AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST
For profit - Limited Liability company
82 Beds
AUTUMN LAKE HEALTHCARE
Data: November 2025
Trust Grade
40/100
#183 of 219 in MD
Photo by Autumn Lake Healthcare at Arlington West
Photo by Autumn Lake Healthcare at Arlington West
Photo by Autumn Lake Healthcare at Arlington West
1 / 5 photos
Last Inspection: May 2022
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Families considering Autumn Lake Healthcare at Arlington West should be aware of several important factors. The facility has a Trust Grade of D, which means it is below average and indicates some concerns about care quality. It ranks #183 out of 219 nursing homes in Maryland, placing it in the bottom half of facilities in the state and #23 out of 26 in Baltimore City County, suggesting limited better options nearby. While the trend shows improvement, with issues decreasing from 30 in 2022 to just 1 in 2025, the staffing situation is concerning, with only 1 out of 5 stars and less RN coverage than 96% of Maryland facilities, which could mean issues might go unnoticed. Specific incidents have raised red flags, such as the use of expired eggs in the kitchen and staff not providing residents with dignity during assistance, which are serious considerations for families evaluating care quality.
- Trust Score
- D
- In Maryland
- #183/219
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Maryland facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Maryland. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 47 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 17%
No red flags
30 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2022: 30 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Maryland average (3.0)
Significant quality concerns identified by CMS
Chain: AUTUMN LAKE HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 47 deficiencies on record
Jun 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined the facility failed to ensure a resident was free from abuse. This was evident for 1 (Resident #74) out of 5 residents reviewed for abuse during ...
Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure a resident was free from abuse. This was evident for 1 (Resident #74) out of 5 residents reviewed for abuse during the facility's recertification survey.
The findings include:
On 6/12/25 at 8:48AM in response to the surveyor's request, the facility's Administrator provided the complete investigative file for the self reported facility incident MD00195518 involving Resident #74 in which abuse of the resident was investigated by the facility. Review of the investigative file revealed Resident #74 reported that Geriatric Nursing Assistant (GNA) #6: entered his room and forcibly turned and positioned him, yelled at him, and put a pillow over his face.
Further review of the complete investigative file for MD#00195518 on 6/17/25 at 12:47PM by the surveyor revealed documentation by the facility on a follow up self report form made to the Office of Health Care Quality that on 8/12/23 Resident #74 reported the allegation of abuse by GNA #6 to facility staff, and after investigation into the allegation, including an interview of the resident's roommate, the result of the investigation was found to be substantiated by the facility and a report was documented as made to the Maryland Board of Nursing (MBON) regarding GNA #6 as well as the facility placing them on a do not return staffing list.
On 6/17/25 at 2:06PM the surveyor reviewed the facility's documentation of the August 2023 complaint form in which the facility had documented their complaint and concern regarding GNA #6 to the MBON and also a letter from August 2023 in which there was a response made from the MBON indicating they received a complaint.
On 6/17/25 at 3:13PM the surveyor conducted an interview with the facility's Administrator who confirmed that Resident #74's allegation of abuse was substantiated by the facility. At this time the surveyor shared the concern with the Administrator who acknowledged the concern.
May 2022
30 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaints, reviews of an active and closed medical records, and complainant and staff interviews, it was determined th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaints, reviews of an active and closed medical records, and complainant and staff interviews, it was determined that the facility staff failed to immediately notify a resident's physician when: 1) a resident had a hypoglycemic event (Resident #65), and 2) when a resident was identified with a significant weight loss (Resident #176). This was evident for 2 of 9 complaints reviewed during an annual recertification survey.
The findings include:
1) Reviews of complaint MD00175030 on 04/20/2022 at 9 AM revealed an allegation that Resident #65 was observed by a family member with a wound that was not identified by the nursing staff. In an interview with the complainant, on 04/21/2022 at 2:25 PM, the complainant stated that Resident #65 had just been observed by him/her to be unresponsive, sweaty, hot to touch, and unable to finish the therapy session this morning. The complainant stated that Resident #65 did not respond to his/her name when being called. The complainant stated that s/he was concerned that the nursing staff was unable to recognize a hypoglycemic event and take steps to correct the hypoglycemia in Resident #65. The complainant stated that Resident #65's glucose level by finger stick was 68 mg/dl and that s/he was worried about the amount of insulin Resident #65 was receiving.
A review of Resident #65's medical record on 04/22/2022 revealed Resident #65 was admitted to the facility on [DATE] with diagnoses that included: a stroke, dementia, protein-calorie malnutrition, a Foley catheter, and type 2 diabetes. A review of Resident #65's physician orders revealed the following:
On 03/24/2022 at 7:30 AM, Resident #65's physician ordered the nursing staff to administer Aspart Insulin, inject 2 units subcutaneously before meals for diabetes and hold for blood glucose less than 120
On 03/24/2022 at 7:30 AM, Resident #65's physician ordered the nursing staff to administer, Aspart FlexPen insulin, Inject as per sliding scale: if 151 - 200 = 1 unit; 201 - 250 = 2 unit; 251 - 300 = 3 units; 301 - 350 = 4 units IF > 350 GIVE 5 UNITS CALL MD/NP, subcutaneously before meals and at bedtime for diabetes.
On 04/15/2022 at 6 PM, Resident #65's physician ordered the nursing staff to administer Glargine insulin, inject 9 units subcutaneously two times a day for diabetes and hold for blood glucose less than 120.
On 04/22/2022 at 4:45 PM, Resident #65's physician ordered the nursing staff to Inject Glucagon, 1 syringe subcutaneously as needed for diabetes, Administer for blood glucose less than 60 or symptomatic and repeat blood glucose 15 minutes after administration. If blood glucose is still less than 70 and the patient is unable to swallow, repeat the dose and notify MD.
A review of Resident #65's documented finger stick glucose readings for April 2022 revealed Resident #65's glucose readings had not dropped below 110 mg/dl.
In an interview was conducted on 04/22/2022 at 3:58 PM with Resident #65's 04/21/2022 day shift charge nurse (Employee #8). Employee #8 stated that Resident #65 did have a hypoglycemic event on 04/21/2022 just after his/her therapy session and before lunchtime. Employee #8 stated Resident #65's fingerstick glucose reading was 63 mg/dl at that time. Employee #8 stated that s/he was alerted to Resident #65's change in condition by Resident #65's family member. Employee #65 stated that s/he notified the facility director of nurses (DON) at this time also. Employee #8 stated that s/he did administer a dose of Glucagon to Resident #65 that was obtained from the DON. When questioned, Employee #8 stated that s/he had not documented anything about Resident #65's 04/21/2022 hypoglycemic event in Resident #65's medical record including a progress note that indicated Resident #65's glucose was 63 mg/dl, the administration of a dose of Glucagon, or notification of the incident to Resident #65's physician. Employee #8 stated that she did not notify Resident #65's physician.
A review of the facility Hypoglycemic Management policy, implemented, reviewed and revised on 05/01/2021, revealed the following guidelines: #3) a resident that has a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatment of hypoglycemia, unless otherwise ordered by the practitioner. #5) If the blood glucose level is 70 mg/dl or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's orders, with follow up blood glucose's as indicated, and notify the practitioner of the results as ordered.
2) Review of complaint MD00175144 on 05/04/2022 revealed an allegation Resident #176 had a significant weight loss and that the responsible party was not informed by the facility nursing staff.
A review of Resident #176's closed medical record revealed nursing documentation that on 10/05/2021 at 12:04 PM, Resident #176's standing weight was 139.6 pounds. On 11/03/2021 at 3:29 PM, the nursing staff documented Resident #176's wheelchair weight to be 110.6 pounds. On 11/08/2021 at 11:37 PM, the nursing staff documented Resident #176's wheelchair weight (weight obtained while resident seated in a wheelchair) to be 110.8 pounds. Between 10/05/2021 and 11/03/2021, the nursing staff documented a 29-pound (20.7%) weight loss. The 11/08/2021 documented reweigh of 110.8 pounds for Resident #176 also shows a significant weight loss of 28.8 pounds (20.6%). Further review of Resident #176's closed medical record failed to reveal Resident #176's physician or representative was immediately made aware of the significant weight loss on 11/03/2021 or 11/08/2021.
A review of the facility weight monitoring policy, dated 07/21/2021, revealed the following:
6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant weight change is defined as:
a. 5% change in 1 month (30 days)
b. 7.5 % change in 3 month (90 days)
c. 10% change in weight in 6 months (120 days)
7. Documentation:
a. The physician should be informed of a significant weight change in weight and may order nutritional intervention.
h. Notification to the resident and/or representative of any significant weight change.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
2) Review of facility reported incident MD00166279 on 5/2/2022 revealed that Resident #225 reported on 4/15/2021 that GNA #35 was rough, loud and would not let them sit back down when they requested t...
Read full inspector narrative →
2) Review of facility reported incident MD00166279 on 5/2/2022 revealed that Resident #225 reported on 4/15/2021 that GNA #35 was rough, loud and would not let them sit back down when they requested to because of leg pain. The facility substantiated verbal abuse and GNA #35 was terminated.
3) On 4/28/2022 at 2:00 PM, review of the record of the facility reported incident MD00140599 revealed that Resident #9 had alleged that GNA #33 slapped him/her. The facility administrative staff investigated the allegation and substantiated the allegation of physical abuse. GNA #33 was terminated.
On 5/6/2022 at 3:15 PM, all concerns related to abuse and neglect were discussed in detail with the Administrator and the Director of Nursing prior and during the survey exit conference.
Based on record review, staff and resident interviews it was determined that the facility staff failed to ensure that residents were free from abuse and neglect. This was evident for 3 of 6 residents (Resident #9, #225, #272) reviewed for facility reported incidents related to abuse and neglect allegations.
The findings include:
1) Review of facility reported incident MD00172452 on 5/2/22 revealed that Resident #272 was verbally abused by staff. Review of the facility's investigation revealed Resident #272 had alleged that an agency Geriatric Nursing Assistant (GNA) #48 was verbally abusive. The facility administrative staff investigated the allegations and substantiated that the agency GNA was verbally abusive. The staffing agency was notified for the GNA not to return to the facility. The Director of Nursing (DON) was advised that the facility would be cited for abuse on 5/4/22 at 11:15 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0608
(Tag F0608)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of a facility reported incidents, the facility abuse policy, and staff interview, it was determined that the fa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of a facility reported incidents, the facility abuse policy, and staff interview, it was determined that the facility failed to notify local law enforcement of an allegation of misappropriation of resident property. This was evident for 1 of 8 residents (Resident #181) reviewed for abuse during an annual recertification survey.
The findings include:
Review of facility reported incident MD00159199 on 04/25/22 revealed Resident #181 reported missing $95 from his/her wallet to the manager on duty on 10/10/2020. The facility reported the allegation of misappropriation of resident property to the State Long Term Care Agency at that time. Review of the facility self-report form, under the box heading, Local Law Enforcement Contacted? the facility administrator indicated NO. The facility completed the investigation into Resident #181's missing $95 on 10/12/2020 and was unable to substantiate the allegation of misappropriation of resident property or determine a possible perpetrator.
Review of Resident #181's closed medical record on 04/25/22 at 2:30 PM revealed Resident #181 was admitted to the facility on [DATE]. At that time the facility staff completed an admission inventory list. The facility staff person did not indicate Resident #181 had brought any cash into the facility on the admission inventory list dated 10/01/2020.
Review of the facility investigation revealed that the facility initiated and investigated Resident #181's allegation of missing $95. The investigation included interviews with staff members. During the investigation, the facility staff offered to secure Resident #181's wallet in the facility safe or a locked box. Resident #181 declined. Resident #118 was then also asked if he/she wanted the facility to report the incident to the local police. Resident #181 declined the facility staff offer to notify local law enforcement of the incident. The facility could not substantiate Resident #181's complaint of stolen cash. The resident was refunded $95.00 by facility check on 10/16/2020.
In an interview with the facility administrator on 05/02/22 at 9:30 AM, the facility administrator stated that his/her practice in the past was to ask the resident if they wanted the facility to report an allegation of misappropriation of property to local law enforcement.
A review of the facility abuse policy, investigating and reporting, that was revised in July 2017, instructed that all violations involving misappropriation of property will be reported by the facility administrator, or his designee, to the following persons or agencies:
1) the State Licensing/certification agency responsible for surveying/licensing the facility
2) the local/State Ombudsman.
3) The resident's representative or sponsor.
4) Adult protective services.
5) Law enforcement officials.
6) The resident's attending physician.
7) The facility medical director.
The facility policy also indicated that an alleged violation of abuse and misappropriation of property will be reported immediately, but not later than 24 hours if the allegation does not involve abuse and has not resulted in serious bodily injury.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined that the facility failed to document the transfer or discharge of a resident was necessary for the resident's welfare and the resid...
Read full inspector narrative →
Based on medical record review and staff interview it was determined that the facility failed to document the transfer or discharge of a resident was necessary for the resident's welfare and the resident's needs could not be met in the facility. This was evident for 1 of 4 residents (Resident #3) reviewed for discharges and transfers during an annual recertification survey.
The findings include.
Review of Resident #3's medical record on 04/27/2022 at 10:36 AM failed to reveal any transfer forms that Resident #3 received prior to being transferred to a sister facility on 01/13/2021. The nursing staff developed a COVID-19 care plan on 01/13/2021 that included the following intervention: to apply a sign on the door informing staff of Droplet & Contact precautions, encourage the resident to wear a mask, monitor poor appetite and dehydration and to report the findings to the resident's physician, and to obtain a temperature and perform a respiratory assessment every shift.
In an interview with the facility Infection Control Preventionist (ICP) #4 on 05/03/2022 at 9:38 AM, the facility ICP #4 stated that the facility had not developed or implemented a policy during the COVID-19 pandemic regarding the transfer of any resident identified as being COVID-19 positive to a sister facility. The ICP continued to state that there was no need to establish a separate COVID-19 unit in the facility because any resident identified as being COVID-19 positive was to be transferred to the sister facility. The facility ICP #4 stated that the facility did eventually have to set up a separate COVID-19 unit in the facility due to the increasing number of residents identified as being COVID-19 positive. The ICP #4 stated the facility established a COVID-19 unit on 01/18/2021.
In an interview with the facility director of nurses (DON) on 05/06/2022 at 10 AM, the DON stated that the facility had not developed a policy for transferring residents out of the facility due to being identified as having COVID-19. The facility DON confirmed that there were no documents in Resident #3's medical record that would identified Resident #3 as being sent to the receiving facility on 01/13/2021. The DON also stated that the facility initiated the transfer of Resident #3 to another facility because of the Federal waiver that was in place at the time.
In an interview with the facility physician assistant #47, on 05/06/2022 at 10:27 AM, the facility physician assistant stated that s/he initially wrote new orders to treat Resident #3 for COVID-19 on 01/13/2021 in house. The facility physician assistant stated that s/he was contacted by the facility administration and was instructed to write an order instructing the staff to transfer Resident #3 to another sister facility for which s/he did.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
2) Review of Resident #3's medical record on 04/27/2022 at 10:36 AM failed to reveal any documentation regarding the transfer of Resident #3 to a sister facility on 01/13/2021. On 01/13/2021, the nurs...
Read full inspector narrative →
2) Review of Resident #3's medical record on 04/27/2022 at 10:36 AM failed to reveal any documentation regarding the transfer of Resident #3 to a sister facility on 01/13/2021. On 01/13/2021, the nursing staff had developed and initiated a COVID-19 care plan that included the following interventions: to apply a sign on the door informing staff of Droplet & Contact precautions, encourage the resident to wear a mask, monitor poor appetite and dehydration and to report the findings to the resident's physician, and to obtain a temperature and perform a respiratory assessment every shift. The nursing staff were making plans to keep Resident #3 in the facility.
In an interview with the facility director of nurses (DON) on 05/06/2022 at 10 AM, the DON stated that the facility had not developed a policy for transferring residents out of the facility due to being identified as having COVID-19. The facility DON confirmed that there were no documents in Resident #3's medical record that indicated Resident #3 or Resident #3's responsible party had been notified in writing for the reason Resident #3 was transferred from the facility on 01/13/2021.
In an interview with Resident #3's family member on 05/09/2022 at 3:02 PM, Resident #3's family member stated that s/he was first made aware of the facility-initiated transfer of Resident #3 to another sister facility on 01/13/2021 due to Resident #3 being diagnosed with COVID-19 on 01/13/2021. Resident #3's family member stated that s/he had no knowledge of a new facility policy to transfer any resident who was identified as being COVID-19 positive. Resident #3's family member stated that s/he has not received any written bed hold notice, transfer paperwork, or any updated COVID-19 policy indicating why a resident would have to be transferred from the facility. Resident #3's family member stated that on 01/13/2021, s/he was informed by a facility staff person that Resident #3 was currently in the process of being transferred.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 of 4 residents (Resident #28, #3) reviewed for facility-initiated transfers.
The findings include:
1) Review of Resident #28's electronic and paper medical record on 4/20/22 at 2:17 PM revealed on 2/10/22 at 12:00 Noon, Resident #28 was transferred to the hospital for acute renal failure and altered mental status. Further review of Resident #28's medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party and/or resident was notified in writing of the hospital transfer.
An interview was conducted with the director of nursing on 4/22/22 at 9:30 AM. She indicated that copies of a transfer form including the bed hold policy should be included in the medical record. She was informed that the transfer documents were not found in the medical record. At 11:10 AM on 4/22/22 the DON indicated that she had reviewed Resident #28's medical record and indicated that she did not find any transfer documents related to Resident #28's transfer to the hospital on 2/10/22.
The nursing home administrator and the director of nursing were both informed of the findings on 4/26/22 at 3:45 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identi...
Read full inspector narrative →
Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 of 4 residents (Resident #28) reviewed for hospitalization during the annual survey.
The findings include.
Review of Resident #28's electronic and paper medical record on 4/20/22 at 2:17 PM revealed the resident had a change in condition on 2/10/22 at 10 AM. The physician was notified and ordered for the resident to be transferred to the hospital for evaluation related to Acute Renal failure and Altered Mental status. There was no documentation as to what interventions were put into place before the transfer, what the resident was told and if the resident understood where he/she was going and why.
An interview was conducted with the director of nursing (DON) on 4/22/22 at 9:30 AM. The DON reviewed Resident #28's medical record related to the transfer documentation and corroborated that there was no documentation related to the sufficient preparation and orientation to the resident prior to transfer to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
3) Review of Resident #41's electronic medical records and paper records on 4/21/22 at 2:00 PM revealed the resident was transferred to the hospital for a scheduled procedure and hospitalized in March...
Read full inspector narrative →
3) Review of Resident #41's electronic medical records and paper records on 4/21/22 at 2:00 PM revealed the resident was transferred to the hospital for a scheduled procedure and hospitalized in March 2022. Further review of Resident #41's medical record documentation revealed that there was no written documentation that the responsible party and/or resident was given a copy of the bed hold policy.
An interview was conducted with the DON on 4/22/22 at 11:01 AM. She explained if a resident transferred to the hospital for a scheduled procedure or surgery and already knew they would back to the facility, the facility did not provide the bed hold policy to the resident or responsible party. The DON insisted that Resident #41 had had a one-day procedure at the hospital originally, but the hospital kept the resident longer than planned. The DON also stated when Resident #41 called the facility to provide an update on the extended hospitalization, she gave information regarding the bed hold policy to the resident. However, the facility did not have any documentation to support the facility providing the bed hold policy to the resident.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
2) In an interview with the facility director of nurses (DON) on 05/02/2022 at 12:50 PM, the DON confirmed that Resident #3 was transferred to a sister facility on 01/13/2021 since the facility had not established a COVID-19 unit and Resident #3 had been determined to be COVID-19 positive.
Review of the facility policy, Bed Hold Notice Upon Transfer, on 05/04/2022 revealed that at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. A therapeutic leave refers to absences for purposes other than required hospitalization.
In a follow-up interview with the DON on 05/06/2022 at 10 AM, the DON stated that the facility had not developed a policy for transferring residents out of the facility due to being identified as having COVID-19. The facility DON confirmed that there were no documents in Resident #3's medical record that Resident #3 nor Resident #3's representative received a copy of the bed hold policy on 01/13/2021.
In an interview with Resident #3's family member on 05/09/2022 at 3:02 PM, Resident #3's family member stated that s/he was first made aware of the facility's desire to initiate a transfer of Resident #3 to another sister facility due to Resident #3 being identified as COVID-19 positive on 01/13/2021. Resident #3's family member stated that s/he had no knowledge the facility had a new policy to transfer a resident who was COVID-19 positive and has not received any written bed hold notice, transfer paperwork, or an updated COVID-19 policy indicating why a resident would have to be transferred from the facility. Resident #3's family member stated that s/he was informed by a facility staff person about Resident #3 that this transfer was in process. Resident #3's family member then stated the facility called and informed him/her when Resident #3 was transferred back to the facility.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM and again with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 3 of 5 residents (Resident #28, #3, #41) reviewed for transfers out of the facility.
The findings include:
1) Review of Resident #28's electronic and paper medical record on 4/20/22 at 2:17 PM revealed the resident had a change in condition on 2/10/22 at 10 AM. The physician was notified and ordered for the resident to be transferred to the hospital for evaluation related to Acute Renal failure and Altered Mental status. Further review of Resident #28's medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party and/or resident was given a copy of the bed hold policy.
An interview was conducted with the director of nursing (DON) on 4/22/22 at 9:30 AM. She was informed that the Bed Hold document was not found in the medical record. At 11:10 AM on 4/22/22 the DON indicated that she had reviewed Resident #28's medical record and indicated that she did not find any transfer documents related to Resident #28's transfer to the hospital on 2/10/22. She provided a blank Bed Hold Notice Upon Transfer form.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
3) End-Stage Renal Disease (ESRD) is the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or Kidney transplantation to maintain life.
Dialys...
Read full inspector narrative →
3) End-Stage Renal Disease (ESRD) is the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or Kidney transplantation to maintain life.
Dialysis is a treatment that filters and purifies the blood using a machine in people whose kidneys can no longer perform these functions naturally. This helps keep their body in balance.
Medical record review was conducted for Resident #32 on 4/21/22 at 3:02 PM. Resident #32 was admitted to the facility in January 2020 with diagnosis that included End Stage Renal Disease and dialysis on Monday, Wednesday, and Friday.
Review of progress notes on 4/22/22 at 9:04 AM revealed a post dialysis note dated 4/18/22 at 11:28 PM indicating an assessment of the resident upon return to the facility from the dialysis center. There was no dialysis note on the chart for Wednesday 4/20/22.
On 4/22/22 at 10:10 AM, in an interview with the surveyor, Resident #32 stated that she/he was not picked up for dialysis on Wednesday 4/20/22.
On 4/22/22 at 10:25 AM, in an interview with the resident's attending physician #25 who was on the 3rd floor unit at the time, he/she stated that Resident #32 usually refused to go to dialysis, and it was not new that the resident did not go on Wednesday 4/20/2022.
On 4/22/22 at 10:28 AM, in an interview with Licensed Practical Nurse (LPN #7), she/he stated that transport was running late, and Resident #32 got inpatient and refused to go for dialysis. When asked if transport did make it to the unit, LPN #7 stated no because she/he had called and canceled the transportation and notified the dialysis center. LPN #7 further stated that was not the first time the resident had refused to go to dialysis. When asked if Resident #32's care plan was updated/revised to reflect the refusal, LPN #7 stated that the unit manager was responsible for updating the care plan.
On 4/22/22 at 10:45 AM, review of progress notes revealed documentation by nursing staff on 4/8/22 at 12:46 PM of Resident #32 refusal of dialysis treatment. On 4/22/22 at 10:52 AM, review of the care plan revealed it was not updated/revised with interventions to reflect resident refusing dialysis treatment.
On 4/22/22 at 11:55 AM, in an interview with the surveyor, the Assistant Director of Nursing (ADON) stated she/he was covering the 3rd floor as a unit manager because the previous unit manager had recently resigned. The ADON confirmed that Resident #32 refused to go to dialysis on Wednesday 4/20/22, however she/he did not update the care plan. The ADON further stated the former unit manager should have updated the care plan to reflect the other times the resident refused to go to dialysis.
On 4/26/22 at 2:50 PM, an interview with the DON was completed. Regarding care plan revision and update, the DON stated that the unit managers were responsible for updating the care plans but since the end of March 2022 there had not been a unit manager on any of the units. So, she/he was now responsible for revising and updating residents' care plans. The DON was made aware of Resident #32 not having an updated care plan.
On 5/6/22 at 3:15 PM, all concerns were discussed in detail with the Administrator and the Director of Nursing prior and during the survey exit conference.
Based on medical record review, and staff interview it was determined that the facility failed to have an effective system in place to ensure care plans are thoroughly evaluated and revised by the interdisciplinary team after each assessment. This was evident for 3 of 3 residents (Resident #26, #32, #66) reviewed for care plan revision.
The findings include.
The Minimum Data Set (MDS) is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs. Assessments are conducted by trained nursing home clinicians on all residents at admission and discharge, in addition to other time intervals (e.g., quarterly, annually, and when residents experience a significant change in status) so that residents receive services in the most integrated setting appropriate to their needs.
After the MDS is conducted, the intra-disciplinary team (nursing, dietician, activities, social worker, pharmacist and physician) confer to create and or update care plans to ensure that most accurate and appropriate interventions are present. A care plan is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. Care plans also provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes.
1) Resident #66's care plan meeting notes and care plans were reviewed on 5/4/22. A care plan meeting was conducted on 12/14/21 and a quarterly meeting was documented on 3/1/22. The social worker documented the Care plan meeting of 3/1/22. There was a blanket statement for the section labeled progress toward goals: Resident remains LTC at this time. See care plans for detailed goals and interventions. Another section of the note is labeled as Updates to Care plan: See care plans for details. Review of the care plans revealed a focus care area indicating the resident had elected to remain in the facility. This focus area was initiated on 9/30/19. The goal of the care area was written as [Resident #66] will adjust to LTC by review date. The goal is not measurable, and the goal has remained the same since 9/30/19. The current target date is 6/4/22 as this date was revised on 2/3/22. The interventions have remained the same since 9/30/19. The interventions were written as: Establish discharge planning goals with resident and Make arrangements with required community resources to support independence post discharge. The interventions are not resident centered, as the interventions do not assist the resident to adjust to long term care. There was not any evaluation for this care plan area or the 21 other care areas.
Concerns of care planning and lack of evaluations were discussed with the Director of Nursing (DON) on 5/4/22 at 11:39 AM.
2) Resident #26's care plans were reviewed on 5/4/22 at 1:30 PM. The social worker documented the last care plan meeting on 4/19/22. This meeting was conducted approximately two months beyond the MDS quarterly assessment date of 2/25/22. The meeting note included progress towards goals; resident continues long term care stay. See resident care plans for detailed goals and interventions. The care plan revealed that there were 17 identified care areas. On 11/1/21 a care plan area was initiated for [Resident #26] has elected to remain LTC at facility The goal was resident will adapt to facility environment through next review The goal is not measurable or quantitative. The only intervention was written as Staff will engage family and resident to ensure adjustment to LTC placement. The quarterly evaluations of the 17 care areas were not found.
Care planning concerns were addressed to the DON on 5/6/22 at 10:16 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
2) A review of Resident #57's medical record on 4/26/22 at 11:10 AM revealed the resident was admitted to the facility in April 2022 with a Foley catheter from a hospital for chronic urinary retention...
Read full inspector narrative →
2) A review of Resident #57's medical record on 4/26/22 at 11:10 AM revealed the resident was admitted to the facility in April 2022 with a Foley catheter from a hospital for chronic urinary retention. Review of the order summary dated 4/18/22 revealed the resident needed a follow-up appointment with Urology within one week. However, there was no documentation found to support that the facility arranged a follow-up visit for the resident with the Urologist until the survey team alerted the facility staff on 4/27/22 at 3:10 PM.
An interview was conducted on 4/27/22 at 2:59 PM with Staff #51, who was responsible for scheduling residents' appointments. Staff #51 verified that Resident #57 had no scheduled appointments with a Urologist since he/she had been admitted to the facility.
Based on medical record review and interview it was determined that the facility failed to ensure staff followed physician orders as evidenced by: 1) failure to ensure ordered consults were addressed. This was evident for 1 of 4 (Resident #57) residents reviewed during the survey; 2) failure to change, label, date and initial oxygen tubing and humidifier bottle. This was evident for 1 of 8 residents (Resident #32) reviewed during the survey. Although this noncompliance resulted in no actual harm to the residents, it has a potential for more than minimal harm if the practice is not corrected.
The findings include:
1) On Tuesday 4/19/22 at 10:35 AM, Resident #32 was observed receiving humidified oxygen via nasal cannula (plastic cannulas in the nostrils). There was no date and/or initial on the oxygen tubing or humidifier bottle indicating when these were changed.
On Thursday 4/21/22 at 10:20 AM, surveyor observed that Resident #32's oxygen tubing and humidifier bottle were not labeled with a date or initial to show when they were changed. The humidifier bottle was almost empty.
In an interview with Resident #32, she/he stated that the staff were supposed to change the oxygen tubing once a week. However, the resident could not remember the last date/time the tubing was changed.
During a review of Resident #32's medical record conducted on 4/21/22 at 3:15 PM, surveyor noted an active physician order dated 1/15/20 for: Change Oxygen and/or Nebulizer equipment tubing and/or mask. label, date and initial. Change humidifier bottle, label, date and initial. every night shift every Wed.
On 4/21/22 at 10:27 AM, in an interview with Resident #32's nurse, Licensed Practical Nurse (LPN) #18, she/he confirmed that the Oxygen tubing and humidifier bottle were not dated or initialed and could not tell when they were last changed. LPN #18 stated that they were supposed to be changed by the night shift nurse every Wednesday. LPN #18 immediately changed and dated the Oxygen tubing and humidifier bottle.
On Thursday 4/28/22 at 9:15 AM, Surveyor observed Resident #32's humidifier bottle almost empty and dated 4/23/22. Based on the physician orders the oxygen tubing and humidifier bottle should have been changed on Wednesday 4/27/22. This was brought to the attention of the Assistant Director of Nursing (ADON) who confirmed surveyor's findings.
On 4/28/22 at 11:24 AM, the Director of Nursing (DON) was made aware of surveyor's observations.
On 5/6/22 at 3:15 PM, surveyor further discussed concerns with the Administrator and DON during the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a clinical record, and complainant and staff interviews, it was determined that the facility fail...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a clinical record, and complainant and staff interviews, it was determined that the facility failed to identify a resident who was at risk for pressure wounds and implement and take steps to create a baseline care plan with nursing interventions to prevent a pressure wound. This was evident for 1 of 5 residents (Resident #65) reviewed for pressure ulcers during an annual recertification survey.
The findings include:
A pressure ulcer also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full-thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full-thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed).
A review of complaint MD00175030 on 04/22/2022 revealed Resident #65 developed a pressure wound after being in the facility for 1 week. The complaint indicated s/he was the person who initially identified Resident #65's pressure wound and informed the staff.
A review of Resident #65's medical record on 04/22/2022 revealed that Resident #65 was admitted to the facility on [DATE] with diagnoses that include a stroke, urinary tract infection, a Foley catheter, diabetes, and dementia. Resident #65 was assessed by the nursing staff on 03/23/2022 at 4:02 PM and noted Resident #65's skin to be intact. A baseline care plan for the potential for the development of pressure ulcer/injury was initiated on 03/23/2022 that included nursing interventions to perform a biweekly (twice a week) skin check on shower days, apply barrier cream during incontinence episodes, assist the resident with bed mobility and toileting as needed, assist/remind/cue resident to turn and reposition, and to follow facility policies/protocols for the prevention/treatment of skin breakdown.
A review of the facility's Pressure Injury Prevention and Management policy, implemented and dated June 2021, revealed that 3a) licensed nurses will conduct a pressure injury risk assessment, using the Braden scale, on residents upon admission/readmission, weekly for four weeks, then monthly or whenever the resident's condition changes significantly. 3b) the tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include, but are not limited to: i-Impaired/decreased mobility and decreased functional ability: ii-Co-morbid conditions such as end-stage renal disease, thyroid disease, or diabetes mellitus: iii-Drugs such as steroids that may affect healing: iv-Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency; v-Exposure of skin to urinary or fecal incontinence; vi-under nutrition, malnutrition, and hydration deficits; and vii-the presence of a previously healed pressure injury.
A review of Resident #65's physician admission progress note, dated 03/26/2022 at 7:37 PM, indicated that Resident #65 went to the hospital and was found to have an acute kidney injury and dehydration and was treated for UTI infection. Resident #65 was stabilized with IV antibiotics and his/her findings were positive for cachexia. Resident #65 meets the criteria for an end-stage condition. Resident #65's physician also diagnosed Resident #65 with dementia that seems to be progressive in nature and listed a plan of care that included staff to continue supportive care and encouraged oral hydration. Resident #65's physician also documented that Resident #65 was totally dependent on daily activities including feeding.
In an interview with Resident #65's physician (employee #26) on 04/25/2022 at 2:20 PM, Resident #65's physician said that Resident #65's skin was intact upon admission to the facility but that now s/he has a Stage III pressure wound. Resident #65's physician then stated that Resident #65 was at risk for developing pressure wounds upon admission and that the facility nursing staff assess all newly admitted residents' risk for developing a pressure wound by completing a Braden scale. Resident #65 was identified with a sacral pressure ulcer on 03/31/2022.
A review of Resident #65's nursing admission Braden scale, dated 03/24/2022 at 6:27 AM, revealed that the nursing staff indicated Resident #65 was assessed to be a low risk for developing pressure ulcers. The nursing staff indicated that Resident #65 had no sensory or perception impairment, was rarely moist, chairfast, and his/her ability to walk was severely limited or non-existent, his/her nutrition was adequate, and there was a potential problem with friction or shearing.
Further review of Resident #65's medical record revealed a nutritional assessment, dated 03/26/2022 at 1:06 PM, that identified Resident #65 as being malnourished and underweight.
In an interview with the facility wound consultant, staff member #57, on 04/27/2022 at 11:20 AM in person, the facility wound consultant stated that s/he first assessed Resident #65's sacral area wound on 04/04/2022 and noted the wound to be unstageable at that time due to 60% of the wound was necrotic. Initially, the facility wound consultant stated that s/he thought it may have been a Kennedy ulcer but stated no because Resident #65's wound was healing well.
A further review of Resident #65's March 2022 Geriatric Nursing Assistant(GNA) documentation on the Documentation Survey Report V2 on 04/27/2022 revealed that the GNA staff recorded during the day shift, 07:00 AM--3:30 PM between 03/23/2022 and 03/31/2022, that for only 1 out of 8 days in March 2022, staff documented that Resident #65 was turned and repositioned. 2 of the other day shifts, the GNA staff did not list any indication of care, and for 5 of the other day shifts the GNA nursing staff indicated 97 which meant not applicable regarding turning and repositioning of Resident #65.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation it was determined that the facility failed to ensure: 1) admitt...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation it was determined that the facility failed to ensure: 1) admitted with a Foley catheter was assessed for removal of the catheter timely (Resident #65); 2) follow a care plan which included positioning foley bag (Resident #57); 3) follow the physician's order for a follow-up appointment with a urologist 1 week after admission (Resident #57), and 4) follow a physician's order for catheter care (Resident #57). The failure of the facility to assess the foley catheter usage placed the resident at risk for infection. This was evident for 2 of 4 residents reviewed for foley catheters during the survey.
A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Always place the drainage bag below the level of the bladder and off the floor to prevent getting infections. (Foley catheter definition on www.merriam-webster.com)
1) Review of Resident #57's care plan on 4/25/22 at 12:20 PM indicated the resident had a care plan for a foley catheter related to neurogenic bladder. The interventions included, position catheter bag and tubing below the level of the bladder and away from the entrance room door.
An observation was made on 4/25/22 at 2:45 PM of Resident #57 lying in bed. Resident #57's foley catheter bag was lying on the floor of the resident's right-hand side which was nearby an entering door. On 4/25/22 at 2:50 PM, the Director of Nursing (DON) was present at the resident's bedside and saw the foley bag. The DON stated that the foley bag should not be lying on the floor and should be away from the entrance room door.
Further observation was made on 4/27/22 at 10:38 AM of Resident #57's room. Resident #57's foley bag was placed on the floor on the resident's left-hand side. On 4/27/22 at 11:10 AM, the DON was called in and made aware of the position of a foley bag. (Cross-reference F880)
A review of Resident #57's medical record on 4/26/22 at 11:10 AM revealed the resident was admitted to the facility in April 2022 from a hospital with a Foley catheter for chronic urinary retention. Review of the facility physician's order summary dated 4/18/22 showed the resident needed a follow-up appointment with a Urology within one week. However, there was no documentation found to support that the facility arranged a follow-up visit for the resident with the Urologist until the surveyor team alerted the facility staff on 4/27/22 at 3:10 PM. (Cross-reference F 684)
During the observation on 4/27/22 at 10:38 AM, Resident #47's foley bag was observed to be full. A second observation was made at 11:10 AM and the bag was still in the same position and had not been emptied. During the interview with the DON at 11:10 AM on 4/27/22, she verbalized the foley bag looked like it was not emptied during the night shift, and she also stated it should be emptied timely at least each shift.
Review of Resident #57's medical record on 4/27/22 at 11:00 AM revealed the physician's order dated 4/18/22 contained catheter care to be completed each shift, 16 French indwelling catheters, empty drainage each shift, ensure leg strap is in place, drainage bag is covered with privacy bag and placed below bladder lever, monitor for s/s of infection.
2) A review of Resident #65's medical record on 04/19/2022 at 2:44 PM revealed Resident #65 was admitted to the facility on [DATE] with diagnoses that included: stroke, urosepsis, dementia, diabetes, and acute kidney failure. Resident #65 was admitted with a Foley catheter in place. On 03/24/2022, Resident #65's physician instructed the nursing staff for Resident #65 to follow up with a urologist in 2 weeks and that the Foley catheter can stay in until being seen by the urologist. A further review of Resident #65's admission medical diagnoses did not reveal an indication, or diagnosis, for Resident #65's Foley catheter to remain in place.
In an interview with the facility director of nurses (DON) on 04/25/22 at 10:51 AM, the DON stated that s/he was unable to find the urology consult note as requested in the hospital discharge summary. The DON reviewed Resident #65's physician orders and noted that on 03/30/22 another order to follow up with the urologist for BPH (benign prostatic hypertrophy) was ordered. The facility DON stated that s/he will review the transportation log and get back to the surveyor.
In a follow-up interview with the facility DON on 04/25/22 at 11:10 AM, the DON stated that Resident #65 now has a urology appointment in May 2022 with the urologist.
In an interview with the urologist's office administrative staff person on 04/25/2022 at 1:20 PM, the administrative staff person stated that Resident #65's urology appointment was initially ordered on 03/30/2022 at 9:22 AM and then on 04/12/2022 the physician canceled the appointment.
In an interview with Resident #65's physician on 04/25/2022 at 2:20 PM, Resident #65's physician stated that s/he was waiting for Resident #65 functioning to get better and that Resident #65 had developed a pressure wound since being admitted . Resident #65's physician was then asked why Resident #65's urologist appointment for 04/12/2022 was canceled. Resident #65's physician stated that s/he was not aware of the appointment being canceled.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility failed to properly store medications as evidenced by fa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility failed to properly store medications as evidenced by failing to ensure that medication and treatment carts were locked when unattended. This was evident for 1 of 2 treatment carts observed on the 2nd floor unit.
The findings include:
Observation was made on 4/19/2022 at 9:12 AM while walking past resident room [ROOM NUMBER] and the bathing/shower room, of a treatment cart in the hallway which was unlocked and unattended. There were various ointments, resident labeled treatments, bandages, and other various nursing supplies observed in the cart. Approximately 1 minute later, the Assistant Director of Nursing (ADON) walked down the hall and observed that the treatment cart was left unlocked and unattended. The ADON stated the treatment cart was supposed to be always locked and then proceeded to lock it.
Review of the Medication Storage policy that was given to the surveyor by the Director of Nursing (DON) on 4/22/2022 at 8:40 AM during the survey stated in #1 General Guidelines: All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.
The Administrator and the DON were made aware of surveyor's concerns prior and during the survey exit on 5/6/2022 at 3:15 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interviews, and medical record review, it was determined that the facility failed to provide dental services within a reasonable time frame following a physici...
Read full inspector narrative →
Based on observation, resident and staff interviews, and medical record review, it was determined that the facility failed to provide dental services within a reasonable time frame following a physician's dental consult request. This was evident for 1 of 2 residents (Resident #26) reviewed for dental.
The findings include:
During an introductory interview of Resident #26 on 4/20/22 at 12:51 PM, it was revealed the resident had a concern about a loose upper front tooth. Resident #26 acknowledged that staff was informed, and the resident was reportedly on a list to be seen by a dentist. Resident #26 was unaware of a date or time of schedule to be seen by a dentist.
A review of Resident #26's medical record on 4/25/22 at 10:13 AM revealed a change of condition progress note written on 2/10/2022 at 2:45 PM. The summary of the change of condition was written as; Resident reported two shaky upper front teeth. attending MD made aware. The Resident verbalized that he/she is unable to drink cold water because of the painful sensation around the teeth when he/she does. MD orders Dental consult.
A physician prescribed order was written on 2/11/22 for DENTAL CONSULT DUE TO LOOSE TEETH. A continued review of Resident #26's medical record did not reveal additional documentation related to the order for a dental consult or follow for care needs related to the resident's teeth.
A follow-up interview was conducted with Resident #26 on 5/2/22 at 2:25 PM. Resident #26 indicated that he/she has not been seen by the dentist and he/she has so much pain he/she uses warm water swishes and is given Tylenol.
On 5/4/22 at 9:44 AM the DON was asked generically about how and who is responsible for making appointments for dental consultations. The DON indicated that depending on the resident's insurance a resident is either sent out or dental comes to the facility. She indicated that the medical records person or the social worker will make appointments for residents. The DON was informed that Resident #26 has had an order since 2/11/22 for a dental consultation due to lose teeth with pain and that there was not any follow-up information related to the order of 2/11/22. She indicated that she would need to follow-up.
The medical records person (Staff #51) was interviewed at 2:00 PM on 5/4/22. She was asked about a dental consult for Resident #26. She implied that she never received the information and that if she does not get the information, she does not know to make an appointment.
The DON was informed at 2:19 PM on 5/4/22 of the interview with the medical records person #51. The DON revealed that per the social worker the resident will be seen by a Medicaid insurance group referred to as 360.
The social worker was interviewed on 5/5/22 at 2:23 PM. She was asked about a dental consult for Resident #26 and when will the resident be seen by a dentist. She indicated that the resident originally was not signed up to participate in the Medicaid 360 insurance program and the resident has since been signed up. She indicated that the next time the 360 group/dental will be on site is in June 2022. The surveyor informed the social worker of the resident's dental concerns that originated on 2/10/22 and the resident's dental condition was not addressed in the resident's care plan or by the resident's attending physician.
On 5/6/22 at 10:16 AM the DON was informed about the interview with the social worker on 5/5/22 and she revealed that the resident had an appointment to be seen on 5/6/22.
The facility staff failed to obtain a dental consult for the resident, and following surveyor intervention, a dental consultation was scheduled for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, and staff interview it was determined that the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Th...
Read full inspector narrative →
Based on observation, and staff interview it was determined that the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This was found to be true for 1 of 2 units (3rd floor) observed during the environmental tour of the facility. This deficient practice has the potential to affect all residents, staff, and visitors on the unit.
Findings include:
An environmental tour of the facility was conducted on 05/03/22 at 1:25 PM with the facility maintenance director. Observation of the 3rd floor Long Term Care Unit revealed that 2 facility geri chairs were noted with armrests in disrepair. (A geri chair is a Medical Recliner Chair designed to allow someone to get out of the confines of their bed and be able to sit comfortably in a variety of positions while being fully supported.)
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
3) During an observation of the 2nd-floor nursing unit on 04/25/22 at 12:30 PM, GNA #22 was observed pulling Resident #21 backwards down the hallway towards the main dining area while the resident was...
Read full inspector narrative →
3) During an observation of the 2nd-floor nursing unit on 04/25/22 at 12:30 PM, GNA #22 was observed pulling Resident #21 backwards down the hallway towards the main dining area while the resident was seated in a Geri chair.
This concern was reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
4) During an observation of the 3rd-floor nursing unit on 4/26/22 at 12:53 PM, GNA #34 was observed assisting Resident #65 eating in the resident's room. Resident #65 was sitting on his/her bed and GNA #34 was standing over the resident.
This concern was reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
These concerns were discussed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
Based on observation and staff interview, it was determined that the facility staff failed to provide residents with dignity and respect by improperly transporting residents down the hall (Resident #70, Resident #173 Resident #21 and assisting a resident to eat (Resident #65). These events were evident during 5 random observations on the facility nursing units during the survey.
The findings include:
1) During an observation of the 3rd-floor nursing unit on 04/20/2022 at 11:11 AM, therapy staff member #14 was observed pulling Resident #70 backwards in a wheelchair down the hallway towards the main dining area.
A review of Resident #70's medical record revealed that Resident #70 was measured to be 72 inches tall during the admission process on 04/01/2022.
In an interview with Resident #70 in the resident's room on 04/20/2022 at 12:25 PM, Resident #70 stated that he/she was currently receiving therapy services for standing and balance. The surveyor observed Resident #70's wheelchair sitting against the wall at the end of his/her bed. The surveyor asked Resident #70, do you have footrests that go to your wheelchair? Resident #70 stated no, I cannot find them. The surveyor then asked Resident #70, does it bother you that staff pull you backwards down the hall instead of facing forward when ambulating you in your wheelchair? Resident #70 stated that his/her feet get tangled underneath the wheelchair because of the lack footrests.
2) During an observation of the 3rd-floor nursing unit on 04/22/2022 at 1:36 PM, the surveyor observed a Geriatric Nursing Assistant (GNA) #36 pulling Resident #173 backwards in a geri chair (a medical chair that can recline) down the hallway towards Resident #173's room.
During a second observation of the 3rd-floor nursing unit on 04/22/2022 at 1:45 PM, the surveyor observed GNA #36 again pulling Resident #173 backwards in a geri chair down the hallway towards the main dining area.
In an interview with Resident #173 on 04/22/2022 at 1:45 PM, the surveyor asked Resident #173 if it bothered him/her that staff members pull him/her backwards while ambulating down the hallway. Resident #173 stated, no. In an interview with GNA #36 on 04/22/2022 at 1:45 PM, GNA #36 stated that s/he was bringing Resident #173 back to his/her room to see if Resident #173 was wet (incontinent).
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM and again reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
4) On 5/2/22 at 9:14 AM, a review of the facility reported incident MD00175139 revealed that Resident #275 reported that GNA #53 used foul language when Resident #275 requested care on 2/22/22.
Verba...
Read full inspector narrative →
4) On 5/2/22 at 9:14 AM, a review of the facility reported incident MD00175139 revealed that Resident #275 reported that GNA #53 used foul language when Resident #275 requested care on 2/22/22.
Verbal abuse was substantiated by the facility and GNA #53 was terminated. The facility's self-report form indicated the resident was assessed for injury or pain. However, there was no documentation to support Resident #275's assessment such as a progress note, change of condition, head-to-toe assessment, or evidence a psych consult was ordered. Also, there was no statement from the perpetrator and/or record of interviews of other residents to whom the accused employee provided care or services.
5) On 5/2/22 at 1:17 PM , a review of the record of the facility reported incident MD00173245 revealed that Resident #276 reported that GNA #56 hit the resident on 10/17/21. Further review of the facility investigation revealed the facility was not able to substantiate the abuse based on the resident statements and witness statements. According to the facility investigation record, upon interview of the resident, Resident #276 stated, nobody hit me, it's too hard to turn in the bed cause it hurts. The facility obtained 3 witness statements from the staff. All three staff denied the abuse incident on Resident #276. However, the facility failed to document Resident #276's assessment regarding the abuse report. Also, there was no statement from the perpetrator and/or record of interviews of another resident to whom the accused employee provided care or services.
Based on interview and review of facility reported incident (FRI) investigation documentation it was determined the facility staff failed to thoroughly investigate incidents of alleged verbal and physical abuse. This was evident for 5 of 6 residents (Resident #9, #225, #226, #275, #276) reviewed for abuse.
The findings include:
1) On 4/28/2022 at 2:00 PM, review of the facility reported incident MD00140599 revealed that Resident #9 had alleged that GNA #33 slapped him/her. The facility administrative staff investigated and substantiated the allegation of physical abuse and terminated GNA #33. Resident #9's roommate was noted as not a reliable witness and was not interviewed. However, other residents to whom the accused employee provided care or services were not interviewed.
On 5/4/2022 at 10:36 AM, in an interview with the Administrator, she/he was made aware that no other residents on GNA #33's assignment had been interviewed. The Administrator stated she/he had no further information to give the surveyor.
2) On 4/29/2022 at 2:15 PM, review of the facility reported incident MD00149102 revealed that on 12/16/19 at 2pm, Resident #226 reported to the unit manger that GNA #34 who was taking care of him/her on 12/15/19 hit them in the back of their neck. Further review of the facility investigation revealed the facility was not able to substantiate the allegation of abuse, however the facility failed to do a thorough investigation. The facility failed to interview other staff members or residents during the investigation.
On 5/2/2022 at 9:53 AM, the Administrator and the DON were asked for copies of the written statements by the other residents to whom the accused employee provided care or services that were interviewed. The Administrator stated that she/he could not find any additional documents pertaining to the above allegation. She/he further stated that she/he was not working in the facility at the time of the incident and did not have access to the records.
3) Review of facility reported incident MD00166279 on 5/2/2022 revealed that Resident #225 reported on 4/15/2021 that GNA #35 was rough, loud and would not let them sit back down when they requested to because of leg pain. Verbal abuse was substantiated by the facility and GNA #35 was terminated, however a thorough investigation was not done. There was no statement from the perpetrator and/or record of interviews of other residents to whom the accused employee provided care or services.
The Director of Nursing (DON) was interviewed on 5/2/2022 at 1:19 PM and could not provide any further documentation and stated that the former DON who completed the investigation no longer worked in the facility.
On 5/4/2022 at 10:36 AM, in an interview with the Administrator, she/he was made aware that the facility staff did not conduct a thorough investigation of the above allegation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) An observation was made on 4/20/22 at 10:13 AM of Resident #57 who was in a semi-sitting position (30-45 degrees) in bed. A s...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) An observation was made on 4/20/22 at 10:13 AM of Resident #57 who was in a semi-sitting position (30-45 degrees) in bed. A second observation was made on 4/20/22 at 11:52 AM, the resident was in the same position (semi-sitting position). A third observation was made on 4/20/22 at 1:18 PM, the resident was in the same position.
A review of Resident #57's medical record on 4/20/22 at 08:30 AM revealed the resident was re-admitted to the facility on [DATE] from an acute care facility with diagnoses including, but not limited to, quadriplegia (a condition in which you have muscle weakness in all four of limbs, both legs and both arms. This weakness and diminished mobility can be temporary or permanent), pulmonary embolism, and pressure wound on the sacrum and Left lateral heel, and vascular wound on Right lateral lower leg.
A review of the order summary for Resident #57 on 4/26/22 at 10:31 AM revealed that the resident had an order for turning and repositioning the resident every two hours or as needed. Further review of Resident #57's treatments administration record documented that the facility staff did the resident's turn and reposition every shift.
An interview was conducted with a Geriatric Nursing Assistant (GNA) #38 on 4/26/22 at 11:25 AM. GNA #38 stated that she did not turn and reposition Resident #57 since the resident had not requested it.
During an interview with Resident #57 on 4/27/22 at 1:20 PM, the resident said, I'm comfortable in this position, want to keep it. The resident denied that changing positions was performed by staff, the resident stated that he/she wanted to stay in the same position.
A review of the care plan for Resident #57 was conducted on 4/27/22 at 2:30 PM. There was no care plan related to the refusal of turning and repositioning.
The Director of Nursing was made aware of this on 4/27/22 at 3:05 PM.
4) On 4/29/22 at 10:30 AM, a review of the facility reported incident MD00173245 revealed that Resident #273 had alleged unknown discoloration on the left upper back and back of the left hand on 11/30/2021. Further review of the facility injury report indicated, Patient has a diagnosis of leukemia and bruises easily, the patient is also on Aspirin daily. However, a review of the care plan for Resident #273 on 4/29/22 at 11:36 AM revealed that there was no care plan or intervention initiated regarding the high risk of bruising.
During an interview with the Director of Nursing (DON) on 4/29/22 at 1:34 PM, she was asked to provide a care plan related to Resident #273 being at high risk for bruising due to a medical diagnosis. The DON confirmed that the care plan was not updated regarding this unknown bruise and injury of unknown origin.
5) A review of Resident #58's clinical record on 04/29/2022 at 3:30 PM revealed Resident #58 was readmitted to the facility on [DATE] with diagnoses that include: urinary retention, hematuria, bilateral pulmonary embolism, and a Foley catheter. Upon admission, Resident #58 was placed on the anticoagulant, Eliquis, 5 mg, orally, twice daily, for bilateral pulmonary embolisms. Taking this medication may increase the risk of bleeding. A care plan to address the risk of bleeding was not developed.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
Based on record reviews, observation, and staff interview, it was determined that the facility failed to: 1) develop and implement comprehensive person-centered care that were resident specific with measurable objectives and goals (Resident #26, #66, #57, #273) and 2) develop a care plan to address the use of an anticoagulant (Resident#58). This was evident for 5 out of 55 residents reviewed during an annual recertification survey.
The findings include:
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.
1) Resident #66's medical record was initially reviewed on 4/20/22 and revealed diagnoses included but were not limited to muscle weakness, difficulty walking, and abnormal posture. The medical record indicated that rehab therapy ended on 6/12/20 and the resident was to continue with a restorative nursing program. Review of the physician orders revealed that three orders were written on 6/12/20 labeled as Restorative Nursing Program. The 3 orders were written as nursing to don (AFO) ankle-foot orthosis and knee brace on LLE (left lower extremity) before ambulation, doff after ambulation 2) Nursing to assist patient ambulate using front wheeled walker with CGA, Gait belt on, with ankle-foot orthosis and knee brace on left lower extremity for 25-50 as tolerated by the patient 3) Nursing to assist patient with functional transfers from bed to/from wheel chair, wheel chair to/from toilet with CGA-min assist, with gait belt on. All three-orders indicated every day shift.
Review of the resident's care plans on 5/4/22 did not reveal any care planning related to a nursing restorative program. There was not an intervention to ambulate the resident with assistance.
A plan of care was written for a focus area of potential for fall related to impaired mobility, incontinence. The goal was written as [Resident #66] will have decreased risk of falls with intervention through the review date. The goal is not measurable as it did not quantify what are the risk factors for this resident.
Concerns of care planning and lack of evaluations were discussed with the DON on 5/4/22 at 11:39 AM.
2) Review of Resident #26's medical record on 4/20/22 at 10:43 AM revealed 2 orders written on 10/28/21 for Restorative program. 1) Nursing will assist patient with ambulation (walk to dine) 100-150 feet using hemi-walker as tolerated with gait belt with contact guard assist. This task will take at least 15 minutes to complete. one time a day, 2) Nursing will assist patient with functional transfers from bed <>w/c <> commode with contact guard assist as tolerated. This task will take at least 15 minutes to complete one time a day.
Review of Resident #26's care plan on 5/4/22 revealed there was a focus area that the resident had an actual fall related to poor balance and poor safety awareness initiated on 10/18/21 and revised on 4/21/22. The goal was written that the resident will be free of injuries related to fall through the review period. The interventions were written as: Bed in low position, non-skid socks and shoes, and PT consult /screen for transferring. There were not any written interventions to assist the resident with ambulation. The care plan was not resident centered as there was not any documentation of restorative care and the interventions that were to be provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on observation, medical record review and staff interview it was determined the facility failed to have a process to ensure that residents with a limited range of motion received the appropriate...
Read full inspector narrative →
Based on observation, medical record review and staff interview it was determined the facility failed to have a process to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 3 of 4 residents (Resident #21, #26, #66) reviewed for limited range of motion during the survey.
The findings include.
1) Resident #21's medical record was reviewed on 4/20/22 at 1:15 PM. A physician's order dated 11/5/21 was found in the electronic health record (EHR) and written as Functional Maintenance Program, Nursing to donn knee brace to right knee and doff after 4-6 hrs (hours) during the day time, Please do skin check before and after if any skin changed noted discontinue brace until further assessment, Nursing to position right knee with pillow and wedge support during Night time for pressure relief and to minimize contracture, donn waffle boot to bilateral foot. No documentation was found to indicate staff sign off daily to show compliance with the physician's order.
Observations of Resident #21 on 4/25/22 at 12:37 PM and 2:36 PM revealed that the resident was not wearing a knee brace. The Licensed Practical Nurse (LPN) #19assigned to Resident #21 was interviewed at 2:36 PM on 4/25/22. She was asked about the resident's knee brace, and she responded that she has not seen the brace since she started working at the facility. When asked, she indicated that she started working at the facility in January 2022.
At 3:05 PM on 4/25/22, a GNA #22 was observed to apply a knee brace on Resident #21's right leg.
An interview was conducted with the nursing home administrator (NHA) and the director of nursing (DON) at 3:00 PM on 4/26/22. The DON stated that they do not have a restorative program here at the facility. She indicated that the order to don and doff the knee brace daily for Resident #21 was not put into the EHR system correctly. Showing a printed copy of the order she revealed that the Order Type was incorrectly identified as Restorative. The order did not transfer to the Treatment administration record (TAR). She indicated that there was not any place in the EHR to document daily compliance for application of the right knee brace.
Review of Resident #21's care plans on 5/2/22 at 9 AM revealed an identified Focus area initiated on 3/14/21 related to the resident having an activity of daily living self-care performance deficit. The goal was written as the resident will improve current level of function with the intervention of rehab services. The interventions indicated that the resident was totally dependent on staff for personal hygiene, oral care, dressing, and transfers. On 4/19/22, right knee brace on 4-6 hours during the day was added.
2) Resident #66 was interviewed on 4/20/22 at 11:22 AM. Resident #66 revealed he/she has limited extent of movement of joints. Resident #66 indicted that he/she is to be walked daily, and he/she was informed that there is not enough staff to be walked daily. Resident #66's EHR orders were reviewed during the interview and a physician's order revealed indicating Resident #66 should be assisted with ambulation.
The resident's physician orders for Restorative Nursing program were reviewed with the DON on 4/26/22 at 3:05 PM. Three orders were written on 6/12/20 were labeled as Restorative Nursing Program, 1) nursing to don (AFO) ankle-foot orthosis and knee brace on LLE (left lower extremity) before ambulation, doff after ambulation 2) Nursing to assist patient ambulate using front wheeled walker with CGA, Gait belt on, with ankle-foot orthosis and knee brace on left lower extremity for 25-50 as tolerated by the patient 3) Nursing to assist patient with functional transfers from bed to/from wheel chair, wheel chair to/from toilet with CGA-min assist, with gait belt on. All three-orders indicated every day shift.
The DON acknowledged that there was not a place for staff to sign off daily as the three orders were not transcribed correctly and the orders did not transfer to the treatment administration record.
Review of the medical record on 5/4/22 revealed that all three restorative orders were discontinued. The order to assist resident to ambulate was discontinued on 4/20/22 and the other 2 Restorative Nursing program orders were discontinued on 4/26/22. No documentation was found as to a reason that the orders were discontinued.
Further EHR review of the resident's care plans revealed that there were no interventions documented to assist the resident with functional transfers, don a AFO and knee brace prior to ambulating, or assist resident with a gait belt on for functional transfers.
3) Review of resident #26's medical record on 4/20/22 at 10:43 AM revealed 2 orders written on 10/28/21 for Restorative program. 1) Nursing will assist patient with ambulation (walk to dine) 100-150 feet using hemi-walker as tolerated with gait belt with contact guard assist. This task will take at least 15 minutes to complete. one time a day, 2) Nursing will assist patient with functional transfers from bed <> w/c <> commode with contact guard assist as tolerated. This task will take at least 15 minutes to complete. one time a day. Both restorative orders were documented on the treatment administrative record (TAR) for 9:00 AM. Nurses consistently sign the TAR as task completed. During the survey the resident was not observed ambulating to dine and was always observed in a wheelchair.
On 5/4/22 at 10:30 AM review of the resident's medical record revealed he/she was found on the bathroom floor and was assessed to have fallen on 4/20/22. The resident was evaluated by rehab and rehab physical therapy was initiated for new onset reduced dynamic balance, decreased strength, decreased functional mobility, increased need for assistance from others and decreased neuromotor control. As of 4/26/22 rehab staff assessed the resident's baseline for safe ambulation using a hemi-walker was 10 feet. The nurses were signing off that the resident ambulated 100 - 150 feet daily without any notes that the resident was unable to perform ambulation for the restorative program.
The director of rehabilitation was interviewed on 5/4/22 at 11:53 AM. She showed and demonstrated the hemi-walker that was kept in the nursing station. She was informed that the nurses were documenting daily that the resident was ambulating a greater distance than the rehab assessed baseline of 10 feet.
Review of the TAR at 1:05 PM on 5/4/22 revealed that the restorative order for ambulating Resident #26 was signed off by the licensed practical nurse #42 assigned to the resident. The nurse was interviewed at this time and was asked how far did the resident ambulate today? She asked what the resident's room number was, reviewed a sheet of paper and stated that she did not see the resident ambulate today.
The resident's care plan was reviewed after the interaction with the resident's nurse. Review of the care plan revealed there was a focus area that the resident had an actual fall related to poor balance and poor safety awareness initiated on 10/18/21 and revised on 4/21/22. The goal was written that the resident will be free of injuries related to fall through the review period. The interventions were written as; Bed in low position, non-skid socks and shoes, and PT consult /screen for transferring. There were not any written interventions to assist the resident with ambulation.
The DON was interviewed on 5/6/22 at 10:16 AM and was informed that the nurse had signed off on an order that was not performed with the resident. She indicated that the resident does walk and discussed that the resident was recently picked up by physical therapy and the evaluated ambulation baseline was only 10 ft and there was no supporting documentation by the nurses as to the resident's progress related to assisted ambulation. She was informed of the lack of care planning. She was shown were a nurse indicated the resident had refuse ambulation on 5/1/22 and there was not any additional documentation related to the resident's refusal.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on observations, staff interviews, and record review, it was determined that the facility failed to obtain accurate weights and verify weights as needed. This was found to be evident for 4 resid...
Read full inspector narrative →
Based on observations, staff interviews, and record review, it was determined that the facility failed to obtain accurate weights and verify weights as needed. This was found to be evident for 4 residents out of 4 residents (Resident #3, #57, #176, #178) reviewed for nutrition and hydration during an annual recertification survey.
The findings include:
Mechanical lifts are devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone. They include floor lifts, sit-stand lifts, and ceiling track lift systems. Some of these lifts can obtain weights on residents. A Hoyer lift is a kind of mechanical lift. (New York State of Opportunity- Health and Safety Alert)
1) An electronic medical record review of Resident #57 was conducted on 4/26/22 at 11:11 AM. The resident's body weight was recorded as:
3/22/22 - 255 lbs. (lift scale)
3/24/22 - 256 lbs. (Hoyer #1)
3/25/22 - 257.7 lbs. (Mechanical Lift)
However, these recorded body weights were crossed out by the facility Dietitian #52. Further medical record review revealed that Dietitian #52 wrote a nutrition note under the resident's progress note on 4/21/22; Weights gathered from 3/22-3/25/ inaccurate, weights then verified for correct weights on April 6, April 19th, and April 20th. Will strikeout weights that were inaccurate. Some variance was noted in Hoyer lifts but verified for accuracy with the most recent weights. BMI still indicates obese I at 30.9
Further medical record review for Resident #57 revealed that Resident #57's initial body weight was 225 lbs. via Hoyer lift on admission date 3/16/22. The resident was transferred to a hospital for lethargy and respiratory distress on 3/29/22. Resident #57 was readmitted to this facility on 4/5/22. The resident bodyweight was 228 lbs. via Hoyer lift on 4/6/22.
An interview was conducted with the maintenance director on 4/26/22 at 1:20 PM. He stated the facility had 3 Hoyer lifts; one for just lifting, and two for lifting and measuring weight.
An interview was conducted with the director of nursing (DON) on 4/27/22 at 9:44 AM. The DON confirmed that Dietitian #52 had worked remotely and had never been in the facility building. The surveyor asked the DON how Dietitian #52 had recognized Resident #57's weight record was inaccurate and that there was an issue with the Hoyer lift scale. The DON stated Dietitian #52's progress note was unreliable.
The surveyor requested any documentation to support how the facility verified weight measurements when Resident #57's weight was changed and reassessed interventions. No other documentation was submitted prior to survey exit. 2) A review of Resident #3's documented weights for the past month, on 05/05/2022 at 2:30 PM, revealed the following:
04/05/2022 - 192.8 pounds
04/06/2022 - 191.2 pounds
04/11/2022 - 193.2 pounds
04/18/2022 - 191.7 pounds
05/05/2022 at 12:25 PM - 158.2 pounds
The weight difference between the 04/05/2022 weight of 192.8 pounds and the 05/05/2022 weight of 158.2 pounds is 34.6 pounds (17.9%). A review of Resident #3's April 2022 documented amount of meals consumed revealed that Resident #3 consistently consumed 76-100 % of his/her breakfast, lunch and dinner.
A review of the facility weight monitoring policy revealed the following:
6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant weight change is defined as:
a. 5% change in 1 month (30 days)
b. 7.5 % change in 3 month (90 days)
c. 10% change in weight in 6 months (120 days)
7. Documentation:
a. The physician should be informed of a significant weight change in weight and may order nutritional intervention.
h. Notification to the resident and/or representative of any significant weight change.
Further review of Resident #3's medical record on 05/05/2022 at 2:30 PM revealed a 05/05/2022 12:25 PM recorded weight of 158.2 pounds. In an interview with the third-floor charge nurse Staff #44 on 05/05/2022 at 2:50 PM, the third-floor charge nurse stated that Resident #3's weight was documented correctly and that s/he oversaw the staff weigh Resident #3 in his/her wheelchair on the third-floor hallway scale. The third-floor charge nurse stated that s/he was not aware of Resident #3's previously recorded weights. Medical record review did not reveal any documentation Resident #3's physician or representative were notified of the significant weight change. On 04/04/2022, the facility dietician documented Resident #3 has alterations in nutrition/hydration related to medical issues and that Resident #3 frequently chooses not to follow diet recommendations. The facility dietician noted Resident #3 had weight gain on 04/06/2022.
In an interview with the facility director of nurses (DON) on 05/05/2022 at 3:15 PM, the DON was made aware of Resident #3's current documented weight of 158.2 pounds as recorded by the facility staff on 05/05/2022. The facility DON stated that s/he just got off the phone with staff #44 regarding another resident's documented weight regarding significant weight loss. The DON stated that s/he would investigate Resident #3's newly charted weight and get back with the surveyor. The DON was asked if the difference documented in Resident #3's weight could have been user error or a mechanical scale error? The facility DON did not produce any type of quality assurance assessment regarding documented resident weight issues since being hired at the facility in July 2021.
In a follow-up interview with the facility DON on 05/06/2022 at 11:33 AM, the facility DON stated that s/he weighed herself/himself on her/his scale at home and then compared the weight to the third-floor scales. The DON stated that as of 05/06/2022, the weight scales on the third floor are inaccurate. The DON stated that s/he contacted the facility maintenance director to obtain a company to calibrate the facility scales.
3) Review of complaint MD00170930 on 04/25/2022 revealed an allegation Resident #178 had a significant weight loss that was not identified by the facility nursing staff. On 08/20/2021, Resident #178's admission weight at the receiving long-term care facility was 81.6 pounds. A review of Resident #178's closed medical record revealed documentation, dated 08/20/2021 at 11:26 AM revealed that Resident #178 was transferred to another long-term care facility. Resident #178's family initiated this transfer.
In an interview with the receiving facility administrator on 05/04/2022 at 11:50 AM, the receiving facility administrator stated that Resident #178's admission weight was 81.6 pounds. Additional weights were also obtained from the administrator.
In an interview with the facility DON on 05/04/2022, 11:50 AM, the DON stated, I believe the admission weight at the receiving facility was incorrect when Resident #178 was admitted . I called the facility in August 2021 and spoke to the facility ADON, it may have been over a weekend, and the receiving facility ADON stated that Resident #178's admission weight had been wrong and subsequent weights were in the 120's.
In a second phone call to the receiving facility, the facility administrator indicated the following August/September 2021 weights were recorded for Resident #178 after the 08/20/2021 admission as:
08/20/2021: 81.6 pounds
08/21/2021: 81.4 pounds
08/24/2021: 84.8 pounds
08/27/2021: 81.9 pounds
08/31/2021: 86.4 pounds
09/03/2021: 86.5 pounds
4) Review of complaint MD00175144 on 05/04/2022 revealed an allegation Resident #176 had a significant weight loss and that the communication from the facility staff was poor.
In an interview with the MD00175144 complainant on 05/04/2022 at 9:55 AM, the complainant stated that s/he was not made aware of Resident #176's weight loss in November 2021 and that communication from the facility was poor.
A review of Resident #176's closed medical record revealed nursing documentation that on 10/05/2021 at 12:04 PM, Resident #176's standing weight was 139.6 pounds. On 11/03/2021 at 3:29 PM, the nursing staff documented Resident #176's weight via wheelchair to be 110.6 pounds. On 11/08/2021 at 11:37 PM, the nursing staff documented Resident #176's weight via wheelchair to be 110.8 pounds. Between 10/05/2021 and 11/03/2021, the nursing staff documented a 29-pound (20.7%) weight loss. The 11/08/2021 documented reweigh of 110.8 pounds for Resident #176 also shows a significant weight loss of 28.8 pounds (20.6%). Further review of Resident #176's closed medical record failed to reveal Resident #176's physician or representative were immediately made aware of the significant weight loss on 11/02/2021 or 11/08/2021.
Further review of Resident #176's closed medical record revealed that the facility dietician #53, erroneously crossed through Resident #176's documented weights (11/03/21 of 110.6 and 11/08/21 of 110.8) and on 11/17/2021 at 1:34 PM noting Resident #176's documented weight on 11/16/2021 at 2:57 PM of 111.6 pounds was valid. Dietician #53 documented that Resident #176 had a significant weight loss on 11/17/2021 at 3:53 PM. There was no indication why Dietician #53 struck out weights on 11/03/2021 and 11/08/2021.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On 4/22/22 at 9:50 AM review of the electronic and paper record for Resident #41 revealed the resident was admitted to the fa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On 4/22/22 at 9:50 AM review of the electronic and paper record for Resident #41 revealed the resident was admitted to the facility on [DATE]. Further review of the resident's electronic medical record revealed a generic progress note written by the consultant pharmacist. The note was a late entry written on 3/31/2022, for a review completed on 3/13/2022. The pharmacist identified a medication irregularity and wrote should Heparin order include a length of therapy? Please evaluate the benefit/risk of using Tizanidine. Are Tizanidine, Baclofen, and Diazepam all needed for spasms? Another note was created on 4/22/22 as a late entry from a review completed on 4/13/2022. The pharmacist wrote, Are Tizanidine, Baclofen, Gabapentin, and Diazepam all needed for Muscle spasms? Are Trazodone and Melatonin both needed for Insomnia? Please evaluate the benefit/risk for Tizanidine.
An interview conducted with the DON on 4/22/22 at 10:30 AM revealed the DON was asked if the medication irregularity identified by the pharmacist in March 2022 and April 2022 was evaluated by the resident's attending physician. The DON returned at 11:55 AM and confirmed that there was no documentation regarding the attending physician's evaluation for March 2022 and April 2022 addressing the medications in question.
5) On 4/22/22 at 10:30 AM review of the electronic and paper record for Resident #67 revealed a generic progress note written by the consultant pharmacist. The note was a late entry written on 3/31/2022, for a review completed on 3/13/2022. The pharmacist identified a medication irregularity and wrote Is Trazodone for Insomnia still needed? If so, please evaluate if a dosage reduction could be attempted at this time. Is a sliding scale insulin order still needed? Please evaluate if a Nortriptyline dosage reduction could be attempted at this time. Another note was created on 4/22/22 as a late entry from a review completed on 4/13/2022. The pharmacist wrote, Please evaluate potential Vancomycin and Ceftazidime effect on Coumadin. Sevelamer suggested for dosing with meals.
An interview conducted with the DON on 4/22/22 at 10:30 AM revealed the DON was asked if the medication irregularity identified by the pharmacist in March 2022 and April 2022 was evaluated by the resident's attending physician. The DON returned at 11:55 AM and confirmed that there was no documentation regarding the attending physician's evaluation for March 2022 and April 2022 addressing the medications in question.
2) On 4/27/22 at 12:36 PM, medical record review revealed that Resident #31 was admitted to the facility on [DATE] with a diagnoses that included Dementia, Depression, and chronic Atrial Fibrillation.
On 4/27/22 at 2:12 PM, review of the Pharmacist monthly medication review progress notes from December 2021 through April 2022 revealed late entry notes with suggest PRN (as needed) Acetaminophen order indicates not to exceed 3 gm/day and No recommendation indicated for 1/10/22, 2/8/22, 3/13/22, and 4/13/22.
On 4/27/22 at 2:35 PM, in an interview with the DON, she/he stated that the Drug Regimen Review policy given to the other surveyor was the only policy they have. That policy was reviewed and did not address time frames for steps in the MRR process and steps the Pharmacist must take when an irregularity requires urgent action.
3) On 4/27/22 at 2:30 PM, medical record review revealed that Resident #24 was admitted to the facility on [DATE] with diagnoses that included Dementia and Depression.
On 4/27/22 at 2:40 PM, review of pharmacy progress notes revealed late entry monthly medication regimen review notes for 11/8/21, 12/8/21, 2/22/22, and 3/13/22 with No recommendations indicated. For 1/10/22 the following was noted; Please evaluate if Seroquel and/or Trazodone dosage reductions could be attempted at this time. For 4/13/22 the note was: Please clarify Seroquel diagnosis of Psychosis.
On 4/28/22 at 11:00 AM, review of the Medication Administration Record for the month of April 2022 was completed. Ongoing review of the medical record did not reveal that the identified medication irregularity for 4/13/22 was evaluated by the resident's attending physician.
On 5/5/22 at 11:20 AM, in an interview with the Medical Director, he/she stated that the Pharmacist's recommendations were flagged for the attending physician to review every 24 hours to 48 hours. However, physicians should review residents' charts every 24 hours. The Medical Director further stated that the recommendations moving forward was for the pharmacist to attend the Quality Assurance Performance Improvement meetings to discuss medication issues.
On 5/6/22 at 3:15 PM, all concerns were addressed with the Administrator and the Director of Nursing prior and during the survey exit conference.
6) A review of complaint MD00164719 on 05/06/2022 revealed allegations Resident #180 was not provided with a quality of care while s/he resided in the facility.
A review of Resident #180's closed medical record initially failed to reveal any monthly pharmacy reports. In an interview with the facility director of nurses (DON) on 05/06/2022 at 11:20 AM, the DON stated that the current pharmacist consultant started working for the facility in February 2020. After obtaining a copy of the pharmacist consultant's review of Resident #180's medication on 03/11/2021 from the DON, the pharmacy consultant suggested adding not to exceed 3 gm/day to Resident #180's order for Tylenol. The 03/11/2021 pharmacy consultants report was not initially located in the closed record. There was no indication that Resident #180's physician reviewed the recommendation and signed off as accepting or declining the recommendation.
A review of the facility policy Drug Regimen Review on 05/06/2022 at 11 AM revealed under #5) Documentation shall include whether any clinical significant medication issues were identified, and how the issues were addressed. Documentation to support follow-up on identified issues shall include: a. Two-way communication (in person, by telephone, voice mail, electronic means, facsimile, or other) between the clinician(s) and the physician by midnight of the next calendar day, AND b. All-physician-prescribed/recommended actions were completed within a reasonable time.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
Based on medical record review and staff interview it was determined the facility staff failed to have a process to ensure that medication regimen reviews occur monthly for all residents and pharmacist recommendations were timely acted upon and documented in the resident's medical record. This was evident for 6 of 6 residents (Resident #24, #28, #31, #41, #67, #180) reviewed for unnecessary medications. Additionally, the facility failed to develop policies and procedures related to time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
The findings include:
Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities.
1) Resident #28's medical record was reviewed on 4/21/22 at 2:52 PM. Resident #28 was admitted to the facility on [DATE]. Monthly Medication regimen reviews were not readily found in Resident #28's medical record. At 3:00 PM on 4/21/22 the nursing home administrator was asked to provide a copy of the facility's Monthly medication regimen review policy. On 4/22/22 at 9:30 AM the director of nursing (DON) revealed that the pharmacist documents the monthly medication reviews in the Electronic Health Record (EHR) under the progress note tab. Review of Resident #28's EHR at 9:35 AM on 4/22/22 revealed one generic progress note written by the consultant pharmacist. The note was written as a late entry note for 3/13/2022 and the note was created on 3/31/2022. The pharmacist identified a medication irregularity as he wrote Please evaluate Heparin and Aspirin usage together. There was not any documentation of a pharmacy medication review in the month of February 2022.
On 4/22/22 at 10:30 AM the director of nursing provided a copy of the facility's Drug Regimen Review policy. She indicated that the pharmacist emails a list of residents that were found by the pharmacist with a medication irregularity at least once a month. The policy was reviewed and shared with the DON that the policy was vague and did not provide time frames for the different steps in the process and the steps the pharmacist must take when an identified medication irregularity requires urgent action. The DON was asked if the medication irregularity identified by the pharmacist in March 2022 was evaluated by the resident's attending physician.
On 4/22/22 at 11:10 AM a re-interview with the DON revealed that she had reviewed Resident #28's paper chart and did not find any documentation of the resident's attending physician responding to the pharmacist's late entry recommendation for 3/13/22.
Further review of Resident #28's medical record revealed the pharmacist had created a late entry note at 9:51 AM on 4/22/2022. The effective date of the note was 2/8/2022. The identified medication irregularity was written as Please evaluate Heparin and Aspirin usage together.
At 11:35 AM on 4/22/22, a meeting was held with the Nursing Home Administrator and the DON. The newly identified pharmacist late entry note from February was added on 4/22/22. The DON indicated that the pharmacist does his reviews off-site. The DON was asked to provide a copy of the Consultant Pharmacist Report from 2/8/22. The DON returned at 12:01 PM with a blank report. There was not any indication of the resident's attending physician's evaluation for the 2/8/22 identified medication irregularity.
Further review of Resident #28's EHR on 4/25/22 at 8:40 AM, revealed that the consulting pharmacist wrote a late entry progress note with an effective date of 4/13/22 and the note was created on Sunday 4/24/22 at 1:19 PM. The consulting pharmacist identified additional medication irregularities as well as the same identified irregularity from 2/8/22. The pharmacist wrote, please evaluate the benefit/risk of use for sliding scale insulin order, should Heparin order include a length of therapy? Please evaluate Heparin and Aspirin usage together, Aspirin and Coreg suggested for dosing with food. Ongoing review of the medical record did not reveal that any of the identified medication irregularities were evaluated by the resident's attending physician.
The medical director was interviewed on 5/5/22 at 11:25 AM. The concern of the late entry pharmacist medication regimen and lack of physician follow-up and lack of a clear policy related to timelines of reviews was shared. The medical director was asked if he receives emails from the consulting pharmacist identified medication irregularities and he responded that he had not received any recent emails from the pharmacist. He was asked what is the time frame that a physician should respond to the pharmacist's monthly review and he indicated within 24 hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
2) On 4/25/22 at 2:20 PM, review of Resident #25's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2022 revealed several blanks for the evening shift on 4/23...
Read full inspector narrative →
2) On 4/25/22 at 2:20 PM, review of Resident #25's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2022 revealed several blanks for the evening shift on 4/23/22 and no corresponding progress notes to explain if the medication was given and/or treatment done by the evening shift nurse. For example, IV Ertapenem (antibiotics) had no staff initials on the 9:00 PM slot and a notation of 9 with staff initials in the 9:00 AM slot.
On 4/25/22 at 2:37 PM, Surveyor conducted an interview with the Assistant Director of Nursing (ADON). The ADON confirmed that the blanks on the MAR and TAR meant the medication was not given and treatment not done. She/he stated that the 9 noted on the 9:00 AM slot meant Other/See Nurse Notes based on the facility's chart codes. The ADON further stated that the evening nurse should have written a progress note to explain why the med was not given/treatment not done. the ADON identified the evening nurse for 4/23/2022 to be a part time nurse that had worked a double shift on 4/23/2022.
Further review of Resident #25's medical record on 4/26/22 at 10:46 AM revealed that the nurse wrote a late entry progress note with an effective date of 4/23/22 that read: 4/23/2022 21:18 eMAR- Medication Administration Note Late Entry: Note Text: Ertapenem not given spoke with pharmacy, states next dose to be delivered on next delivery dose to be given once arrival oncoming nurse made aware
3) On 4/22/22 at 10:10 AM, in an interview with the surveyor, Resident #32 stated that she/he was not picked up for dialysis on Wednesday 4/20/22.
On 4/22/22 at 10:25 AM, in an interview with the resident's attending physician #25 who was on the 3rd floor unit at the time, he/she stated that Resident #32 usually refused to go to dialysis, and it was not new that the resident did not go on Wednesday 4/20/2022.
On 4/22/22 at 10:28 AM, in an interview with Licensed Practical Nurse (LPN #7), she/he stated that transport was running late, and Resident #32 got inpatient and refused to go for dialysis. When asked if transport did make it to the unit, LPN #7 stated no because she/he had called and canceled the transportation and notified the dialysis center. LPN #7 further stated that was not the first time the resident had refused to go to dialysis. When asked were that incident was documented, LPN #7 stated she/he had forgotten to document about it and proceeded to put in a late entry note.
On 4/22/22 at 11:55 AM, in an interview with the surveyor, the Assistant Director of Nursing (ADON) confirmed that Resident #32 refused to go to dialysis on Wednesday 4/20/22, however it was not documented.
On 5/6/22 at 3:15 PM all concerns were discussed in detail with the Administrator and the Director of Nursing during the survey exit conference.
4) Review of complaint MD00164719 on 05/05/2022 revealed an allegation Resident #180 had a significant weight loss.
A review of Resident #180's closed medical record on 04/25/2022 revealed a dietician #20 progress note, dated 01/12/2021 at 6:37 PM that indicated Resident #180's oral intake was good with 0-26% of meals being ingested. The facility dietician's progress note was reviewed because Resident #180 was noted with a significant weight loss at this time. Facility staff documented that Resident #180 weighed 231 pounds on 12/29/2020 and 203 pounds, 28 pounds (12.1%) weight loss on 01/08/2021, and 202 pounds, 29 pounds (12.5%) weight loss on 01/11/2021.
In an interview with the facility dietician #20 on 05/05/2022 at 8:28 AM, dietician #20 stated that the dietary progress notes on 01/12/2021 at 6:37 PM were incorrect regarding the 0-26% intake being good. Dietician #20 stated that the progress note in Resident #180's chart should have indicated Resident #180's oral intake was poor on 01/12/2021.
These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
Based on the review of the medical record review, observations, and interviews, it was determined the facility staff failed to: 1) maintain medical records in the most accurate form as the facility failed to completely identify the positions of staff in the electronic health record. All resident records are affected by this lack of staff identification; 2) maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. This was evident for 3 out of 8 residents (Residents #25 and #32 and #180) reviewed for medical records during the survey,
The findings include:
A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.
While conducting medical record reviews during the survey it was discovered that progress notes would have a name of the clinician, but the note did not include a title, or the staff position. This is most evident in review of the staff administration legend on each monthly medication administration record (MAR) or the treatment administration record (TAR). The legend on each MAR of TAR lists the staff's initials, long username (full name), username, followed by the last column designation. The designation was blank for most staff documenting in the medical records.
The NHA and the DON were informed of the concern related to lack of identification of the clinicians on 4/26/22 at 3:45 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined that the facility failed to maintain strict infectio...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined that the facility failed to maintain strict infection control processes evidenced by: 1) staff failing to keep a urinary catheter bag off the floor. This was evident for 1 of 4 residents (#57) reviewed for a foley catheter and 2) failed to provide education and convey updates to staff on COVID-19. This deficient practice has the potential to affect all residents, staff, and visitors in the facility.
The findings include:
A urinary catheter (also known as foley catheter) is a flexible tube placed in the body which is used to empty the bladder and collect urine in a drainage bag. (Foley Catheter definition on Merriam-webster)
Germs can travel along the catheter and cause an infection in the bladder or kidney that could cause a catheter-associated urinary tract infection if proper infection control practices are not put in place and followed. (Centers for Disease Control guideline)
1) Observation was made on 4/25/22 at 11:50 AM of Resident #57 lying in bed. Resident #57's foley catheter bag was lying on the floor wedged under the frame of the over the bed tray table. A second observation was made on 4/25/22 at 2:50 PM and the bag was still in the same position.
On 4/25/22 at 2:50 PM, the Director of Nursing (DON) was present at the resident's bedside and saw the foley bag. The DON stated that the foley bag should not be lying on the floor and should be away from the entrance room door. A third observation was made on 4/27/22 at 10:38 AM, the foley bag was full of urine (about 800cc) and lying on the floor.
On 4/25/22 at 3: 00 PM on review of the hospital Discharge summary dated [DATE] revealed that Resident #57 had an indwelling foley for chronic urinary retention.
The DON was made aware of the findings on 4/27/22 at 11:10 AM.
2) An interview with an Infection preventionist and the DON was conducted on 4/28/22 at 1:10 PM. During the interview the DON stated previous assistant director of nursing (ADON) who resigned from the position in July 2021 provided all COVID-19 education to all staff. Also, she stated since the previous ADON resigned, the current staff did not have access to the training documentation records.
On 5/5/22 at 9:22 AM, the DON provided some documentation related to COVID-19 education provided to the facility staff. From 2/7/2020 to 1/29/2021, education was provided a total of 10 times to the facility staff. On 2/7/21 hand hygiene/ hand washing/ABHR competency education was provided, and 25 staff signed on the attendance list.
On 3/24/20 COVID-19 education was provided, and one staff signed on the attendance list. On 3/24/20, 71 staff signed the attendance list for COVID-19 preparedness education. On 9/18/20, a COVID-19 outbreak protocol education was held, and 34 staff signed on the attendance list. On /5/5/22 at 10:00 AM the DON confirmed the facility's average staff number was higher than 80 facility staff. However, the training records provided did not include all the staff employed by the facility.
The DON and the Nursing Home Administrator were made aware of this finding on 5/5/22 at 2:57 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility staff failed to document that resident and/or th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Parties (RPs) were provided education on Influenza and Pneumococcal vaccines before requesting consent. This was evident for 5 (Resident #25, #26, #32, #53, and #67) of 5 residents reviewed for Immunizations during the survey.
The findings include:
Pneumococcal vaccine help prevents pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease)
Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people 65 years and older, pregnant people, and people with certain health conditions or a weakened immune system are at the greatest risk of flu complications. Influenza (Flu) vaccines can prevent influenza. (Centers for Disease Control and Prevention- vaccines and preventable disease)
On 4/27/22 at 2:50 PM, a medical record review was conducted for Resident #25. A facility's consent form dated 9/24/21 was filed in the resident's paper chart. The resident consented for the Flu vaccine and refused the Pneumococcal vaccine. However, no other documentation was found in the record that the resident received education regarding the benefits or risks of receiving the Flu and Pneumococcal vaccine.
A review of the electronic medical chart under the immunization tab for Resident #26 was conducted on 4/28/22 at 08:50 AM. The review revealed the resident refused the Flu and Pneumococcal vaccine without a date recorded. A consent form was filed on the resident's paper chart marked as refused Flu and Pneumococcal vaccine dated 9/24/21. However, there was no supportive documentation regarding the resident receiving education regarding the risks or benefits of receiving the vaccines.
Further review of the electronic medical chart under the immunization tab revealed Resident #32 refused the Pneumococcal vaccine without the date recorded and received the Flu vaccine on 11/15/21. Neither the consent form nor documentation of education was filed on the resident's paper chart or electronic medical chart.
A medical record review of Resident #53 on 4/28/22 at 10:10 AM revealed under the electronic medical chart, the immunization tab recorded the resident refused Flu and Pneumococcal vaccines without a date recorded. There was no consent or education documented found on the resident's paper chart or electronic chart.
Further electronic and paper medical record review for Resident # 67 revealed that the resident received a Flu vaccine on 10/7/21 and a Pneumococcal vaccine on 11/5/21. However, no documentation was found for the consent form or evidence of education provided to the resident.
During an interview with the Director of Nursing (DON) and Infection Control Preventionist (ICP) on 4/28/22 at 10:40 AM, the DON explained that the facility assessed a new resident's vaccination eligibility upon their admission. If the resident is a candidate for the vaccine, a consent form will be signed by the resident self or RPs, and the signed consent will be filed in the resident's paper chart. Also, the DON stated the facility did not separately document regarding providing education to residents. The consent form of vaccination status for the facility was reviewed with the DON during the interview. The form did not include education regarding the benefits and potential side effects of the Flu and Pneumococcal vaccine.
The Nursing Home Administrator was made aware of the above concern on 5/5/22 at 2:50 PM.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected multiple residents
Based on the staff interview, review of facility policies, and facility's tracking record, it was determined the facility failed to provide COVID-19 testing for the unvaccinated staff. This was eviden...
Read full inspector narrative →
Based on the staff interview, review of facility policies, and facility's tracking record, it was determined the facility failed to provide COVID-19 testing for the unvaccinated staff. This was evident for 3 of 50 staff (Licensed Practical Nurse (LPN) #39, Registered Nurse (RN) #40, and Geriatric Nursing Assistant (GNA) #41) reviewed for COVID-19 testing during the survey.
The finding includes:
During the entrance conference with the Nursing Home Administrator (NHA) on 4/19/22 at 8:35 AM, she stated that the facility currently had three unvaccinated staff (LPN #39, RN #40, and GNA #41).
On 4/28/22 at 1:40 PM during an interview with the Infection Control Preventionist (ICP), she stated that since the county COVID-19 rate was elevated, the facility had started to do the COVID-19 testing twice a week from the week of 4/18/22 for the unvaccinated staff. Before the week of 4/18/22, the facility performed a COVID-19 test once a week for the unvaccinated staff. The ICP also submitted the staff COVID-19 testing log.
On 4/28/22 at 1:44 PM a review of the testing log revealed that for the week of 4/25/22, GNA #41 missed the COVID-19 testing one time, and the week of 4/18/22 RN #40 and GNA #41 missed the COVID-19 testing one time, and the week of 4/4/22 no test was done for GNA #41 and RN #40.
On 4/28/22 at 2:00 PM a review of the facility policy, Employee COVID-19 Vaccination Mandate and Staffing Contingency Plan, was conducted. The policy indicates that the facility will implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19 to include: requiring at least weekly testing for exempted staff, and staff who have not completed their primary vaccination series until the regulatory requirement is met, regardless of whether the facility or service site is located in a county with low to moderate community transmission, in addition to following CDC recommendation for testing unvaccinated staff in facilities located in counties with substantial to high community transmission.
During an interview with the DON and the ICP on 4/29/22 at 8:48 AM, they were made aware of the above concerns and no other documentation was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview, it was determined the facility failed to: 1) document education provided regarding the benefits, risks, and potential side effects of receiving the ...
Read full inspector narrative →
Based on medical record review and staff interview, it was determined the facility failed to: 1) document education provided regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents and staff, and 2)maintain a consent form in the residents' medical record. This was evident for 1 of 5 residents (Resident #67) and 8 facility staff members reviewed for COVID-19 vaccinations during the survey.
The findings include:
1) On 4/27/22 at 2:30 PM, Resident #67's medical record review was conducted. The electronic medical record under the immunization tab revealed Resident #67 received the COVID-19 vaccine on 1/7/21, 1/29/21, and 10/20/21. However, no documentation was found for the consent form and evidence of education was provided under the resident's paper chart or electronic medical record.
During an interview with the Director of Nursing (DON) on 4/28/22 at 9:00 AM, she stated Resident #67 received the COVID-19 vaccine from a pharmacy vendor. Since the vendor pharmacy received consent and provided a factsheet before the vaccines were given and took all documentation back, there was no signed consent in the resident's paper chart. She added she would try to get it from the vendor pharmacy. No further supportive documentation was submitted to the surveyor team until the exit meeting. Also, the DON stated the facility did not document the benefit and potential risks of the COVID-19 vaccine.
2) Review of COVID-19 vaccination records for facility staff members was conducted on 4/28/22 at 10:30 AM. A review of Staff #17, #22, #29, #37, and #38's COVID-19 vaccination records failed to show that they received education regarding COVID-19 vaccination benefits, risks, and potential side effects.
An interview was conducted with DON and Infection Control Preventionist (ICP) on 4/28/22 at 10:40 AM. The ICP stated that the former assistant director of nursing (ADON, #45) had provided COVID-19 vaccine education to all staff. The ICP and DON also stated since ADON #45 resigned, current staff was unable to find education and/or training documentation.
On 5/5/22 at 9:22 AM, the DON submitted staff training records from 2/7/20 to 3/27/21. However, the records did not include the benefits and potential risks associated with the COVID-19 vaccine.
The nursing home administrator was made aware of the above concerns on 5/5/22 at 2:50 PM.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
2) During an initial kitchen tour conducted on 4/19/22 at 8:46 AM, a half-filled box with pasteurized eggs (103 of 180 eggs) was found on the bottom shelf of a refrigerator. There was a handwritten da...
Read full inspector narrative →
2) During an initial kitchen tour conducted on 4/19/22 at 8:46 AM, a half-filled box with pasteurized eggs (103 of 180 eggs) was found on the bottom shelf of a refrigerator. There was a handwritten date marked as 01/18 and a printed date was left on the side of the box that read best before/sell by 2/18/22.
On 04/19/22 at 09:01 AM an interview was conducted with the Certified Dietary Manager (CDM). She stated, the facility kept the eggs for 6 months, and the eggs were given only to residents who wanted pasteurized eggs.
On 4/26/22 at 2:12 PM, an interview was conducted with the Registered Dietitian (RD #21). RD #21 stated since the nursing home has a population at high risk for foodborne illnesses, the pasteurized eggs should not be used after the marked date on the package which was 2/18/22. Surveyors informed RD #21 that 103 of 180 eggs had remained in the box in the refrigerator. RD #21 said, it needs to be thrown away.
The Nursing Home Administrator and Director of Nursing were made aware of the above concerns on 5/6/22 at 3:10 PM.
Based on observation, interview, and documentation review it was determined that the facility staff failed to store, prepare, and maintain a sanitary environment in accordance with professional standards for food service safety by failing to ensure dishwasher hot water temperatures are frequently checked to ensure cleanliness and sanitation of dishware, failing to ensure safe refrigerator temperatures and failing to dispose of outdated food items. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen.
The findings include:
1) An initial environmental kitchen food services inspection was conducted on 4/19/22 at 8:46 AM. The dishwasher temperature log was found near the dishwasher hanging on a clipboard. A review of the Dishwasher Temperature log revealed that the staff was not consistently monitoring the temperatures of the dishwasher. The entire log was observed to have missing temperature monitor checks on each day of the month when dishware and utensils are washed. Most of the April 2022 Dishwater Temperature Log was blank. There was not any documentation of the dishwasher wash and sanitation water temperatures for 4/4, 4/5, 4/6, 4/7, 4/8, 4/9, 4/12, 4/17, 4/18, and 4/19/22. The Certified Dietary Manager (CDM) was asked to provide a copy of the current Dishwater Temperature Log for April 2022.
On 4/26/22 at 8:20 AM an interview was conducted with the CDM. A review of the current dishwasher temperature log revealed that all the previous blank dates 4/4/22 to 4/12/22 were filled in by one staff member for 10 days straight. The dishwasher temperature log shown that the temperature sanitation level was not monitored for the dinner mea The documented times checked by the dietary staff were recorded as 7 or 7:30 AM, 10:30 or 11:30 AM, and 1 PM.
The minimal requirement for the wash temperature of the facility's dishwasher is 150 degrees Fahrenheit (F) and the minimum rinse temperature is 180 degrees F. Most of the temperatures for April 2022 were recorded as the minimum of 150 degrees F. wash temperature and 180 degrees F. rinse temperature. The CDM turned on the dishwasher and ran the machine through 3 cycles and the dishwater wash temperature did not meet the requirement of 150 degrees F.
Observation of the dietary staff dishwasher lunchtime service was observed at 2:10 PM on 4/26/22. Observations of the dishwasher through 3 complete wash and rinse cycles did not reveal a wash temperature greater than 146 degrees F. The rinse temperature rose above the minimum temperature to 184 degrees F on the third observed cycle. The CDM was made aware, and she ran the dishwasher to observe that the wash cycle was below 150 degrees F.
The facility called in a dishwasher service technician as the nursing home administrator requested the surveyors to meet with him at approximately 3 PM on 4/26/22. The service technician ran the dishwasher with surveyors observing and the wash temperature only reached 149 degrees. The service technician returned to the surveyors within the hour to share that he found a malfunction of the dishwasher and had repaired the malfunction and reported wash temperatures around 160 degrees F.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0565
(Tag F0565)
Minor procedural issue · This affected most or all residents
Based on review of facility documents and interviews of facility staff, ombudsman, and resident council, it was determined that the facility failed to regularly conduct resident council meetings and f...
Read full inspector narrative →
Based on review of facility documents and interviews of facility staff, ombudsman, and resident council, it was determined that the facility failed to regularly conduct resident council meetings and failed to act promptly upon the resident council's grievances and concerns. All resident's have the potential to be affected by the concerns raised by the resident council. The facility did not hold a resident council meeting for 4 months between December 2021 and April 2022.
The findings include.
The resident council meeting minutes for meetings held on 11/22/21, 12/9/21 and 4/18/22 were reviewed on 4/22/22. The resident concerns that were identified on 11/22/21 minutes continued to be an issue with the resident council meeting on 4/18/22. Resident council concerns from the 11/22/21 meeting minutes included concerns related to the housekeeping/laundry department lost clothing and lack of cleanliness. The resident's documented concerns related to short staffing and the Geriatric Nursing Assistants (GNA's) stating that they are short staffed as well as GNA poor work quality. The difficulties with agency staff that did not seem to care, were rude speaking and not knowing answers when questions were asked and difficulties with getting showers and/or showered timely were also noted in the minutes. The quality of the food and kitchen related issues had the greatest number of concerns such as food was not appetizing, not enough alternatives, vegetables were always mushy and the alternative meal was not always available. Pancakes were hard as hockey pucks and bacon was just fat were noted as well as Cake being hard as a rock. Juice was noted to be watered down, bread and buns fall apart when picked up, and dislikes listed on meal tickets were still served on trays. Additionally it was noted that kitchen workers have an attitude and are rude when answering the phone and if an alternative is requested it takes forever to get it.
Each department had responded to the resident's concerns. The dietary department response was very vague, and the dietary department failed to follow thru with the department's response of: Will start a food committee. Meet once a month on Wednesday.
The resident council minutes for meeting of 12/9/21 did not include any department responses for the residents' documented concerns. Dietary concerns were documented as Food sucks, not getting double portions all the time,punch is watered down, residents do not get what they ordered.
An interview was conducted with the resident council president, vice president and 8 additional attendees of the resident council on 4/22/22 at 2 PM. The residents at the council interview indicated that the facility postponed the monthly meetings since there was not an activity director, they indicated that meetings were held regularly before the activity director left. The same issues persist 4 months later without any resolve. The council members shared a concern of not enough towels or wash cloths available, and some indicated that staff have used pillowcases as washcloths.
The minutes from the 4/18/22 meeting were reviewed during the council interview including that laundry is not returned timely or does not come back and bedrooms are not cleaned daily or consistently. Supplies such as soap or hand sanitizer are not being filled. Ongoing concerns with nursing staff shortages and bad attitudes were noted. Dietary concerns also persist, as the food is not hot, and not much has changed from previous concerns. Meat is not cooked all the way through, or meat is overcooked. Plastic wrapped plates are making the food/moist wet by the time residents residents receive the food tray.
On 4/22/22, after the council interview the ombudsman was interviewed at 3:30 PM. She indicated that the nursing home administrator postponed the meetings for lack of an activity director, and she had prompted the facility to conduct a meeting on 4/18/22. She acknowledged that anybody could assist the resident to hold a council meeting.
Review of the survey selected final resident sample revealed that 10 of 14 interviewable residents had expressed negative concerns related to the food quality.
An interview was conducted with the dietary manager on 4/26/22 at 8:30 AM. The dietary response to the resident council meeting of 11/21/21 was discussed. She was asked if the meetings occurred and who was conducting. She implied that there was one meeting.
At 8:55 AM on 4/26/22 the nursing home administrator (NHA) provided a copy of an email from the previous activity director dated 12/21/21 with the subject line of Food meeting with residents. This email did not indicate who was in attendance. The body of the email was documented as During meeting tray delivering times were discussed. Residents were told if trays were served later then [name of dietary manager] needs to be notified so she could see if it was the kitchen or the carts sitting on the floor. The new menus were discussed. Alternate menus were discussed and how ordering alternative meals should be placed as soon as possible.
On 4/26/22 at 3:45 PM the NHA and the DON were informed of the concerns related to the facility's failure to conduct monthly resident council meetings and the lack of follow through with the responses to the resident's concerns.
An interview was conducted with the resident council president on 5/3/22 at 8:47 AM. The resident council president indicated that one food committee meeting was conducted sometime in December 2021. The meeting was held with the resident council president, one additional resident, the dietary manager and the previous activity director. The resident council president indicated that a discussion was held on how to improve food service but there was not any further feedback or additional food committee meetings.
MINOR
(C)
Minor Issue - procedural, no safety impact
Grievances
(Tag F0585)
Minor procedural issue · This affected most or all residents
Based on review of facility documents and interviews of facility staff, and resident council, it was determined that the facility failed to act promptly upon the resident council's grievances and conc...
Read full inspector narrative →
Based on review of facility documents and interviews of facility staff, and resident council, it was determined that the facility failed to act promptly upon the resident council's grievances and concerns. All residents have the potential to be affected by the concerns raised by the resident council.
The findings include.
The resident council meeting minutes for meetings held on 11/22/21, 12/9/21, and 4/18/22 were reviewed on 4/22/22. The resident concerns that were identified on 11/22/21 minutes continued to be an issue with the resident council meeting on 4/18/22. Resident council concerns from the 11/22/21 meeting minutes included concerns related to the housekeeping/laundry department lost clothing and lack of cleanliness. The residents documented concerns related to short staffing and the Geriatric Nursing Assistants (GNA's) stating that they are short-staffed well as GGNA's poor work quality. The difficulties with agency staff that did not seem to care, were rude speaking and not knowing answers when questions were asked and difficulties with getting showers and/or showered timely were also noted in the minutes. The quality of the food and kitchen-related issues had the greatest number of concerns such as food was not appetizing, not enough alternatives, vegetables were always mushy, and the alternative meal was not always available. Pancakes were hard as hockey pucks and bacon was just fat were noted as well as Cake being hard as a rock. The juice was noted to be watered down, bread and buns fall apart when picked up, and dislikes listed on meal tickets were still served on trays. Additionally, it was noted that kitchen workers have an attitude and are rude when answering the phone and if an alternative is requested it takes forever to get it.
Each department responded to the resident's concerns. The dietary department's response was very vague, and the dietary department failed to follow thru with the department's response of: Will start a food committee. Meet once a month on Wednesday.
The resident council minutes for the meeting of 12/9/21 did not include any department responses for the residents' documented concerns. Dietary concerns were documented as Food sucks, not getting double portions all the time, punch is watered down, residents do not get what they ordered.
An interview was conducted with the resident council president, vice president, and 8 additional attendees of the resident council on 4/22/22 at 2 PM. The residents at the council interview indicated that the facility postponed the monthly meetings since there was not an activity director, they indicated that meetings were held regularly before the activity director left. The same issues persist 4 months later without any resolution. The council members shared concerns about not having enough towels or washcloths available, and some indicated that staff have used pillowcases as washcloths.
The minutes from the 4/18/22 meeting were reviewed during the council interview including that laundry is not returned timely or does not come back and bedrooms are not cleaned daily or consistently. Supplies such as soap or hand sanitizer are not being filled. Ongoing concerns with nursing staff shortages and bad attitudes were noted. Dietary concerns also persist, as the food is not hot, and not much has changed from previous concerns. Meat is not cooked all the way through, or meat is overcooked. Plastic-wrapped plates are making the food/moist wet by the time residents receive the food tray.
A review of the survey selected final resident sample revealed that 10 of 14 interviewable residents had expressed negative concerns related to the food quality.
An interview was conducted with the dietary manager on 4/26/22 at 8:30 AM. The dietary response to the resident council meeting of 11/21/21 was discussed. She was asked if the meetings occurred and who was conducting them. She implied that there was one meeting.
At 8:55 AM on 4/26/22 the nursing home administrator (NHA) provided a copy of an email from the previous activity director dated 12/21/21 with the subject line Food meeting with residents. This email did not indicate who was in attendance. The body of the email was documented as During meeting tray delivering times were discussed. Residents were told if trays were served later then [name of dietary manager] needs to be notified so she could see if it was the kitchen or the carts sitting on the floor. The new menus were discussed. Alternate menus were discussed and how ordering alternative meals should be placed as soon as possible.
On 4/26/22 at 3:45 PM the NHA and the DON were informed of the concerns regarding the lack of follow through with the responses to the resident's concerns.
An interview was conducted with the resident council president on 5/3/22 at 8:47 AM. The resident council president indicated that one food committee meeting was conducted sometime in December 2021. The meeting was held with the resident council president, one additional resident, the dietary manager and the previous activity director. The resident council president indicated that a discussion was held on how to improve food service but there was not any further feedback or additional food committee meetings.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observations, review of daily staffing records, and staff interview it was determined the facility failed to post the total number and actual hours worked by categories of Registered nurses, ...
Read full inspector narrative →
Based on observations, review of daily staffing records, and staff interview it was determined the facility failed to post the total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides per shift and failed to have the staff data requirements available in an accurate, clear and readable format. This was identified that the facility did not have staffing information readily available in a readable format for residents and visitors for 14 out of 14 days of the survey.
The findings include.
Initial tour of the facility on 5/19/22 did not reveal a facility wide staff posting indicating the total number and actual hours worked by categories of Registered nurses (RN), Licensed practical nurses (LPN), and Certified nursing aides (CNA) per shift.
Each subsequent survey day did not reveal the Federal requirements for the posting of nursing staffing. Dry erase staffing boards at the nursing stations on each floor were reviewed each survey day. The dry erase staffing boards did not identify the nurses as a RN or an LPN.
An interview was conducted with the nursing home administrator (NHA) on 5/4/22 at 10:46 AM. The Nursing home administrator was asked the whereabouts of the posted staffing and she indicated that there is a posting in the service elevator corridor and on the white boards at the nursing station on each floor. The survey team indicated that the Federal requirements for staffing were not observed on any day of the survey. She confirmed that the facility has not been posting the daily staffing as per the Federal regulation.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0885
(Tag F0885)
Minor procedural issue · This affected most or all residents
Based on reviews of a medical record and staff interviews, it was determined that the facility failed to notify all current residents that if it is discovered that the resident has a positive test for...
Read full inspector narrative →
Based on reviews of a medical record and staff interviews, it was determined that the facility failed to notify all current residents that if it is discovered that the resident has a positive test for COVID-19, the resident may have to be transferred to another facility. This was evident for 1 of 2 residents (Resident #3) reviewed regarding infection control during an annual recertification survey.
The findings include:
In an interview with the facility director of nurses (DON) on 05/02/2022 at 12:50 PM, the DON confirmed that Resident #3 was transferred to a sister facility on 01/13/2021 since the facility had not established a COVID-19 unit.
In an interview with the facility Infection Control Preventionist (ICP) (employee #4) on 05/03/2022 at 9:38 AM, the facility ICP stated that the facility had not developed or implemented a policy during the COVID-19 pandemic regarding the transfer of any resident identified as being COVID-19 positive to a sister facility. The ICP continued to state that there was no need to establish a separate COVID-19 unit in the facility because any resident identified as being COVID-19 positive was to be transferred to the sister facility. The facility ICP stated that the facility did eventually have to set up a separate COVID-19 unit due to the increasing number of residents identified as being COVID-19 positive. The ICP stated the facility established a COVID-19 unit on 01/18/2021.
Review of Resident #3's medical record on 04/27/2022 at 10:36 AM failed to reveal any transfer forms that Resident #3 received prior to being transferred to a sister facility on 01/13/2021. The nursing staff developed a COVID-19 care plan on 01/13/2021 that included the following intervention: to apply a sign on the door informing staff of Droplet & Contact precautions, encourage the resident to wear a mask, monitor poor appetite and dehydration and to report the findings to the resident's physician, and to obtain a temperature and perform a respiratory assessment every shift.
Review of the facility policy, Bed Hold Notice Upon Transfer, on 05/04/2022 revealed that at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. A therapeutic leave refers to absences for purposes other than required hospitalization.
In an interview with the facility physician assistant #47, on 05/06/2022 at 10:27 AM, the facility physician assistant stated that s/he initially wrote new orders to treat Resident #3 for COVID-19 on 01/13/2021. The facility physician assistant stated that s/he was contacted by the facility administration and was instructed to write an order to transfer Resident #3 to another sister facility which s/he did.
In an interview with Resident #3's family member on 05/09/2022 at 3:02 PM, Resident #3's family member stated that s/he was first made aware of the facility's desire to initiate a transfer of Resident #3 to another sister facility due to Resident #3 being identified as COVID-19 positive on 01/13/2021. Resident #3's family member stated that s/he had no knowledge the facility had a new policy to transfer a resident who was COVID-19 positive and had not received any written bed hold notice, transfer paperwork, or an updated COVID-19 policy indicating why a resident would have to be transferred from the facility. Resident #3's family member stated that s/he was informed by a facility staff person about Resident #3 that this transfer was in process. Resident #3's family member then stated the facility called and informed him/her when Resident #3 was transferred back to the facility.
These concerns were bought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM.
These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during the exit conference.
Nov 2018
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, it was determined that the facility staff failed to provide a resident with an adaptive type call bell that would allow the resident to summon staff while wearing bilateral hand ...
Read full inspector narrative →
Based on observation, it was determined that the facility staff failed to provide a resident with an adaptive type call bell that would allow the resident to summon staff while wearing bilateral hand mittens. This was evident for 1 (Resident #29) of 28 residents reviewed during an annual recertification survey.
The findings include:
During a tour of the facility on 10/29/18 at 12:16 PM, the surveyor observed Resident #29 to be lying in bed with bilateral hand mittens in place. Resident #29's call bell was within reach, but his/her call bell was the type that a person would need the use of their hand and available finger to press/engage to summon a staff member for assistance. Resident #29 was unable to use his/her hands and fingers to manipulate the call bell at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
Based on medical record review, resident and staff interviews, it was determined the facility staff failed to notify Resident (#6), the Guardian or Responsible Party (RP) verbally or in writing of a p...
Read full inspector narrative →
Based on medical record review, resident and staff interviews, it was determined the facility staff failed to notify Resident (#6), the Guardian or Responsible Party (RP) verbally or in writing of a planned room change. This was evident for 1 of 28 residents selected for review during the survey process.
The findings include:
On 10/29/18 at 12:22 PM Resident #6 stated that s/he had a room change some time ago and wanted to know why s/he had to change rooms. Resident #6 stated that no one told her/him of the room change or why s/he had to move.
Review of the medical record revealed 1 nursing note written on 4/17/17 stating Resident #6's room was changed; a call was placed to the Guardian and staff was unable to leave a voice message. Further review of the medical record failed to provide any additional documentation to show that Resident #6, her/his RP or guardian were provided with a notification or explanation verbally or in writing of the reason for the room change.
In an interview with the unit manager Staff #4 on 10/31/18 she stated that Resident #6 was not getting along with her/his previous roommate and s/he was moved to another room. When asked if Resident #6 or her/his RP or Guardian were notified she said that would be done by the social worker.
In an interview with the Social Worker Staff #5 on 10/31/18 at 1:45 PM the Social Worker Staff #5 confirmed that Resident #6 was not getting along with her/his previous roommate and was aware of the room change. When asked if Social Worker Staff #5 notified Resident #6, the Guardian or the RP verbally or in writing the Social Worker Staff #5 stated that s/he could not remember.
In an interview with the Administrator on 11/1/18 at 9:05 AM s/he was made aware of this concern and was unable to provide any additional documentation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility staff failed to maintain a current advanced healthcare dire...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility staff failed to maintain a current advanced healthcare directive within the medical record indicating Residents (#2) choices regarding life sustaining treatment. This was evident for 1 of 28 residents selected for review during the survey process.
The findings include:
An advance healthcare directive, also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity.
The MOLST (Medical Orders for Life Sustaining Treatment) form makes treatment wishes known to health care professionals. Maryland MOLST is a portable and enduring form for orders about cardiopulmonary resuscitation and other life-sustaining treatments.
Medical record review for Resident #2 revealed that upon admission on [DATE] the attending physician completed the MOLST form with a surrogate decision maker. Further medical record review revealed a Physician's certification of capacity completed on 01/30/18 indicating that Resident #2 had the capacity to make his/her own health care decisions.
In an interview with the Administrator on 10/31/18 it was confirmed that Resident #2 was competent and had been making his/her own healthcare decisions. The facility staff failed to maintain a current advanced healthcare directive within the medical record for Resident #2's choices regarding life sustaining treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on review of administrative documents, complaint and staff interview, it was determined that a facility staff member failed to report an allegation of 1) missing money in a timely manner to the ...
Read full inspector narrative →
Based on review of administrative documents, complaint and staff interview, it was determined that a facility staff member failed to report an allegation of 1) missing money in a timely manner to the facility administrator, and 2) report an allegation of abuse to the State survey agency. This was evident for 2 (Resident #2 #71) of 28 residents reviewed during an annual recertification survey. The findings include:
1) Review of facility reported incident MD00132571 on 10/29/18 revealed, during a care plan meeting on 10/15/18 Resident #2 reported that s/he had approximately $100.00 stolen from a sock in his/her wardrobe cabinet.
In an interview with Resident #2 on 10/30/18 at 10:10 AM resident confirmed that s/he was missing one hundred and some dollars and was still waiting to hear the outcome of the investigation.
In an interview with the facility administrator on 10/30/18 at 1:18 PM, the facility administrator stated that he became aware of the missing money following the care plan meeting held on 10/15/18 and immediately began the investigation.
Review of the facility investigation revealed a documented interview with LPN staff #6 who stated that on 10/13/18 she spoke with Resident #2 who was looking for money s/he said was misplaced. Staff #6 later returned and asked Resident #2 if s/he had found the money. At that time Resident #2 said s/he had not found it yet and would continue to look for it. Further documentation review failed to reveal any additional evidence that Staff #6 reported Resident #2's missing money to the administrative staff or that an investigation had been initiated.
Follow up interview with the Administrator on 10/30/18 at 2:15 PM confirmed that Staff #6 did not report the missing money on 10/13/18.
2) Review of complaint MD00124504 on 10/30/18 revealed an allegation staff was abusive to Resident #71.
In an interview with the facility administrator on 11/01/18 at 12:00 PM, the facility administrator stated that during an appeal hearing with an administrative law judge (ALJ) on 06/07/18, Resident #71 claimed to the ALJ that s/he had been physically, mentally, and verbally abused by the staff in the facility. T
he facility administrator was able to produce an investigation into Resident #71's allegation but also stated that s/he did not report Resident #71's allegations of abuse to the State Survey Agency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review, staff and resident interviews it was determined the facility staff failed to initiate an investigation after an allegation of abuse was made by a resident (Resident #6). This w...
Read full inspector narrative →
Based on record review, staff and resident interviews it was determined the facility staff failed to initiate an investigation after an allegation of abuse was made by a resident (Resident #6). This was evident for 1 of 28 residents reviewed during the survey process. These findings included:
During an interview with Resident #6 on 10/29/18 at 12:22 PM Resident #6 stated that, there is a guy down the other hall the last room on the left. He has pissed on me 3 times, he just came right over to my bed and said you can't get up and he just pissed on me. I told the nurses, but they didn't do anything but move me to this room.
On 10/31/18 at 11:05 AM in an interview with the unit manager (Staff #4) surveyor asked if she was aware of the incident with Resident #6 and a previous roommate whom he/she said had urinated on him/her? She said she was aware, and stated that is what Resident #6 said but there was not any evidence of urine. She further stated that her/his roommate would urinate in the room, but they never saw any urine on Resident #6.
On 10/31/18 at 1:45 PM interview with Social worker (staff #5) who stated that she was aware of the incident and that Resident #6 said the other resident urinated on him/her but there was no clear evidence that the other resident urinated on Resident #6. Surveyor asked if she had any documentation of the incident or if she was aware of an investigation being completed? Staff #5 stated that she wasn't sure but would look to see what notes were written.
Medical record review failed to provide any documentation of the alleged incident or that the allegation had been reported to the administrative staff and therefore no investigation was initiated.
In an interview with the Administrator on 11/1/18 at 9:05 AM s/he confirmed that an investigation had not been initiated for this allegation of abuse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
3. Medical record review on 10/30/18 revealed that Resident #39 was transferred and admitted to an acute care hospital on 5/24/18 and returned to the facility on 6/14/18.
Interview with the Social Wor...
Read full inspector narrative →
3. Medical record review on 10/30/18 revealed that Resident #39 was transferred and admitted to an acute care hospital on 5/24/18 and returned to the facility on 6/14/18.
Interview with the Social Worker on 10/30/18 at 11:30 AM confirmed that Resident #39, their representative or the State Ombudsman were not provided with written notification of the transfer.
2. A medical record review for Resident #40 was conducted on 10/30/18. Review of the physician order written on 9/5/18 revealed that Resident #40 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the ombudsman.
Based on medical record review and interview, it was determined that the facility failed to notify the resident or their responsible party in writing with a copy to the state ombudsman of resident's (Resident #39, #40, #56) transfer to the hospital and the reasons for the transfer. This was evident for 3 of 28 residents sampled during the annual survey. The findings include:
1. On 9-16-18 Resident #56 was sent to the hospital due to a change in condition. The Administrator confirmed on 10/30/18 at 1:30 PM that the facility did not notify the resident's responsible party in writing of the transfer and the reason for the transfer. The facility also did not send a copy of the transfer to the state ombudsman.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
3. Medical record review on 10/30/18 revealed that Resident #39 was transferred and admitted to an acute care hospital on 5/24/18 and returned to the facility on 6/14/18.
Interview with the Social Wor...
Read full inspector narrative →
3. Medical record review on 10/30/18 revealed that Resident #39 was transferred and admitted to an acute care hospital on 5/24/18 and returned to the facility on 6/14/18.
Interview with the Social Worker on 10/30/18 at 11:30 AM confirmed that Resident #39, their representative was not provided with a copy of the facility bed hold policy.
2. Review of the medical record for Resident #40 revealed the resident was transferred to an acute care facility on 9/5/2018. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital.
On 10/31/18 at 11:06 AM, the Administrator confirmed that Resident #40 and the Resident's responsible party did not receive the facility bed hold policy when Resident #40 was transferred to the hospital.
Based on medical record review and interview, it was determined that the facility failed to notify the resident or the resident's responsible party in writing of the facilities bed-hold policy (Resident #39, #40, #56) before or soon after transferring them to the hospital. This was evident for 3 of 28 residents reviewed during the annual survey. The findings include:
The bed-hold policy describes the facilities policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization.
1. Resident #56 was transferred to the hospital on 9-16-18 due to a change in condition. The facility Administrator confirmed on 10-30-18 at 1:30 PM that the facility did not send a copy of their bed-hold policy to Resident #56's responsible party upon transfer to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of the medical record and interviews with staff, it was determined that the facility staff failed to develop a comprehensive side or bed rail use care plan for a resident (#30). This w...
Read full inspector narrative →
Based on review of the medical record and interviews with staff, it was determined that the facility staff failed to develop a comprehensive side or bed rail use care plan for a resident (#30). This was evident for 1 of 28 residents reviewed during the annual survey.
The findings include:
A care plan is a written guideline of care based on the individual resident's needs developed by an interdisciplinary team which includes nursing, rehabilitation staff, and dietary that communicates to other health care professionals.
After assessment by the facility's physical therapist, ¼ side rails were placed on the bed for Resident #30's use. On 10-30-18 at 10:50 AM the 3rd floor Unit Manager confirmed Resident #30 did not have a care plan concerning side rail use to guide the facility staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview it was determined that the facility staff failed to 1) ensure that quarterly resident care plan meetings were held within the required timeframes, 2...
Read full inspector narrative →
Based on clinical record review and staff interview it was determined that the facility staff failed to 1) ensure that quarterly resident care plan meetings were held within the required timeframes, 2) follow a resident's protective device care plan by documenting that the staff is checking a resident's distal pulses, and 3) update a resident's care plan regarding the prolonged use of an antibiotic cream around a gastrostomy tube site (Residents #6, #11, #29). This was true for 3 out of 28 residents reviewed during a recertification survey. The findings include:
The MDS is a federally-mandated assessment tool that is completed upon admission, quarterly and as needed for any significant change. The MDS helps nursing home staff gather information on each resident's strengths and needs.
A review of Resident #6's clinical record revealed documented care plan meetings on 01/19/17 and 04/21/17 with an attendance roster. Electronic record review revealed multiple Social Work notes all labeled as Care Plan Notes. Review of all Social Work notes which were provided by the Administrator on 11/01/18 failed to provide evidence of the occurrence of quarterly Care plan meetings, to identify participation of members of the interdisciplinary team, or to show evidence that Resident #6, his/her family representative or Guardian were invited.
Interview with the Administrator on 11/01/18 at 9:05 AM confirmed the facility staff failed to review and revise care plans for Resident #6 and failed to include the resident and his/her family representative or Guardian in care planning.
2) Review of Resident #29's medical record revealed a nursing care plan related to the use of bilateral hand mittens. One of the nursing interventions was for the staff to monitor limb distal to hand mitten for discoloration, warmth, sensation, and to check Resident #29's pulses every shift. Review of the nursing documentation for monitoring Resident #29's distal pules failed to reveal the staff were documenting this nursing intervention was being done.
3) Review of Resident #11's medical record revealed a care plan addressing that Resident #11 has potential for ulceration of skin, caused by prolonged pressure related to: immobility, incontinence, cognitive impairment. The current physician order is to administer the antibiotic cream, Silvadene, to Resident #11 peg tube site, twice daily. This order was initiated 04/08/17. The potential for skin ulceration does not list any nursing interventions regarding Resident #11 peg tube site.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of a medical record and staff interview, it was determined that the facility staff failed to address the continued use of an antibiotic cream for a resident. This was evident for 1 (Re...
Read full inspector narrative →
Based on review of a medical record and staff interview, it was determined that the facility staff failed to address the continued use of an antibiotic cream for a resident. This was evident for 1 (Resident #11) of 28 residents reviewed during an annual recertification survey.
The findings include:
Review of Resident #11's medical record on 10/29/18 revealed a physician's order, dated 04/08/18, instructing the nursing staff to apply the antibiotic cream, Silvadene, to Resident #11's gastrostomy tube site, twice daily, related to the site being sore. Further review of Resident #11 medical record revealed physician notes dated 05/27/18, 07/28/18, 08/23/18 and 10/27/18 that documented Resident #11's peg tube site as intact and that Resident #11's skin was warm and dry with no break down.
Review of Resident #11's nursing quarterly care plan review, dated 08/18/18 at 7:42 AM, also indicated Resident #11's skin was intact.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on medical record review, resident observation and staff interview, it was determined that the facility staff failed to ensure that a resident's environment was free from potential accidents (Re...
Read full inspector narrative →
Based on medical record review, resident observation and staff interview, it was determined that the facility staff failed to ensure that a resident's environment was free from potential accidents (Resident #30). This was evident for 1 of 28 residents selected for review in the annual survey.
The findings include:
On 10/29/18 at 10:50 AM during the initial resident interviews stage of the annual survey Resident #30 was observed in his/her room. Due to the disease process Resident #30 was unable to self transfer from the bed to the wheelchair or to return. Geriatric Nursing Assistant (GNA) #1 had Resident #30 in the sling of a bedscale/hoyer lift 10 to 12 inches off the bed in the air. A bedscale/hoyer lift is a mechanical device to weigh and transfer residents from the bed to the chair and the reverse.
GNA #1 then left the room closing the door leaving Resident #30 alone hanging in the up position off the bed. GNA #1 returned to the room to pick up something and left a second time. This surveyor remained with Resident #30 during the incident. GNA #1 then returned at approximately 10:55 AM with 2 more GNA's and completed the transfer of Resident #30 from the bed to the wheelchair.
Review of the facility hoyer lift transfer policy does not allow a resident's to be left alone in the sling of the hoyer lift during transfers or weighing. It does require that two GNAs be present for a safe transfer
The second floor Unit Manager was made aware of the deficient practice on 10/29/18 at 11:15 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to obtain consent from the resident or...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to obtain consent from the resident or their responsible party before initiating side or bed rails on the resident's bed (Residents #30 and #56). This was evident for 2 of 28 residents reviewed in the annual survey.
The findings include:
1. On admission on [DATE] Resident #30 signed the facilities care and services consents form. The form asked the resident if they wished to use side rails, considered a restraint, on their bed. Resident #30 checked the box that stated I do not wish to use side rails.
On 09/04/18 the facility's therapy department assessed Resident #30 for use of side or bed rails. The therapy department determined the use of side rails would be beneficial for Resident #30 in providing a sense of security and for bed mobility. The side rails were instituted but Resident #30 did not sign a consent authorizing use nor did the facility obtain a physician's order for side rail use.
This finding was confirmed with the second floor Unit Manager on 10/30/18 at 10:30 AM.
2. Resident #56 was admitted to the facility on [DATE] and their responsible party signed on the care and service consent form that they did not want side rails used for the relative. On 10/08/18 the therapy department assessed Resident #56 for side rail use and stated the side rails would assist with bed mobility and provide a sense of security and help avoid rolling out of the bed. Side rail use was initiated. The facility did not obtain consent from the responsible party for side rail use nor obtained a physician's order to use side rails.
This finding of no consent for side rail use nor a physician order was confirmed by the third floor Unit Manager on 10/30/18 at 12:20 PM.
Jul 2017
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0241
(Tag F0241)
Could have caused harm · This affected 1 resident
Based on observation during a dining experience in the third floor dining room, it was determined that the facility staff failed to promote dignity during dining. This was evident when the Geriatric N...
Read full inspector narrative →
Based on observation during a dining experience in the third floor dining room, it was determined that the facility staff failed to promote dignity during dining. This was evident when the Geriatric Nursing Assistant (GNA) assisting a resident with feeding was observed chewing gum and not interacting with the resident.
The findings include:
Observation was made on 07/24/2017 12:49 PM of GNA Staff #1 while assisting Resident #6 with feeding, was observed chewing gum and not conversing or interacting with Resident #6 during the meal.
The third floor Charge nurse Staff #2 was made aware on 7/24/17 at 1:34 PM. The Director of Nursing (DON) was made aware of concerns on 7/26/17 at 8:43 AM. At that time the DON stated that he/she was made aware on 7/24/17 by staff #2 and that reeducation was immediately arranged for all staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0323
(Tag F0323)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to ensure residents are free of accide...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to ensure residents are free of accidents (Resident #98-MD00115015). This is evident for 1 of 30 residents selected for review during Stage 2 of the survey sample.
The MDS (Minimum Data Set) is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions.
The findings include:
Review of Resident #98's medical record review revealed the Resident was admitted to the facility on [DATE] with diagnosis of dementia. On 4/21/17 the facility staff completed a MDS assessment and coded the Resident with a BIMS of 6 out of 15, indicating severe cognitive impairment. At that time the facility staff also coded the Resident in Section G Functional Status for transfers as a 3, indicating 2+ persons physical assist. Further review of the medical record revealed the Resident has an Activities of Daily Living (ADL) Self Care Performance Deficit care plan with an intervention of total assistance with transfers.
Review of the facility's investigation of Facility Reported Incident MD00115015 revealed on 6/24/17 the Resident's nurse (Staff #4) stated the Resident's GNA (Staff #3) reported to her while transferring the Resident to bed the Resident hit his/her head on the headboard. Review of the Nursing Supervisor's (Staff #5) statement revealed Staff #3 reported to Staff #5 while providing ADL care to the Resident, the Resident fell and hit his/her head on the bed board and sustained a wound on his/her right brow. Staff #5 documented the Resident's wound to be a width of 0.1 cm, length negligible.
Interview with the Director of Nursing on 7/25/17 at 8:45 AM revealed Staff #3 was fired for not following the Resident's care plan of having 2 staff members for the transfer of the Resident from the wheelchair to the bed on 6/24/17. Also at that time the Director of Nursing stated total assistance indicates 2 + staff members.
Observation of the Resident on 7/25/17 at 9:21 AM revealed no wound. Interview with the Resident at that time revealed the Resident did not recall the incident on 6/24/17.
Interview with the Director of Nursing on 7/26/17 at 11:00 AM confirmed the facility staff failed to ensure a resident is free of accidents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0371
(Tag F0371)
Could have caused harm · This affected 1 resident
2. The facility staff failed to distribute food under sanitary conditions during a dining observation on the third floor. Staff did not properly handle open straws or sanitize hands appropriatly while...
Read full inspector narrative →
2. The facility staff failed to distribute food under sanitary conditions during a dining observation on the third floor. Staff did not properly handle open straws or sanitize hands appropriatly while providing feeding assistance to Resident #6.
During a dining observation on 07/24/17 at 12:49 PM Geriatric Nursing Assistant (GNA) Staff #1 was observed opening straws for several residents with his/her bare hands touching both ends of the straws before placing them into their drinks.
GNA Staff #1 was then observed providing feeding assistance for Resident #6. While feeding Resident #6 GNA Staff #1 was handed a plate from another resident at the table, he/she took the plate to the trash emptying the remaining food into the trash can. He/She then placed the dirty dish into a container, went to the food service cart for another plate of food, at which time GNA Staff #1 brushed his/her hair back from his/her face as he/she carried the plate back to that resident. GNA staff #1 then resumed feeding Resident #6 and was observed brushing his/her hair back from his/her face 3 more times during the meal. GNA staff #1 did not sanitize his/her hands during the dining observation.
The third floor unit manager staff #2 was made aware on 7/24/17 at 1:35 PM. The Director of Nursing (DON) was also made aware of these concerns on 7/25/17 at 8:43 AM. The DON stated that the concerns were brought to his/her attention on 7/24/17 and that staff reeducation was arranged to begin the same day.
Based on observation, staff interview and a review of the facility's High Temperature Dishwashing Log it was determined that the facility failed to ensure the dishwasher was at the appropriate temperatures for all of the wash and/or rinse cycles for three out of the four months reviewed and failed to distribute food under sanitary conditions.
The findings include:
This surveyor reviewed the High Temperature Dishwashing Logs for March, April, May and June on 7/26/17. The log notes the minimum acceptable wash temperature is 160 and the minimum acceptable rinse temperature is 180. It also noted that staff are to report temperatures higher than 190 or below 180 for the final rinse to a manager.
Review revealed that for April 2017 the morning wash temperatures varied between 150 and 154 for every day but 4/30. The morning rinse temperatures varied between 170 and 178 for 4/1, 4/2, 4/6, 4/9, 4/11, 4/14, 4/16, 4/20, and 4/25. The afternoon wash temperatures varied between 150 and 154 for every day but 4/25 and 4/30. The afternoon rinse temperatures were 173 for 4/3 and 173 for 4/11. The evening wash temperatures were 151 for 4/1, 153 for 4/2, 152 for 4/7, 152 for 4/10, 150 for 4/29, and 158 for 4/30. The evening rinse temperatures were 177 for 4/15, 166 for 4/17, 160 for 4/18, 160 for 4/20, 160 for 4/22, 175 for 4/23, 175 for 4/25, 170 for 4/26, 175 for 4/27, 175 for 4/28, and 179 for 4/29. Temperatures were not obtained for 4/24/17.
Review revealed that for May 2017 the morning wash temperatures varied between 142 and 159 except for 5/18 and 5/23. The morning rinse temperatures were 174 for 5/12, 171 for 5/15, and 173 for 5/26. The afternoon wash temperatures varied between 142 and 158 except for 5/12, 5/18, and 5/29. The evening wash temperatures were 152 for 5/21, 159 for 5/27, and 152 for 5/28.
Review revealed that for June 2017 the morning wash temperatures varied between 140 and 158 for the entire month. The morning rinse temperatures were 173 for 6/1, 173 for 6/2, 174 for 6/12, 172 for 6/23, 174 for 6/26, and 174 for 6/29. The afternoon wash temperatures varied between 142 and 152 except for 6/15. The afternoon rinse temperatures varied were 172 for 6/1, 173 6/12, 173 for 6/23, and 173 for 6/26. The evening wash temperatures 152 for 6/1, 154 for 6/3, 153 for 6/5, 150 for 6/11, 147 for 6/24, 142 for 6/25, and 152 for 6/30. The evening rinse temperatures varied between 172 and 179 except for 6/1, 6/2, 6/3, 6/4, 6/5, 6/8, 6/10, 6/24, 6/25, and 6/30.
The Dietary Services Manager (Staff # 6) was interviewed on 7/26/17 at 10:45 AM. He/She confirmed the findings and stated that he/she was beginning the retraining process. Staff # 6 suggested the documentation was the result of staff members simply writing what was previously documented rather than an actual mechanical issue.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0514
(Tag F0514)
Could have caused harm · This affected 1 resident
2. The facility failed to ensure that resident records were accurately mantained as protected health information was stored within the incorrect medical chart.
A review of resident #105's medical rec...
Read full inspector narrative →
2. The facility failed to ensure that resident records were accurately mantained as protected health information was stored within the incorrect medical chart.
A review of resident #105's medical record revealed the presence of admission processing documents, a Medical Eligibility Form and a Psychiatric Consult Note belonging to an individual who was not admitted to the facility.
The Director of Nursing was made aware of the findings on 7/25/2017 at 12:25 PM and confirmed that the health information was stored in the incorrect patient record and the documents belonged to an individual who had not been admitted to the facility.
Based on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete form for Residents (# 41 and 105). This was evident for 2 of 30 residents selected for review in the stage 2 survey sample.
The findings include:
A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.
1. The facility staff failed to accurately document the results of a finger stick.
Medical record review for Resident # 41 revealed on 10/7/16 the physician ordered: finger sticks (FS) at breakfast and dinner and notify the physician for FS above 401 or below 60. A finger stick (FS) is a blood glucose test that measures the amount of a type of sugar, called glucose, in the blood. The site, free of surface arterial flow, where the blood is to be collected is sterilized with a topical germicide, and the skin pierced with a sterile lancet and a small drop of blood is obtained. Record revealed on 11/23/16 at 4:30 PM, the facility staff obtained the FS and documented the FS as 39. Further review of the medical record revealed the facility staff failed to notify the physician of the results or failed to treat the low FS results. Interview with the Director of Nursing on 7/26/17 at 1:00 PM revealed the facility staff failed to accurately document the results of the FS and revealed 39 was not the actual FS result.
Interview with the Director of Nursing on 7/27/17 at 11:00 AM confirmed the facility staff failed to maintain the medical record in the most accurate form for Resident # 41 by failing to accurately document a FS result.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Maryland facilities.
Concerns
- • 47 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Autumn Lake Healthcare At Arlington West's CMS Rating?
CMS assigns AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Autumn Lake Healthcare At Arlington West Staffed?
CMS rates AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Autumn Lake Healthcare At Arlington West?
State health inspectors documented 47 deficiencies at AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST during 2017 to 2025. These included: 43 with potential for harm and 4 minor or isolated issues.
Who Owns and Operates Autumn Lake Healthcare At Arlington West?
AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AUTUMN LAKE HEALTHCARE, a chain that manages multiple nursing homes. With 82 certified beds and approximately 75 residents (about 91% occupancy), it is a smaller facility located in BALTIMORE, Maryland.
How Does Autumn Lake Healthcare At Arlington West Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST's overall rating (1 stars) is below the state average of 3.0 and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Autumn Lake Healthcare At Arlington West?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Autumn Lake Healthcare At Arlington West Safe?
Based on CMS inspection data, AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Autumn Lake Healthcare At Arlington West Stick Around?
AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Autumn Lake Healthcare At Arlington West Ever Fined?
AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Autumn Lake Healthcare At Arlington West on Any Federal Watch List?
AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.