CHESAPEAKE SHORES MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/15/2010	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
02/15/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Potential for minimal harm
02/15/2010	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
02/15/2010	a separate and independent backup electrical power source.	Pattern	Potential for minimal harm
01/12/2010	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
01/12/2010	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
01/12/2010	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
01/12/2010	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
01/12/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
01/12/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/12/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
01/12/2010	Follow all laws and professional standards.	Widespread	Minimal harm or potential for actual harm
10/31/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
10/31/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
10/31/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
10/31/2008	hallway or ground-level exits in all residents' rooms.	Isolated	Minimal harm or potential for actual harm
10/31/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm
10/31/2008	restrictions on the use of highly flammable materials.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
10/10/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Do an assessment of the resident every year.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Potential for minimal harm
10/10/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Follow all laws and professional standards.	Widespread	Potential for minimal harm
10/10/2008	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Have a detailed, written plan for disasters and emergencies.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Actual harm
09/13/2007	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
09/13/2007	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
09/13/2007	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
09/13/2007	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
09/13/2007	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Make sure that a doctor approves a resident's admission in writing and that each resident has a doctor.	Isolated	Actual harm
09/13/2007	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
09/13/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Provide bedrooms that don't allow residents to see each other when privacy is needed.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Provide at least one room to use as a dining room and for activities, that is a good size, with good lighting, airflow and furniture.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Have enough backup water supply for important areas of the nursing home.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Give or get lab tests to meet the needs of residents.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Give or get x-rays and other tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
09/13/2007	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
09/13/2007	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
05/15/2007	fire-resistant room wall surfaces.	Pattern	Potential for minimal harm
05/15/2007	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Potential for minimal harm
05/15/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
05/15/2007	a fire alarm system that can be heard throughout the facility.	Pattern	Potential for minimal harm
05/15/2007	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Potential for minimal harm
05/15/2007	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
05/15/2007	exits that are free from obstructions and can be used at all times.	Pattern	Potential for minimal harm

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Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death