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Health Inspection Summary

Chestertown Nursing and Rehab

415 Morgnec Road

Chestertown, MD 21620

(410) 778-1900

Deficiency Category	Inspection Date: 9/28/23 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 2/15/19 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 10/19/17 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	3	0	1
Quality of Life and Care Deficiencies	3	1	1
Infection Control Deficiencies	2	0	0
Resident Assessment and Care Planning Deficiencies	2	3	3
Nursing and Physician Services Deficiencies	1	0	0
Resident Rights Deficiencies	7	4	2
Nutrition and Dietary Deficiencies	3	1	0
Pharmacy Service Deficiencies	6	0	1
Environmental Deficiencies	1	0	1
Administration Deficiencies	1	0	1

Detailed result for inspection on 9/28/23

Date of last standard health inspection:	9/28/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	29
Average number of Health Deficiencies in Maryland:	18.8
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Respond appropriately to all alleged violations.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide safe, appropriate dialysis care/services for a resident who requires such services.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Develop and implement policies and procedures for flu and pneumonia vaccinations.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Post nurse staffing information every day.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Ensure residents have reasonable access to and privacy in their use of communication methods.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Reasonably accommodate the needs and preferences of each resident.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Some
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to manage his or her financial affairs.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Some
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident’s drug regimen must be free from unnecessary drugs.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Ensure that residents are free from significant medication errors.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Some
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 locked, compartments for controlled drugs.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Ensure medication error rates are not 5 percent or greater.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Many

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Many

Detailed result for inspection on 2/15/19

Date of last standard health inspection:	2/15/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	9/28/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	9
Average number of Health Deficiencies in Maryland:	14.4
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	2/15/19	4/15/19	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	2/15/19	4/15/19	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	2/15/19	4/15/19	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	2/15/19	4/15/19	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	2/15/19	4/15/19	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	2/15/19	4/15/19	2 - Minimal harm or potential for actual harm	Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.	2/15/19	4/15/19	2 - Minimal harm or potential for actual harm	Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	2/15/19	4/15/19	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	2/15/19	4/15/19	2 - Minimal harm or potential for actual harm	Few

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 10/19/17

Date of last standard health inspection:	10/19/17Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	10
Average number of Health Deficiencies in Maryland:	12
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	10/19/17	12/31/17	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide necessary care and services to maintain or improve the highest well being of each resident .	10/19/17	12/31/17	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	10/19/17	12/31/17	2 - Minimal harm or potential for actual harm	Few
Conduct initial and periodic assessments of each resident's functional capacity.	10/19/17	12/31/17	2 - Minimal harm or potential for actual harm	Some
Ensure each resident receives an accurate assessment by a qualified health professional.	10/19/17	12/31/17	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Give residents a notice of rights, rules, services and charges.	10/19/17	12/31/17	2 - Minimal harm or potential for actual harm	Few
Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives.	10/19/17	12/31/17	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.	10/19/17	12/31/17	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.	10/19/17	12/31/17	2 - Minimal harm or potential for actual harm	Some

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep accurate, complete and organized clinical records on each resident that meet professional standards.	10/19/17	12/31/17	2 - Minimal harm or potential for actual harm	Some

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Respond appropriately to all alleged violations.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	9/28/23	12/4/23	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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