centers for Disease Control Residents Affected - Some 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, Resident R13, Resident R66, and Resident R8) out of 29 sample residents. This failure had the potential to put these residents at more risk of developing flu and pneumonia.

Findings include:

Review of CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed 09/12/24, indicated .CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The tables below provide detailed information . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you .Give one dose of PCV20 [pneumococcal conjugate vaccines] or PCV21 . If PCV15 is used, this should be followed by a dose of PPSV23 [pneumococcal polysaccharide vaccine] at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak .If PCV20 or PCV21 is used, Give a dose of PCV15 at least one year later .For adults [AGE] years or older who have only received a PPSV23, CDC recommends you .May give one dose of PCV20 or PCV21 .The PCV20 or PCV15 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you .Give PPSV23 as previously recommended For adults who have received PCV13, Give one dose of PCV20 or PCV21 or PPSV23 to be administered at least a year later . If PCV20 and PCV21 are used, their pneumococcal vaccinations are complete .

Review of the facility's policy titled Influenza Vaccine dated March 2022, which was provided by the facility, stated .Prior to the vaccination, the resident (or resident's legal representative) . will be provided information and education .(See current vaccine information statements at https://www.cdc.gov/vaccines/hcp/vis/index. html for educational materials.) Provision of such education shall be documented in the resident's . medical record.

Review of the facility's policy titled Pneumococcal Vaccine dated October 2023, which was provided by the facility, stated, .Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination . Administration of the pneumococcal vaccines are made in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations at the time if the vaccination.

1. Review of Resident R11's updated Face Sheet located under the Profile' tab in the electronic medical record (EMR) revealed the resident was readmitted to the facility on [DATE REDACTED] with the diagnosis of diabetes mellitus, and chronic obstructive pulmonary disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 215188 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Review of Resident R11's Immunizations located in the EMR under the Immunization tab in the EMR revealed Resident R11 received the flu vaccine on 11/04/24; however, there was no documented evidence the resident and/or the Level of Harm - Minimal harm or resident representative received education on the flu vaccine. Continued review revealed Resident R11 received the potential for actual harm PPSV on 09/23/19; however, it was documented on 12/15/21 Resident R11 refused a pneumococcal vaccine. There was no documented evidence the resident and/or the resident representative received education on the Residents Affected - Some pneumococcal vaccination or was offered the pneumococcal vaccination since 09/23/19.

2. Review of Resident R13's undated Face Sheet located in the EMR under the Profile tab revealed Resident R13 was readmitted to the facility on [DATE REDACTED] with the diagnosis of asthma, and myocardial infarction.

Review of Resident R13's Immunizations located under the Immunization tab in the EMR revealed Resident 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.

3. Review of Resident R66's undated Face Sheet located under the Profile tab in the EMR revealed Resident R66 was admitted to the facility on [DATE REDACTED] with the diagnosis of atrial fibrillation, stage four pressure ulcer, and hypertension.

Review of Resident R66's Immunizations located under the Immunization tab in the EMR revealed Resident 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 Resident 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.

4. Review of Resident R8's undated Face Sheet located under the Profile tab in the EMR revealed Resident R8 was readmitted to the facility on [DATE REDACTED] with the diagnosis of heart failure, atrial fibrillation, and vascular dementia.

Review of Resident R8's Immunizations located under the Immunization tab in the EMR revealed Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 215188