AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER
For profit - Limited Liability company
225 Beds
AUTUMN LAKE HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
34/100
#95 of 219 in MD
Photo by Autumn Lake Healthcare Post Acute Care Center
Photo by Autumn Lake Healthcare Post Acute Care Center
Photo by Autumn Lake Healthcare Post Acute Care Center
1 / 5 photos
Last Inspection: March 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Autumn Lake Healthcare Post-Acute Care Center has received a Trust Grade of F, indicating significant concerns about the facility's overall quality and safety. They rank #95 out of 219 nursing homes in Maryland, placing them in the top half, but their poor trust grade raises red flags for potential residents. The facility's trend is improving, with issues declining from 20 in 2023 to just 1 in 2024, which is a positive sign. Staffing is a strength here, with a turnover rate of 26%, much lower than the state average, suggesting that staff are experienced and familiar with the residents. However, there have been serious concerns, including a critical incident where a cognitively impaired resident was physically abused by staff, resulting in a fall and a fractured hip, along with other issues like improper food handling and failure to follow physician orders for residents. While the quality measures are rated excellent, families should weigh these strengths against the facility's serious past incidents and current average ratings in health inspections and RN coverage.
- Trust Score
- F
- In Maryland
- #95/219
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 26% annual turnover. Excellent stability, 22 points below Maryland's 48% average. Staff who stay learn residents' needs.
- Penalties ⚠ Watch
- $15,593 in fines. Higher than 85% of Maryland facilities, suggesting repeated compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 46 minutes of Registered Nurse (RN) attention daily — more than average for Maryland. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
34/100
Top 43%
Review needed
20 → 1 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 20 issues
2024: 1 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (26%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (26%)
22 points below Maryland average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
3-Star Overall Rating
Near Maryland average (3.0)
Meets federal standards, typical of most facilities
Federal Fines: $15,593
Below median ($33,413)
Minor penalties assessed
Chain: AUTUMN LAKE HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 33 deficiencies on record
1 life-threatening
Oct 2024
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, the facility staff failed to thoroughly investigate a complaint of a neglect (Resident #35). This was evident for 1 out of 39 residents reviewed during a ...
Read full inspector narrative →
Based on medical record review and interview, the facility staff failed to thoroughly investigate a complaint of a neglect (Resident #35). This was evident for 1 out of 39 residents reviewed during a complaint survey.
Findings include:
Review of Resident #35's facility reported incident (MD 00190514) on 10/8/23 at 11:00 am revealed the resident's family made an allegation of neglect after the resident fell on the unit on 3/14/23 and sustained a fracture leg.
The surveyor reviewed the facility investigation on 10/8/24 at 11:30am revealed that the facility failed to thoroughly investigate the events surrounding the allegation of neglect. The investigation contained information about the fall incident on 3/14/24. The facility investigation did not contain other resident interviews disproving widespread negligence from staff.
Interview with the Director of Nursing on 10/8/24 at 2:00pm confirmed the facility investigation of Resident #35's did not contain resident interviews disproving widespread negligence from staff.
Mar 2023
20 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, administrative record review, and staff interviews, it was determined that the facility failed t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, administrative record review, and staff interviews, it was determined that the facility failed to protect a cognitively impaired resident (Resident #362) from physical abuse from a facility staff member on 5/15/22. This was evident for 1 of 29 residents (Resident #362) reviewed for abuse during an annual recertification survey. Resident #362 sustained a fall during a physically abusive incident and suffered a fractured hip. Thereafter, Resident #362 never regained his/her ability to walk independently. This failure to protect residents from physical abuse by facility staff members resulted in an Immediate Jeopardy. However, the facility developed, initiated, and completed an acceptable plan of correction to prevent further abuse which met all elements of past noncompliance. The period of noncompliance began on 5/15/22 and ended on 6/22/22.
The Findings Include:
Minimum Data Set (MDS) is a comprehensive assessment of a resident completed by facility staff. The MDS is a multi-disciplinary tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain, and medications to name a few) to be addressed. The MDS assessment is part of the broader Resident Assessment Instrument (RAI) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident.
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.
Brief Interview for Mental Status (BIMS) is an assessment that assists staff in evaluating a resident's cognitive status. A score of 13-15 implies cognitively intact status, 08-12 implies moderately impaired status, and 00-07 implies severe impairment status. A score of 99 indicates the facility attempted the assessment but the resident was unable to answer a sufficient number of questions to complete the assessment.
Medical record review on 3/2/23 at 9:30 AM revealed Resident #362 was a long-term care resident admitted to the facility on [DATE] with significant comorbidities including a dementia related diagnosis. The resident was alert and oriented to self with a BIMS score of 99 documented in the quarterly MDS assessment dated [DATE]. Resident #362 was cognitively impaired and received extensive assistance with care.
Medical record review and review of facility-reported incidents MD00178528 and MD00178603 and complaint MD00177160 on 3/2/23 at 10:00 AM revealed a hospital discharge report dated 5/31/22 which indicated Resident #362 was sent to the hospital on 5/16/22 and stayed until 5/31/22. Resident #362 went to the hospital for an X-ray to determine if the resident sustained a fracture from the fall on 5/15/22. The X-ray revealed the resident sustained a left hip fracture. Resident #362 underwent hip pinning surgery on 5/18/22 and required a 14-day hospital stay to treat after-surgery pain and be provided physical therapy. Resident #362 was unable to walk after sustaining the fall on 5/15/22.
Additional medical record review on 3/6/23 at 8:30 AM revealed the MDS quarterly assessment dated [DATE] assessed Resident #362 as requiring supervision while ambulating on the unit or in his/her room. After the surgery to Resident #362's left hip, the MDS quarterly report dated 6/24/22 assessed the resident as being unable to walk on the unit and required a wheelchair to ambulate.
On 3/7/23 at 12:59 PM, in an interview with the Director of Nursing (DON) and the Administrator regarding the abuse allegations against GNA #38, a contracted staff member, the DON revealed the facility substantiated abuse after viewing video surveillance of a 5/15/22 abuse incident involving Resident #362. The DON and the Administrator displayed the video surveillance of the 5/15/22 abuse incident for the survey team.
Review of video surveillance revealed that on 5/15/22, GNA #38 walked toward Resident #362 in view of several other cognitively impaired residents and attempted to take plastic gloves from Resident #362's hands. Resident #362 moved away from GNA #38 as GNA#38 attempted to remove the plastic gloves from Resident #362's hands. GNA #38 then moved aggressively toward Resident #362, pushing and striking him/her repeatedly. Resident #362 tried to avoid GNA#38's punches by backing up toward a wall resulting in Resident #362 hitting a wall and falling on his/her left side. While Resident #362 fell on his/her left side, the jacket the resident was wearing fell from his/her shoulders. GNA#38 then continued to repeatedly strike Resident #362 while the resident fell. GNA #38 then picked up Resident #362's jacket, threw it at him/her, and then walked away from the incident location. None of the nursing staff were present in the hallway before, during or after the incident.
In an interview after viewing the 5/15/22 abuse incident, the DON stated none of the unit's nursing staff witnessed the 5/15/22 abuse incident because they were providing resident care at the time of the incident. The DON also advised that the nursing unit was comprised of cognitively impaired residents and the residents did not remember the 5/15/22 abuse incident when facility staff members attempted to interview them. The DON also revealed the facility did not know the incident was an allegation of abuse until the video surveillance was retrieved on the morning of 5/16/22. The DON also stated the video quality was poor when the facility initially attempted to view the 5/15/22 abuse incident initially so the facility contacted the video vendor to provide a better quality of the video. The DON stated the facility was able to view the video surveillance, for the first time, on 5/17/22. The DON officially terminated GNA #38 from his/her contract on 5/17/22. The DON also stated GNA#38 last worked for the facility on 5/15/22, the date of the abuse incident. The DON stated that she received the information about the resident's left hip fracture on 5/18/22. The DON then called law enforcement to report the employee abuse and issued a complaint to the Maryland Board of Nursing on 5/19/22. The DON stated the resident was unable to walk independently after the 5/15/22 abuse incident.
On 3/8/22 at 9:50 AM, in an interview with the DON and the Assistant Director of Nursing (ADON) regarding abuse training protocols before and after the 5/15/22 abuse incident, the DON stated the facility now requires agencies to provide proof of background checks, abuse training, and valid nursing license prior to the contracted nursing staff's first shift. The DON stated the facility changed their onboarding procedures for contracted nursing staff after the 5/15/22 incident. The facility also now requires new agency nursing staff to complete an orientation prior to their first shift. The orientation is performed by the DON, ADON or supervisor prior to the contracted employee's first shift. The DON also stated she performed an audit on the training received by current agency nursing staff and the abuse training provided by the agencies. The DON stated two agencies were unable to provide their abuse training materials for facility approval. The DON was able to approve two other agencies for facility use. These two agencies provided the facility with their training materials including abuse prohibition training. The DON reviewed the submitted training and approved the agencies' abuse training as adequate for potential future contracted staff. The DON also stated the facility no longer employs agency nursing staff for the cognitively impaired/memory care unit, which was the location of the 5/15/22 abuse incident.
On 3/8/23 at 12:30 PM, in interview with the DON and the ADON regarding the orientation packet given to all agency nursing staff after the 5/15/22 abuse incident, the DON stated that all agency nursing staff are given the packet prior to their first shift at the facility. The DON was asked if the training materials contained abuse education and the DON stated that the training packet contained an abuse education review because all staff from facility contracted agencies had their abuse training reviewed and approved prior to the facility accepting the agency contract. The DON also stated after completion of the orientation, the contracted nursing staff member signs an acknowledgment form which the facility keeps for their records. The survey team reviewed and verified the abuse in-service training dated 5/15/22 through 5/19/22 for all staff including abuse training certificates for permanent staff dated throughout the month of February 2023 and acknowledgment forms for agency staff orientation from June 2022 to the present and new permanent staff abuse training certificates from July 2022 to February 2023.
On 3/10/22 at 11:00 AM, the surveyor interviewed the DON and the Administrator regarding the training cycle for abuse prohibition. The DON stated permanent staff members have yearly training by March of each year. If there is an allegation of abuse, the facility provides in-service training for all staff including contracted staff members. New permanent staff members are required to complete abuse training prior to finishing their probation period and all new agency staff members have a review of abuse training prior to their first shift.
On 3/17/22 at 7:30 PM, the survey team verified that after the resident abuse incident on 5/15/22, in-service education for abuse and neglect training for all staff members was completed by 5/19/22. By 5/19/22, the facility also completed an audit sweep of all residents which included skin assessments by nursing staff to assess for signs and symptoms of abuse including possible bruising, and resident interviews by social service staff to assess for any resident concerns related to possible abuse. In addition, the facility implemented a new process to validate that contracted nursing staff received education on abuse and neglect and instituted a policy to not allow contract nursing staff to work their first shift in the facility without verification of the abuse and neglect training. On 6/22/22, the facility gained access of abuse and neglect education verification from the last of the nursing agencies the facility utilized for contract staffing. However, the facility continued to staff from this agency after 5/19/22 and prior to obtaining the verification access on 6/22/22.
The facility implemented a monitoring plan beginning 5/19/22 that included random checks by social services staff and nursing. These random checks were conducted at least weekly for four weeks and then continued monthly. The monthly checks were still in place at the open of the survey, and the facility DON was accountable for the monitoring portion of the facility correction plan.
With a corrective action plan including monitoring fully in place prior to the survey open, the elements of past noncompliance were met. The past noncompliance for the immediate jeopardy began with an substantiated abuse incident that occurred on 5/15/22, and ended on 6/22/22 when the facility fully implemented the new policy to not allow contract staff to work on facility units without verification of abuse and neglect training.
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, record review and interview, the facility failed to accommodate the needs of a resident by failing to ensure a resident had the medical equipment needed for their disability stat...
Read full inspector narrative →
Based on observation, record review and interview, the facility failed to accommodate the needs of a resident by failing to ensure a resident had the medical equipment needed for their disability status. This was evident in 1 of 72 (Resident #103) residents reviewed during the facility's annual survey.
The findings include:
On 2/22/23 at 11:32 am, the surveyor observed Resident #103 with bilateral lower extremity edema sitting in a wheelchair without the foot rests. The surveyor interviewed Resident #103 regarding the resident's needs. Resident #103 stated he/she requested wheelchair footrest, but the facility had failed to meet the request.
Review of the medical records on 3/9/23 at 3:33 PM revealed a podiatry note dated 2/23/23 which revealed Resident #103 was diagnosed with insufficient blood flow to his/her lower extremities. The loss of blood flow to the lower extremities put Resident #103 at risk for pressures ulcers at his/her lower extremities so pressure relieving devices were needed per podiatry recommendations.
On 03/09/23 04:30 PM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding concerns for Resident #103's foot care needs. The ADON stated that she was aware of the podiatry recommendations for Resident #103.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on observations and interviews with the resident and facility staff it was determined the facility failed to ensure that a newly admitted resident received breakfast the following morning after ...
Read full inspector narrative →
Based on observations and interviews with the resident and facility staff it was determined the facility failed to ensure that a newly admitted resident received breakfast the following morning after being admitted . This was found to be evident for 1 (Resident # 607) of 107 residents sampled during the facility's annual Medicare/Medicaid survey.
The findings include,
Residents that resided on the first floor were screened on 2/21/23 at 11:00 AM in accordance with the Long-Term Survey Process. During a brief interview each resident was asked if they are doing okay and if they have any concerns regarding the care that they were receiving at the facility.
Upon entering Resident # 607's room, the resident was asked if there were any concerns regarding the care that was provided by the staff, and the resident replied, I did not get breakfast today. The resident further stated that no one came in to bring breakfast to him/her.
An interview was conducted immediately with Licensed Practical Nurse (LPN) #8 at 11:05 AM and he was made aware that Resident #607 did not receive a breakfast tray. The nurse stated the resident was admitted the prior evening and the dietary department was supposed to send a tray for the resident. He went on to say that when residents are admitted a meal ticket is completed at that time and sent to the kitchen. He explained that somehow, a breakdown occurred resulting in the resident not receiving a breakfast tray and that he would notify the kitchen.
During a subsequent interview on the same date at 11:20 AM, LPN #8 informed the surveyor that Resident # 607 received a box of cereal and a carton of milk. The resident was also provided with an early lunch tray at 11:30 AM.
The Administration team was made aware of the concerns on 2/21/23 at 3:00 PM.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on medical record review and interviews it was determined that the facility failed to notify the physician when a resident refused medications that have the potential to adversely affect their h...
Read full inspector narrative →
Based on medical record review and interviews it was determined that the facility failed to notify the physician when a resident refused medications that have the potential to adversely affect their health when missed. This deficient practice was evident in 1(Resident #107) of 5 medical records reviewed for physician notification.
The findings include:
On 03/02/23 at 12:29 pm, a review of Resident #107's Medication Administration Record (MAR) for February 2023 revealed the resident missed a dose of the antispasmodic medication on 02/01/23 at 8:00 am. Antispasmodics are used to relieve cramps or spasms of the stomach, intestines, and bladder. Further review of the MAR revealed that the resident refused 11 doses of a Statin medication for high cholesterol and 10 doses of an Anticholinergic for an Overactive Bladder.
On 03/02/23 at 1:14 pm during an interview with Director of Nursing (DON) #2 when asked what the expectations of the staff are when a resident misses a medication or treatment, the DON reported the staff are to notify the provider, call the pharmacy to see why the medication is unavailable, and see if there is an alternative medication. For residents who opt not to receive medication or treatment, the physician will be notified. The staff should encourage the resident to take the medication and write a note. The DON was made aware that Resident #107 did not receive their dose of medication for bladder spasms on 02/01/23 at 8 am and several doses of a statin and anticholinergic. There was no documentation in the electronic medical record (EMR) of the physician being aware.
On 03//02/23 at 1:46 pm, DON #2 reported the resident refuses medication a lot. The surveyor requested documentation the physician was aware the resident refuses medication.
On 03/03/23 at 1:20 pm, further review of Resident #107's EMR revealed the resident had a care plan dated 04/28/21 for refusing medication. The care plan was revised on 09/22/22. The intervention was to notify the MD of the resident's request to withhold medications. DON #2 was unable to verify Resident #107's physician was aware the resident was refusing medications.
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 resident and staff interviews it was determined that the facility staff failed to report an allegation of verbal abuse to the state agency within two hours. This was evidenced in 1 (Resident ...
Read full inspector narrative →
Based on resident and staff interviews it was determined that the facility staff failed to report an allegation of verbal abuse to the state agency within two hours. This was evidenced in 1 (Resident #42) of 5 records reviewed for abuse.
The finding includes:
On 03/06/23 at 2:45 pm during an interview, Resident #42 stated he/she reported to Social Services Designee #24 that a female GNA came into the room on the evening of 03/04/23 badgering the resident about leaving the facility. The alleged GNA told the resident they didn't want him/her there.
On 03/06/23 at 3:14 PM during an interview, Social Services Designee #24 indicated Resident #42 mentioned something happened over the weekend and Social Services Designee #24 reported it to Unit Manager #13.
On 03/06/23 at 3:28 PM, in interview with Administrator #1 and the Director of Nursing #2, both verbalized being unaware of the alleged incident of verbal abuse that took place on the Terrace Level during the evening shift of 03/04/23 which verified the staff did not report the alleged abuse to the state agency within two hours.
On 03/14/23 at 11:45 am Administrator #1 reported the employees are supposed to report allegations of abuse immediately to him. If he is not available, the employees must report allegations to Director of Nursing #2 or their immediate supervisor.
On 03/15/23 at 11:02 am during an interview with Unit Manager #13, she reported Social Services Designee #24 asked her to speak with Resident #42. She assumed that Social Services Designee #24 took care of everything as far as reporting the allegation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews with facility staff it was determined the facility failed to ensure that the resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews with facility staff it was determined the facility failed to ensure that the resident and or the resident responsible party (RP) received a written transfer notice with documentation of the reason for the transfer to the hospital prior to transfer. This was found to be evident for 3 (Residents #161, #166, and #556) of 4 residents reviewed for hospital transfers during the facility's annual Medicare/Medicaid survey.
The findings include:
1. A medical record review was done on 2/23/23 at 2:56 PM and it revealed R# 161 was sent to the hospital. The resident had a change of condition on 4/19/22 and was sent to the hospital for further evaluation. The survey team requested a copy of the facility's transfer form that was provided to the resident upon transfer. The facility was unable to provide this document.
The resident was sent to the hospital on [DATE]. The survey team requested a copy of the facility's transfer form that was provided to the resident upon transfer. The facility was unable to provide this document to the survey team.
The resident had a change in condition on 10/27/22 and was transferred to the hospital. The survey team requested a copy of the resident's written transfer form that is to be given to the resident. The facility was unable to provide the requested documents to the survey team.
2. A medical record review was done on 2/23/23 at 3:30 PM for Resident # 166 and it revealed the resident was sent out to the hospital on 2/14/23 for a change in condition and a second opinion of care at the family's request. The survey team requested a copy of the resident's written transfer form and the facility was unable to provide documentation of the transfer form that was provided to the resident prior to the transfer.
During an interview with the DON and Administrator on 3/2/23 at 1:15 PM a copy of the facility's bed hold policy and a copy of the facility's standard transfer form was brought to the survey team. The DON and the Administrator were unable to provide documentation of a transfer form and bed hold policy for the 3 hospitalizations for Resident #161 or for Resident # 166 hospitalization on 2/14/23. They further explained that the facility staff will be provided with education moving forward.
3. Review of the medical record for Resident #556 on 3/9/23 at 2:41 PM revealed that in February 2023 Resident #556 was transferred to an acute care facility due to a change in his/her medical status. There was no evidence found in the medical record that written notification was made to the resident and/or the responsible party regarding the reason for the transfer and location of the transfer. During an interview with the ADON (Assistant Director of Nursing) on 3/9/23 at 4 PM, she stated the notice could not be located.
All concerns were discussed with the Administrative Team at the time of exit on 3/21/23 at 7:45 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 with staff it was determined that the facility failed to have a system in place to ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or resident responsible party (RP) are given written notification of the facility bed-hold policy when they are being transferred out of the facility to a hospital. This was found to be evident for 3 (Residents #161, #166, and #556 ) of 4 residents reviewed for hospital transfers during the facility's annual Medicare/Medicaid survey.
The findings include,
1. A medical record review was done on 2/23/23 at 2:56 PM and it revealed Resident #161 was sent to the hospital due to a change of condition on 4/19/22. The survey team requested a copy of the facility's bed-hold form that was provided to the resident upon transfer. The facility was unable to provide this document to the survey team.
The resident was sent to the hospital on [DATE]. The survey team requested a copy of the facility's bed-hold form that was provided to the resident upon transfer. The facility was unable to provide this document to the survey team.
The resident had a change in condition on 10/27/22 and was transferred to the hospital. The survey team requested a copy of the bed-hold form that is to be given to the resident. The facility was unable to provide the requested documents to the survey team.
2. A medical record review was done on 2/23/23 at 3:30 PM for Resident #166 and it revealed the resident was sent out to the hospital on 2/14/23 for a change in condition and a second opinion of care at the family's request. The survey team requested a copy of the resident's written bed-hold form and the facility was unable to provide the documentation that was provided to the resident prior to the transfer.
During an interview with the DON and Administrator on 3/2/23 at 1:15 PM a copy of the facility's bed-hold policy and a copy of the facility's standard transfer form was brought to the survey team. The DON and the Administrator were unable to provide documentation of bed hold policy for the 3 hospitalizations for Resident #161 or for Resident #166 hospitalization on 2/14/23. They further explained that the facility staff will be provided with education moving forward.
3. Review of the medical record for Resident #556 on 3/9/23 at 2:41 PM revealed that in February 2023, Resident #556 was transferred to an acute care facility due to a change in his/her medical status. There was no evidence found in the medical record that written notification was made to the resident and/or the responsible party regarding the facilities bed-hold policy.
During an interview with the ADON (Assistant Director of Nursing), on 3/9/23 at 4 PM, she stated the notice could not be located. On 3/10/23 at 10 am the Administrator presented a form that was titled Bed Hold Authorization, which was not signed by the resident/resident representative, also there was no information regarding the facilities bed-hold policy.
All concerns were discussed with the Administrative team at the time of exit on 3/21/23 at 7:45 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 with the facility staff it was determined that the facility failed to ensure Minimu...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by: 1.) failure to accurately code: speech, vision, hearing, health condition and pain for 1 (Resident #155) of 2 residents reviewed for pain; 2.) failure to accurately code a resident for falls for 1 (Resident #506) of 5 residents reviewed for falls and 3.) failure to accurately code a resident for bowel and bladder incontinence for 1 (Resident #163) out of 5 residents reviewed for bowel and bladder incontinence during the investigation stage of the survey.
The findings include.
The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The MDS provides a comprehensive assessment of the resident's functional capabilities and helps nursing home staff identify health problems. It is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. MDS assessments need to be accurate to ensure each resident receives accurate care and care planning.
1. On 3/14/23 at 10:30 AM Resident #155 medical history was reviewed and revealed that the resident was admitted to the facility with a complex medical history including quadriplegia (unable to move any extremities), chronic respiratory failure with ventilator dependence. Further review of the medication administration records reveal that the resident was receiving oxycodone 5 milligram two times a day for pain. (Oxycodone is part of a group of drugs known as opioids used for pain).
Review of the MDS Annual assessment dated [DATE] section B-Hearing, Speech, and Vision, revealed the following regarding the resident: his/her hearing is adequate, he/she is understood and usually understands, and that his/her vision is adequate. Review of section J-Health Condition revealed the resident did not receive any scheduled pain medication and a pain assessment interview should be conducted. Further review of section N medications revealed that the resident did not receive any scheduled pain medications.
During an interview with the MDS coordinator #61 on 03/14/23 12:13 PM and reviewing the February 2023 MDS sections-B, J and N the surveyor asked if she was familiar with the resident and she stated somewhat. The surveyor asked what type of test was completed for the resident to determine the answers on section B-Hearing, Speech and Vision, the MDS and the MDS coordinator #61 revealed that she needed to investigate and would get back to the surveyor. While reviewing the physician orders and the Medication Administration Record (MAR) she acknowledged that the resident was getting a scheduled pain medication and was also receiving an Opioid.
In a follow-up conversation with the MDS coordinator #61 on 3/14/23 at 2:15 PM she acknowledges that the coding on section B was incorrect and that a modification for section B, J and N was being sent and she will begin education on the correct way of assessment and coding.
2. Resident # 506 medical records were reviewed on 3/20/21 at 11:30 AM and revealed the resident was admitted to the facility for rehabilitation. Further review of the medical records revealed that the resident was found on the floor, x-rays were obtained and he/she was found to have a moderately deformed fracture of the left femur without dislocation.
Review of the MDS Discharge Return assessment section dated 11/5/22 section J Health Condition J1800 indicates if any falls since Admission/Entry or prior assessment. No was checked indicating that the resident did not have any falls. Due to the facility inaccurately coding of falls they failed to code that Resident #506 sustained a major injury.
While reviewing the medical records and the MDS with the MDS coordinator #61 on 3/20/21 at 2:30 PM she acknowledged that it was coded inaccurately and that a modification was completed.
3. Review of Resident # 163's medical record on 2/23/23 at 8:30 AM revealed the resident was admitted with the following but not limited to diagnosis: Marfan's Syndrome (a genetic condition that affects connective tissue which provides support for the body and organs), Cardiac Arrest, and Anoxic (lack of oxygen) Brain Damage.
Further review of Resident # 163's Quarterly MDS assessment dated [DATE] revealed, Section H0300 Bladder and Bowel was coded as (2) frequently incontinent.
An interview was conducted with the MDS Coordinator # 9 on 2/23/23/at 9:30 AM and she stated that the GNA documented this incorrectly. She went on to say that it was not coded to reflect the resident's actual assessment which is always incontinent and that it should have been coded as (3) accordingly. She confirmed the inaccuracy.
An interview was conducted with the DON on the same date at 9:50 AM and she told the survey team that when the MDS Coordinator hit the reset button, it cleared everything and pulled prior information, resulting in Resident #163 being coded in error. She went on to say that the MDS Coordinator should have checked for accuracy by talking to the GNA and the nurse on the floor to see if there was a change in the resident's status. She stated that education will be provided to the staff.
The Administration team was made aware of all concerns at the time of exit on 3/21/23 at 7:45 PM.
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
3. On 03/13/22 at 10:53 am , a review of the electronic medical record revealed Resident #410 was admitted to the facility with a Foley catheter January 2022 from a local hospital.
On 03/13/23 at 12:...
Read full inspector narrative →
3. On 03/13/22 at 10:53 am , a review of the electronic medical record revealed Resident #410 was admitted to the facility with a Foley catheter January 2022 from a local hospital.
On 03/13/23 at 12:18 PM, a review of the electronic medical record revealed the resident did not have a care plan for the Foley catheter. The surveyor asked Director of Nursing #2 for a copy of Resident #410's care plan for the foley catheter.
On 03/13/23 at 12:33 Director of Nursing #2 confirmed a care plan was not done.
On 03/13/23 at 12:29 PM during an interview with Assistant Director of Nursing #3 reported care plans are done upon admission and updated as changes occur, quarterly, and as needed. A resident with a foley catheter would have a care plan.
The Director of Nursing (DON) was made aware of care plan concerns at time of survey exit on 3/21/23 at 7:45 PM.
Based on medical record review and interview with staff it was determined that the facility staff failed to develop a care plan to 1.) reflect the presence of and current treatment of the residents' behavior for 1 of 5 (Resident #188) residents reviewed for unnecessary medications; 2.) to reflect a resident who required staff to provide care and mobility for 1 out of 4 (Resident #155) reviewed for mobility and 3.) reflect the specific care for a resident who was admitted with a Foley catheter (Resident #410). This deficient practice was evident for 3 of 10 residents reviewed for care plans during the facility's annual Medicare/Medicaid survey.
The findings include:
A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress.
1. Review of Resident #188's medical records on 03/15/23 04:23 PM revealed the resident was admitted to the facility for long term care and with diagnosis that includes encephalopathy (a broad term for any brain disease that alters brain function or structure).
Further review of the medical records revealed a change in condition note dated 2/13/23 which revealed the following: Brief synopsis of change: new medication: Quetiapine (antipsychotic) 12.5 milligram via G (Gastric)-tube BID (twice daily) for agitation/aggression. Summary of change in condition: Resident refusing ADL care, (Activities of Daily Living), vital signs and hitting at care givers. ADL's refers to personal hygiene - bathing/showering, grooming, nail care, and oral care.
Review of the resident care plans on 03/20/23 03:03 PM failed to reveal a care plan to reflect the presence of and current treatment of the residents behavior and antipsychotic medication use. The surveyor requested a copy of the care plan from the Assistant Director of Nursing (ADON).
During an interview with the ADON on 3/20/23 at 3:30 PM she acknowledged that a care plan for behavior and antipsychotic medication use had not been initiated.
The DON (Director of nursing) was made aware of care plan concerns at time of survey exit on 3/21/23 at 7:45 PM.
2. Resident #155's medical records were reviewed for positioning and mobility on 3/20/23 at 9:08 AM. Review of the medical records revealed the resident was admitted to the facility for long term care and with diagnosis that included quadriplegic (unable to move any extremities), chronic respiratory failure with ventilator dependence, anoxic (no oxygen) brain injury, encephalopathy (disease that affects the function of the brain) and contracture (stiffening) of the upper extremities. Care plans were also reviewed. After reviewing the care plans, the surveyor was unable to locate a care plan for ADL's mobility and positioning and requested a copy of the resident care plan.
During an interview with the DON on 3/20/23 at 11:30 AM she acknowledged that the resident did not have a care plan for ADL's. After surveyor intervention, the DON provided an individualized care plan for the resident.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation and interviews it was determined that the facility failed to follow the proper procedures to safely transfer a resident. This was evident for 1 of 8 residents (Resident #93) revie...
Read full inspector narrative →
Based on observation and interviews it was determined that the facility failed to follow the proper procedures to safely transfer a resident. This was evident for 1 of 8 residents (Resident #93) reviewed for accidents during the facility's annual Medicare/Medicaid survey.
The findings include:
A Hoyer lift is a patient lift used by caregivers to safely transfer patients. It can be used for lifting patients from the floor or onto a healthcare bed. The lift also can assist in other surface-to-surface patient transfers, such as moving from a bed to a bath or chair. such as moving from a bed to a bath or chair.
On 3/16/23 at 11 AM the surveyor observed a resident in the middle of the hallway being hoisted up from his/her chair and the 2 staff members transported the resident from the hallway into the room
During an interview with geriatric nursing assistant (GNA) #78 the surveyor asked what resident was being transported into the room, she replied it was Resident #93. The surveyor asked what the procedure for moving a resident from the Hoyer lift into a bed. GNA #78 informed the surveyor the correct way was to have the resident in the room next to the bed and transfer him/her into the bed. The surveyor asked why the resident was not transferred in his/room instead of transporting the resident from the hallway into his/her room and place them in bed and GNA #78 stated it was too much stuff in the room and I just did it this way. Surveyor clarified with GNA #78 that even though she should not have transported the resident that distance in a Hoyer lift she did it anyway and she replied yes.
During an interview with GNA #82 the surveyor asked if he knew the process of transferring a resident to the bed and he said it should be done in the resident's room. When asked why the transfer was not done correctly, he replied it's not my patient, I was just helping.
On 3/16/23 at 12:00 PM the Director of Nursing was interviewed about transferring a resident to the bed, she verbalized that it should take place in the resident's room. Review of the facility procedures for transferring residents revealed it is to keep the chair or wheelchair to which the resident is to be moved close to the bed so that the resident is only moved a short distance in the lift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews it was determined that the facility failed to maintain infection control practices. This def...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews it was determined that the facility failed to maintain infection control practices. This deficient practice was evident in 2 (Resident #48 and #133) of 2 residents observed with urinary drainage bags and 1 treatment cart located on the Terrace Level.
The findings are:
On 02/21/23 at 8:19 am during observation rounds on the Terrace Level, the surveyor observed the treatment cart located outside of room [ROOM NUMBER] was unlocked. Drawer #2 had used wound cleanser without a resident label, opened and exposed gloves, and gauze. Drawer #3 had a package of opened and exposed abdominal pads. Drawer #4 had an open package of Calcium Alginate, an open package of 4 x 4 gauze, and unpackaged gauze in Drawer #5.
On 02/21/23 at 8:27 am LPN #14 confirmed the surveyor's findings on the treatment cart.
On 02/21/23 at 8:44 am while in Resident #133's room, surveyor observed the leg of the bedside table was over the resident's urinary drainage bag on the floor. The resident's phone, a container of powder, and waste were on the floor. LPN #14 confirmed the surveyor's findings.
On 02/21/23 at 12:25 pm, the surveyor observed Resident #48 urinary drainage bag on the floor in the resident's room. GNA #19 confirmed the surveyor's findings.
On 03/10/23 at 5:05 pm during an interview with Unit Manager #13, she reported each Nurse and Medicine Aid is responsible for the cart they are using. The nurses are responsible for ensuring the carts do not have outdated supplies and rounds are done at least monthly.
On 03/21/23 at 12:12 pm during an interview with Assistant Director of Nursing #3, she reported the facility has Foley care orders in the system. The staff are instructed to clean the perineal area with soap and water, flush the catheter as needed if the Foley is occluded. The Foley bag should be on the end of the bed and covered with a privacy bag.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews it was determined the facility failed to ensure all residents had access to a working call b...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews it was determined the facility failed to ensure all residents had access to a working call bell system. This deficient practice was evident in 1 of 7 (Resident #30) residents reviewed for a working call bell system.
The findings include:
On 3/09/23 at 6:08 pm, while on the Terrace Level in room [ROOM NUMBER], Resident #30 came into the room via wheelchair and verbalized being cold. The surveyor instructed the resident to initiate the call bell for assistance. The surveyor observed the resident press the call bell twice. After five minutes none of the staff came to room [ROOM NUMBER]. The surveyor went outside of the room and noticed the call bell light outside of the resident's room was not on. The surveyor went to the nurse's station to get assistance for Resident#30. LPN #80 came to the resident's room and verified the call bell system for resident #30 was not working. The nurse connected the call bell cord to a y-connector and the call bell light came on.
On 03/10/23 at 05:25 pm Director of Nursing #2 was made aware of the incident with the call bell system and went to the resident's room. Maintenance Director #10 came to the Terrace Unit and reported call bell system was switched; they took the dual switch out. The call bell was plugged into a non-working device, but it was changed out on 03/10/23.
CONCERN
(E)
📢 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interviews, it was determined that the facility staff failed to provide an envir...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interviews, it was determined that the facility staff failed to provide an environment that promotes the dignity and respect for residents. This was found to be evident for Residents #16, #158, #37 and #362 and residents in Rooms #14, #18, #19, #20 sampled during the facility's annual Medicare/Medicaid survey.
The findings include:
1. Review of the facility reported incident MD00178528 dated 6/9/2022 and MD00178603 dated 6/10/2022, revealed that on 5/15/22 the facility received an accusation of resident to employee abuse by GNA #38, a contracted staff member.
The Director of Nursing (DON) started the facility investigation of the abuse incident on 5/15/22. The facility had video surveillance of the area where the abuse incident was alleged to have taken place. The facility investigation was completed by 5/18/22 which substantiated GNA #38 violated facility policy by committing gross misconduct as shown in the video footage of the 5/15/22 abuse incident. The facility's self-report documents dated 5/18/22 reported facility video surveillance on 5/15/22 showed GNA #38 moving aggressively toward resident #362 which caused the resident to lose his/her balance and fall. The facility notified local law enforcement, terminated the facility staff member's contract, and reported the facility staff member to the Maryland Board of Nursing (MBON).
On 3/7/23 at 12:59 pm, the surveyor interviewed the DON and the Administrator regarding the abuse allegations against GNA #38 on 5/15/22. The DON stated that the facility was able to substantiate abuse after viewing video surveillance of the 5/15/22 abuse incident. The DON and the Administrator displayed the video surveillance of the 5/15/22 abuse incident for the survey team. The survey team viewed GNA #38 walking toward resident #362. The video showed several residents in the hallway at the time of the 5/15/22 abuse incident. GNA #38 walks toward resident #362 and attempted to take plastic gloves from the resident's hands. Resident #362 moves away from GNA #38 has she attempted to remove the plastic gloves from his/her hands. GNA #38 then moved aggressively toward resident #362, pushing and striking him/her repeatedly. Resident #362 tried to avoid GNA#38's punches by backing up towards a wall. Resident #362 hits the wall behind him/her, falls on his/her left side, while the jacket he/she was wearing fell from his/her shoulders. GNA#38 continues to repeatedly strike resident #362 while the resident falls. GNA #38 then picked up resident #362's jacket, throws it at him/her, and walks away from the incident location. None of the nursing staff were present in the hallway before, during or after the incident. The survey team asked the DON about the location of nursing staff during and after the incident. The DON stated the nursing staff were providing resident care at the time of the incident. The survey team asked the DON if they were able to obtain interviews from the residents present during the 5/15/22 abuse incident. The DON stated that the nursing unit is comprised of cognitively impaired residents and the residents did not remember the 5/15/22 abuse incident when facility staff members attempted to interview them. The DON also revealed the facility did not know the incident was an allegation of abuse until the video was retrieved on the morning of 5/16/22. The DON also stated the video quality was poor when the facility attempted to view the 5/15/22 abuse incident initially. The facility contacted the video vendor to provide a better-quality of the video. The DON stated the facility was able to view the video surveillance, for the first time, on 5/17/22. The DON officially terminated GNA #38 from his/her contract on 5/17/22. The DON also stated GNA#38 last worked for the facility on 5/15/22, the date of the abuse incident. The DON stated that she received the information about the resident's left hip fracture on 5/18/22. The DON then called law enforcement to report employee abuse and issued a complaint to the Maryland Board of Nursing on 5/19/22. The DON stated the resident was unable to walk independently after the 5/15/22 abuse incident.
On 3/10/22 at 11:00 am, the surveyor interviewed the DON and the Administrator regarding facility expectations of staff protecting residents' dignity. The administrator stated the facility trains its staff members to provide excellent customer service to its residents. The surveyor expressed concerns regarding the 5/15/22 physical abuse incident and the failure of the facility to protect resident #362's dignity.
2. Review of the facility-reported incident MD00182414 on 3/13/23 at 1:08 pm revealed that on 2/15/22 Resident #37 reported activities aide #69 turned off the light to the main dining room after lunch while residents were still in the room.
Review of the facility investigation on 3/13/23 at 2:00 pm revealed a customer satisfaction form dated 2/18/22 completed by Social Services Director #23 for Resident #37. The customer satisfaction form stated Resident #37 reported Activity Aide #69 turned off the dining room light while residents were in the dining room. Activity Aide #69 stated that the lights were hurting his/her eyes. Resident #37 reported the incident to Activity Aide #68. Activity Aide #68 addressed the concern of the resident with Activity Aide #69. Activity Aide #69 approached Resident #37 and started yelling at him/her about reporting the incident to Activity Aide #68.
Review of the facility investigation on 3/13/23 at 2:30 pm revealed a statement from Social Services Director #23 completed on 2/15/22 revealed Resident #37 reported Activity Aide #69 confronted him/her after reporting the 2/15/22 incident between the resident and Activity Aide #69. Social Services Director #23 asked Activity Aide #68 about the incident and Activity Aide #68 told the Social Services Director #23 that he/she would get the Activity Aide #69 to apologize to Resident #37. Activity Aide #69 went to Resident #37 and attempted to intimidate the resident about telling activity aide #68 about the incident.
Review of the facility investigation on 3/13/23 at 3:00 pm revealed a discipline action form dated 2/18/22 which shows activity aide #69 was terminated on 2/18/22.
On 03/14/23 at 11:48 AM, the surveyor interviewed the Administrator regarding facility expectations of staff protecting resident's dignity. The administrator stated the facility trains its staff members to provide excellent customer service to its residents. The surveyor expressed concerns regarding the verbal abuse incident and the failure of the facility to protect Resident #37's dignity.
5. On 02/21/23 at 8:35 am during observation rounds, the surveyor observed Staff #16 walk into the resident's room [ROOM NUMBER] and the resident's room [ROOM NUMBER] without knocking on the door. During a brief interview, Staff #16 reported to the surveyor he/she was just trying to get everything done.
6. On 02/21/23 at 8:37 am the surveyor observed GNA #17 walk into room [ROOM NUMBER] without knocking. GNA #17 made the surveyor aware he/she should have knocked first to respect the resident's privacy. At 9:09 am GNA #17 walked into room [ROOM NUMBER] without knocking.
On 02/21/23 at 9:53 am during an interview with LPN # 19, he/she stated the staff are supposed to knock on the resident's door prior to entering the room and they are expected to wait for a response before entering.
On 03/10/23 at 5:09 pm Unit Manager #13 reported the staff are supposed to knock on the resident's door and wait for a response before entering the room.
All concerns were discussed with the Administration team at the time of exit on 3/21/23 at 7:45 PM.
3. During observation rounds on 2/21/23 at 8:48 AM Resident #16 was observed with a soiled brief on his/her bedside table with a yellow and brown dried substance. The Unit Manager #49 verified the findings and removed the soiled brief. During a follow-up round on 3/7/23 at 11 AM, the resident room was noted with dirty tissue and an empty juice container on the floor. The Unit Manager #49 was made aware, and the items were removed from the resident room.
4. During observation rounds on 2/21/23 at 9:30 am Geriatric Nursing Assistant (GNA) #7 was observed sitting on Resident #158's bed feeding him/ her breakfast. GNA #7 was asked why she was not using the chair next to the bed. She stated it was broken. It should be noted the chair appeared to be in good repair. The Unit Manager #49 was made aware of the observation on 2/21/23 at 9:45 AM.
During a follow-up interview with the Unit Manager at 12 PM on 2/21/23 she stated, Resident #158 chair was checked by the Maintenance Department and verified the chair was in good repair.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, it was determined that the facility staff failed to provide...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, it was determined that the facility staff failed to provide and maintain a safe, clean, and homelike environment for the residents. This was evident for 2 (3rd floor Dementia Unit and the Terrace Unit) of 4 units observed during the survey.
Findings Includes:
1. A tour of the 3rd floor Dementia unit was conducted on 02/21/23 at 08:00 AM where a loose partially attached bumper panel on the left side of elevator door casing was observed. Multiple dark stains, black streaks, dents, and holes were noted on the lower portion of the unit's hallway. Further observation revealed folded candy wrappers located inside the handrail ledge near the unit's utility closet.
An observation of the unit's dining room at 08:40 am revealed 5 dining chairs with their seat areas pushed in and frayed fabric dangling from their bottoms. Observation of the two window seals and air conditioning units revealed a plastic cup with a dried substance inside sitting on the left air conditioning unit with a loose electrical cable on the floor underneath. The flooring under both air conditioning units had deep, dark, black/brown discoloration, dust, crumbs, and debris noted. Using a foot, surveyors were unable to rub the observed discolorations. Several areas of baseboards on the perimeter of the room, were observed to be loose or missing from the walls.
Observations of resident room [ROOM NUMBER] at 09:02 am revealed a large dark stain the length of the bed on the floor in between two resident's beds. Resident #145 was present in the room and interviewed. When asked, the resident stated the stain had always been there. In addition, the resident's privacy curtains were noted with dark brown stains. Further observations of residents' rooms noted multiple stains on the privacy curtains in Rooms #301, #307, and #309.
An observation of the Dementia Unit in the presence of the Maintenance Manager (MM) #10 was conducted on 03/06/23 at 12:12 pm. The Maintenance Manager was alerted to the observations noted during the 02/21/23 observations. During an observation of room [ROOM NUMBER] surveyors noted a closet near the left side of the window with an unhinged door. The MM #10 attempt to realign the door was unsuccessful. The MM #10 replied that residents on the unit are hard on the furniture. Further observation of the air conditioning unit in the room revealed debris, dark stains, and dust inside the grates and on the floor underneath.
Observations of the air conditioning units in all the residents' room and the dining area revealed accumulated debris, dust, and dark stains inside the grate and underneath. When shown to the MM #10, s/he stated that all the air conditioning units are routinely powered washed.
During observations in resident room [ROOM NUMBER], #302, #303, #305, #306, and #307 surveyors noted wall baseboards were peeled away from the wall. The walls under the sinks in room [ROOM NUMBER], #306 and #307 were noted to have peeled off. Observation of room [ROOM NUMBER] revealed the dresser hatch on a closet door was broken and the light fixture in the bathroom was missing.
Observation of a missing light fixture behind the door of room [ROOM NUMBER] was lost, in addition the room's air conditioning unit door was unhinged and rested on the floor. This was also observed in rooms #315 and #318. An additional disengaged door was found laid against the air conditioner unit by surveyors in room [ROOM NUMBER].
Observation of the unit's dining room was conducted during the 12:30 pm lunch service. Surveyors observed three chairs in use by residents that had bowed seat bottoms and frayed material. Further review noted the left rear leg of one of the chairs was cracked. The Maintenance manager was alerted, and the chairs were removed from the room.
2. On 02/21/23 at 8:31 am during observation rounds, the surveyor observed a used facial mask on the floor in room [ROOM NUMBER] near Bed A. The surveyor observed GNA #15 walk past the mask on the floor and exit the room. The hand sanitizer dispensers outside of room [ROOM NUMBER] and room [ROOM NUMBER] did not dispense hand sanitizer.
On 02/21/23 at 8:57 am the surveyor entered the Shower Room located on the Terrace Level and observed the shower head on the floor in Stall #2, Stall #3 shower head had a steady flow of water dripping onto the floor, a piece of gum in a pack was under the shower chair, and paper around the drain. The room with the tub had a used pair of gloves in the corner, and the vent over the tub was hanging down from the ceiling. At 9:01 am CMA #18 verified the surveyor's findings.
On 02/21/23 at 10:17 am the surveyor observed dried tube feeding on the bottom of the pole in room [ROOM NUMBER] B. GNA #33 verified the surveyor's findings. At 10:29 am the surveyor observed dried tube feeding on the pole in room [ROOM NUMBER]-B.
On 02/21/23 at 10:22 am the surveyor and EVS (Environmental Services) Director # 20 walked through the Shower Room on the Terrace level; the surveyor's findings were confirmed. EVS Director # 20 reported the shower nozzle in Stall #3 was too wide to fit the holder and the hanging vent would be checked.
On 02/24/23 at 11:00 am the surveyor entered the Shower Room on the Terrace Level, Stall #1 had a wet washcloth on the floor and the shower head in Stall #3 had a steady flow of water running onto the floor of the stall.
On 03/14/23 during an interview with EVS Director #20, he stated the EVS department was responsible for keeping the facility clean, moving and transferring of belongings, wheelchair cleaning, and all the laundry (linen and personal). Every room is cleaned daily in the morning; around 2 pm the rooms are refreshed. The shower rooms are cleaned around 10 am. Anything in the resident's rooms that is not connected to the resident they are responsible for cleaning.
CONCERN
(E)
📢 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #356's facility reported incident MD00187893 on 3/16/23 at 10:53 am revealed the resident threatened staff...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #356's facility reported incident MD00187893 on 3/16/23 at 10:53 am revealed the resident threatened staff and other residents on 1/18/2023 and hit Resident #257. Reviewed of the facility investigation revealed the facility failed to interview all staff that were scheduled for the unit at the time of the incident on 1/18/23. The facility only interviewed the three GNAs scheduled on 1/18/23. None of the nurses were interviewed and one of the statements was missing the a name.
4. Review of Resident #361's facility-reported incident MD00177002 on 3/15/23 at 10:53 am revealed the resident reported to the facility that one of the beauticians called him/her a pejorative term. Per the report, the Resident #361 declined to have the police notified. Review of the facility investigation revealed the facility failed to interview all staff and residents that were present during the incident. One of the statements gathered during the facility investigation mentioned a resident and two other beauticians were present at the time of the incident. None of these statements were present in the investigation documents given to the surveyor.
The surveyor asked the ADON to explain the facility's investigation protocol for an abuse allegations during an interview on 3/16/23 at 3:30 pm. The ADON revealed the investigation protocol for an abuse allegation includes interviews with staff and residents about the incident. The surveyor expressed concern on 3/16/23 at 3:30 pm regarding the investigations involving Resident #356's actions and the incident with Resident #361.
All concerns were discussed with the Administration team at the time of exit on 3/21/23 at 7:45 PM.
2. On 03/14/23 at 10:22 am the surveyor received a copy of the investigation from Administrator #1 regarding Resident #42's allegation that a female GNA came into the room on the evening of 03/04/23 badgering the resident about leaving the facility. A review of the facility's investigation revealed there was no statement from Unit Manager #13 who was made aware of the alleged abuse by Social Services Designee #24. All the staff who worked on the Terrace Level during the time of the alleged incident were not interviewed. There were no statements from the two nurses and one Geriatric Nursing Assistant (GNA) who worked in the Terrace Unit on 03/04/23 during the evening shift when the alleged incident occurred.
On 03/14/23 at 11:45 am during an interview with LPN #22, he/she verbalized working on the Terrace level on 03/04/23 from 3 pm - 11 pm but was not aware any resident made an allegation of abuse.
On 03/15/23 at 10:42 am during an interview with Administrator #1, he stated he started working at the facility in November 2022 and he is the Abuse Prohibitionist. He received training as the Abuse Prohibitionist through a computer-generated training called Healthcare Academy and the In the Knows training packet. When there is an allegation of abuse, he is the person everyone reports to; he assesses the situation and investigates it. There is a regional person to consult with. During the investigation, questions are asked about the time and place the alleged incident happened. The resident, staff, staff taking care of the resident, staff on that shift, anybody taking care of them prior, and any person who had contact with the resident is interviewed.
On 03/15/23 at 11:02 am during an interview with Unit Manager #13, she reported Social Services Designee #24 asked her to speak with Resident # 42. She assumed that Social Services Designee #24 took care of everything as far as reporting the allegation. When she spoke with Resident # 42, he/she was unable to provide the name of the person, but it happened during the evening shift on 03/04/23. Resident #42 said the person had braids going back in a ponytail. Unit Manager #13 checked the schedule to see who worked that evening.
On 03/15/23 at 12:50 pm, during a telephone interview with GNA #90, he/she reported working at the facility 4-6 days a week depending on the facility's availability, and he/she completed abuse training at the facility in January and February of 2023. GNA #90 indicated when he/she worked the evening shift on 03/04/23 it was a wonderful shift, and he/she has worked with Resident #42 many times including the previous night. She indicated the Administrator #1 had called and said someone asked Resident #42 when he/she was leaving the facility. GNA #90 verbalized not knowing what Administrator #1 was talking about. GNA #90 denied asking Resident #42 why he/she is still at the facility. GNA #90 reported having braids in his/her hair and while working his/her hair is in a ponytail.
On 03/15/23 at 1:00 pm, a review of the facility's Abuse, Neglect, and Exploitation Policy revealed Section V Investigation of Alleged Abuse, Neglect, and Exploitation page 4 and #4 states: Identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation.
On 03/15/23 at 1:22 pm during an interview with Director of Nursing # 2, she reported when they have an allegation of abuse, they interview the resident and staff who cared for the resident during the time of the allegation, and staff who worked on the floor. They also interview Social Services and anybody who was involved with the resident.
Based on an administrative record review and interviews with the facility staff it was determined the facility failed to complete a thorough investigation into allegations of abuse. This was found to be evident for 4 (Residents #609, #42, # 356, and # 361) of 20 residents reviewed for abuse during the facility's annual Medicare/Medicaid survey.
The findings include:
1. Intake MD00184687 was reviewed on 3/15/23 at 10:00 AM for allegations of abuse. According to the intake information, Resident #609's family reported to the facility on [DATE] that the resident was pushed from the wheelchair by Geriatric Nurse Assistant (GNA) #89. The facility DON was asked on 3/15/2023 at 10:15 AM if they had an investigation into the allegations and the facility subsequently provided the survey team with documentation of Resident #609 sustaining a hematoma to the forehead from a fall that occurred on 10/12/22 in the afternoon.
Further review of the documentation on the same date at 10:30 AM included interviews with other residents, and interviews with staff assigned to the resident that were dated 10/12/22 and 10/13/22, however, the family reported the abuse allegation to the facility on [DATE]. There were no interviews with residents or staff at that time.
Another interview was conducted with the DON on 3/15/23 at 1:20 PM and she stated that on 10/17/22 the resident's family came into the facility with the police to report abuse allegations. She went on to say that the police did speak with Resident # 609 at that time but did not file a report. The DON confirmed that the facility did not have documentation of an investigation into the abuse allegations on 10/17/22, only documentation of the resident fall that occurred on 10/12/22. She further stated that the GNA was suspended and later terminated because the GNA delayed notifying the nurse at the time of the fall and the abuse allegation was unsubstantiated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on record review and staff interview it was determined that the facility failed to: 1.) ensure that a plan of care was adjusted to reflect significant weight loss for (Resident #60) reviewed for...
Read full inspector narrative →
Based on record review and staff interview it was determined that the facility failed to: 1.) ensure that a plan of care was adjusted to reflect significant weight loss for (Resident #60) reviewed for nutrition and 2.) revise care plans with appropriate goals and interventions for 2 (Resident #155 and Resident #178) of 8 residents reviewed for pressure ulcers, 2 (Resident #155 and Resident #188) of 5 residents reviewed for tube feeding, and 1 (Resident #188) of 3 residents reviewed for tracheostomy and 1 (Resident #178) 1 residents reviewed for anticoagulant therapy during the facility's annual Medicare/Medicaid survey process.
Findings include:
The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The MDS provides a comprehensive assessment of the resident's functional capabilities and helps nursing home staff identify health problems. It is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings.
A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress.
1. Failed to ensure that a plan of care was readjusted to reflect significant weight loss for (Resident # 60).
A review of Resident #60's medical record on 03/01/23 at 09:48 AM revealed the resident was admitted to the facility with diagnoses that included: kidney disease with the dependence on hemodialysis (Hemodialysis is a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyze, are used to clean your blood), high blood pressure, and Dementia.
A review of the resident's care assessment (MDS) showed that the resident's functional status was extensive and required one person to physically assist the resident to eat and drink.
A review of five weights recorded from December 28, 2022, to March 7, 2023, revealed that Resident #60 had lost 12.8 lbs. in three months indicating a loss of 5% of their total body weight. However, a review of the resident's care plan initiated on July 30, 2019, failed to acknowledge, or show any revisions were made to the resident's plan of care related to the current significant weight loss.
An interview was conducted with Resident #60's nurse #53 on 3/14/2023 at 10:00 AM. Nurse #53 stated they were familiar with the resident and the resident often refused to eat their meals. S/he added that the resident had skipped more than one meal multiple times during the week. When this occurred s/he would offer cookies or crackers throughout the shift. The resident had refused their meal that morning but accepted a couple of cookies from them. When asked, Nurse #53 stated that it was expected if any resident had a significant weight loss they would be notified by the Registered Dietician or unit manager and would participate by following the care interventions to reverse the weight loss. When asked, the nurse replied that s/he was not aware of a current weight loss for Resident #60.
An interview was conducted with the Registered Dietitian (RD) #62 in the presence of the Director of Nursing (DON) on 03/16/23 at 01:34 PM. The RD stated that s/he retrieved Resident #60's weight every week from the Dialysis Center. The weight received was an average taken from the three weights recorded that week at the center. The RD stated she was aware of the resident's recent significant weight loss. When asked if there were any interventions or comments added to the resident's care plan regarding the weight loss, s/he replied that she didn't. The DON was asked by surveyors what were the expectations when there is a discovery that a resident had a significant weight loss. The DON replied that it was expected that she, the resident's unit manager, and the physician would be notified, and interventions would be put in place for the residents' nursing, dietary, and assigned facility staff to follow.
2. Failed to revise care plans with appropriate goals and interventions
Resident #155's medical records were reviewed for pressure ulcers and tube feeding on 3/6/23 at 9:08 AM. Review of the medical records revealed the resident was admitted to the facility for long term care and with diagnosis that include quadriplegic (unable to move any extremities), chronic respiratory failure with ventilator dependence, pressure ulcers and gastrostomy tube for feeding. Care plans were also reviewed. Further review of the care plans for tube feeding revealed that it was initiated in August 2022 and no further revisions were made. In addition, the care plan for pressure ulcers was initiated in May 2022, and it was not revised until March 2023 after surveyor intervention.
Review of Resident #188's medical records on 03/15/23 04:23 PM revealed the resident was admitted to the facility for long term care and with diagnoses that included respiratory failure requiring a tracheostomy and a gastrostomy tube for feeding. Review of the care plans for Tracheostomy care revealed that it was initiated August 2022 with no current revision. Review of care plans for tube feeding revealed that it was initiated in August 2022, and it was not revised until March 2023 after surveyor intervention.
On 3/15/23 Resident #178 medical records were reviewed and revealed the resident was admitted to the facility for long term care and with diagnosis that include chronic respiratory failure with ventilator dependence and pressure ulcers. Further review of the care plans for pressure ulcers revealed it was initiated in May 2022 and not revised until March 2023. In addition a care plan for anticoagulation was reviewed and revealed that it was initiated in May 2022 and not revised until January 2023.
The DON (Director of Nursing) was made aware of care plan concerns at time of survey exit on 3/21/23.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
7. On 3/7/23 at 10:30 PM on the ventilator unit on the terrace level, the surveyor asked registered nurse (RN) #75 to review the medication administration records (MAR) for residents #172, #121, #155 ...
Read full inspector narrative →
7. On 3/7/23 at 10:30 PM on the ventilator unit on the terrace level, the surveyor asked registered nurse (RN) #75 to review the medication administration records (MAR) for residents #172, #121, #155 and #188. Review of the MAR screens for those residents were red. When questioned what red means he replied that the medication is overdue. He further clarified stating I haven't signed them off.
On 3/20/23 at 3:15 PM the Director of
Nursing (DON) provided a copy of the MAR for the Terrace level ventilator unit and a MAR for a resident that was observed during medication pass, after the surveyor notified her of staff not signing off medication when they were being administered to residents. The following information was provided from the residents' medical records:
8. Resident #172 on 3/1/23 the following medications were due at 6:00 PM Omeprazole 20 mg, and Carvedilol 25 mg however they were signed off at 9:04 PM
9. Resident #121 on 3/1/23 the following medications were due at 5:30 PM and 6:00 PM, Transdermal patch 1.5 mg due at 5:30 PM, Ferrous sulfate mg, Oxcarbazepine 3.33 ml and Magnesium 400 mg due at 6:00 pm however they were signed off at 9:06 PM
10. Resident #155 on 3/7/23 the following medication was due at 8:00 PM, Keppra 1000 mg signed off 10:18 PM.
11. Resident #122 on 3/1/23 the following medications were due at 6:00 PM, Famotidine 20 mg, Oxybutynin 5 mg and signed off 9:09 pm. On 3/12/23 Coumadin due at 9 PM signed off at 11:10 PM.
12. Resident #188 on 3/1/23 the following medications were due at 6:00 PM, Omeprazole 20 mg, Hydroxyzine 12.5 ml, Eliquis 5 mg, Quetiapine 12.5 mg, Vitamin C 1 tablet, however they were signed off at 9:10 PM.
13. Resident #514 On 3/8/23 Carvedilol 25 mg was due at 8:00 PM signed off at 10:30 PM and Clonidine 0.2 mg due at 6:00 PM signed off at 9:10 PM.
14. Resident #41 the following medications were due at 8 am, Calcitriol 0.25 mcg, Cholecalciferol 125 mcg, Carvedilol 12.5 mg, Cosopt eye drops, Sacubitril-Valsartan 24-25 mg, Spironolactone 25 mg, Multivitamin 1 tablet and Nifedipine 25 mg, and they were all signed off at 11:36 am which was 2.5 hours after the medications were due.
During an interview with the Director of Nursing on 3/21/23 at 8:30 AM she acknowledges that it is standard of practice that when a medication is administered to a resident it is signed off before moving to the next resident. She further verbalized that they have begun education.
All concerns were discussed with the Administration team at the time of exit on 3/21/23 at 7:45 PM.
Based on record review, observation, and interview, it was determined that the facility staff failed to: 1.) administer a medication in accordance with the standards of practice for residents (Resident #87, #186, #117, #158, #84, #556) and 2.) document after medications were administered for residents (#172, #121, #155, #122, #188, #514 and #41). This was evident for 13 of 20 residents selected for review during a medication chart check during the facility's annual Medicare/Medicaid survey.
The findings include:
1. Review of Resident #87's medical record on 3/5/23 at 9 pm revealed an ordered for Melatonin 3 MG (Milligrams) by mouth at bedtime for insomnia. The melatonin was to be administered at 9 pm with administration signed as given. Review of the Medication Administration Record (MAR) for 3/1/23 at 9 pm revealed the Nurse, LPN #5 documented the Melatonin as being administered at 11:10 pm.
During interview with the DON (Director of Nurse) on 3/5/23 at 10 pm, she verified the findings. During interview with the LPN #5 she stated the standard of practice is to administer the medication one hour before or after the medication is due.
2. Review of Resident #186's medical record on 3/5/23 at 10:15 pm revealed an ordered for Tylenol Extra Strength Tylenol 500 mg (Acetaminophen) one tablet by mouth three times a day for pain. The Tylenol was to be administered at 4 pm on 3/5/23; however, the medication was not signed off as being administered until 9:28 pm, according to the Medication Administration Audit report.
During interview with the CMA (Certified Medication Aide) #42 she stated the medication was administered at 4 pm, but she did not sign it off as being administered until 9:28 pm.
3. Review of Resident #117's medical record on 3/5/23 at 10:25 pm revealed an ordered for Eliquis (Apixaban) one tablet by mouth two times a day for acute embolism and thrombosis. The Eliquis was to be administered at 4 pm on 3/5/23; however, the medication was not signed off as being administered until 6:28 pm, according to the Medication Administration Audit report. During interview with the CMA (Certified Medication Aide) #42 she stated the medication was administered at 4 pm, but she did not sign it off as being administered until 6:28pm.
4. Review of Resident #158's medical record on 3/6/23 at 9:15 am revealed an ordered for Methimazole Tablet 0.5 mg by mouth every 8 hours for hyperthyroidism. The Methimazole was to be administered at 10 pm on 3/3/23; however, the medication was not signed off as being administered until 3/4/23 at 12:07 am, according to the Medication Administration Audit report. During an interview with the Nurse, LPN #91 she stated the medication was given at the correct time but was signed off later.
5. Review of Resident #84's medical record on 3/6/23 at 11:15 am revealed an ordered for Lorazepam 1 mg by mouth every 12 hours for agitation. The Lorazepam was to be administered at 8 pm on 3/3/23; however, the medication was not signed off as being administered until 11:49 pm, according to the Medication Administration Audit report. During an interview with the Nurse, LPN #5 on 3/6/23 at 2 pm she stated the medication was given at the correct time but was signed off until 11:49 pm.
6. Review of Resident #556's medical record on 3/6/23 at 11:15 am revealed an ordered for Valproic Acid Oral solution 250 mg/5 ml (Valproate Sodium) 10 ml by mouth two times a day for seizures. The Valproic Acid was to be administered at 8 pm on 3/3/23; however, the medication was not signed off as being administered until 11:16 pm, according to the Medication Administration Audit report. During an interview with the Nurse, LPN #5 on 3/6/23 at 2 pm she stated the medication was given at the correct time but was not signed off until 11:16 pm.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on QAPI record review and interview, the facility failed to adequately monitor its practices around abuse, specifically abuse prevention, abuse reporting, and abuse investigation. The facility h...
Read full inspector narrative →
Based on QAPI record review and interview, the facility failed to adequately monitor its practices around abuse, specifically abuse prevention, abuse reporting, and abuse investigation. The facility had repeat deficiencies for abuse prevention, abuse reporting and abuse investigation during this annual survey after submitting a plan of correction in January 2022.
Findings include:
On 3/21/23 at 7:30 am, review of facility's previous survey findings revealed the facility had deficiencies for abuse prevention, abuse reporting, and abuse investigations in January 2022. The facility submitted a Plan of Correction in January 2022 to address the deficiencies and the the Plan of Corrections was approved.
On 3/21/23 at 7:40 am, review of deficient practices found during the facility's annual survey revealed repeated deficient practice for abuse prevention, abuse reporting, and abuse investigations.
On 3/21/23 at 11:30am, during an interview with the Assistant Director of Nursing (ADON) and the QAPI Custodian #4, the surveyor revealed the survey team found repeated deficiencies around abuse prevention, abuse reporting, and abuse investigations. The surveyor reviewed the QAPI records from January 2022 to the present with the ADON and the QAPI Custodian #4. The review revealed limited information was shown on the records around its abuse monitoring. QAPI Custodian #4 stated that the records did not show the specific abuse monitoring activities being done around abuse prevention, abuse reporting, and abuse investigations.
The surveyor expressed concerns to the ADON and the QAPI Custodian #4 on 3/21/23 at 12:00pm.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Failure of staff to follow physician orders to meet the resident needs.
On 02/23/23 at 02:52 pm a tour of the Dementia Unit f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Failure of staff to follow physician orders to meet the resident needs.
On 02/23/23 at 02:52 pm a tour of the Dementia Unit floor was conducted. An observation of Resident #40's room revealed Resident #40 sitting up in their bed. Surveyors noted on top of a bedside table a capped disposable Styrofoam cup, handwritten with 02/22/2023 and 11-7 am shift. Also noted was an uncapped straw inserted inside the cup. Further observation revealed two handwritten signs that indicated No Straws posted on the wall next and above the resident's headboard.
When asked, Resident #40 indicated that it was their cup and that they had drank from it using the straw. The resident gestured to surveyors to come closer. When surveyor approached the opposite side of the bed, it was noted that a floormat laid between the resident's bedside table and the bed. The resident was asked if they could reach their cup and the resident shook their head and said No.
A review of Resident #40's medical record was conducted on 02/24/23 at 08:30 am. The resident had diagnoses which included Dementia, Dysphagia, (difficulty in swallowing), and muscle weakness. Review of Resident #40's order summary sheet showed an order dated 2/17/20 that read; Liberalized Diabetic diet, Ground texture, thin liquids.
Further review of the medical record revealed the February 2023 quarterly care plan assessment stated the resident was able to eat and drink with supervision and required physical assistant support from one person. Further review of the medical record found no documentation to support that the resident was required to have floor mats placed at bedside or was not to have the use of straws.
On 2/24/2023 at 09:30 an observation of Resident #40 s room revealed that the handwritten signs were replaced with two typed signs that stated, NO STRAWS. Further observation found a capped disposable insulated cup with no straw with the handwritten date of 2/24/23. There was no floor mat noted. However, the bedside table holding the beverage cup was towards the head of the bed and the cup stood closer to the far end of the resident's nightstand table. Surveyor asked Resident #40 if s/he could reach their beverage, the resident looked back over their right shoulder and stated No. The resident stated that they were thirsty. One of the unit's nurses walking by in the hallway was alerted to the resident's need and they instructed staff to assist Resident #40 with their beverage.
A review of Resident's 40's physician order sheet noted that the 02/17/2020 order was updated on 2/23/2023 to Liberal Diabetic diet, ground texture, thin liquid consistency, NO STRAWS. Further review found no documentation in the medication or treatment administration records that indicated the added instructions regarding the straws.
During an interview conducted on 2/24/2023 at 2:30 pm, the DON was made aware of the observations conducted and asked what was their expectation of staff in providing individualized care to residents. The DON replied that it is expected that all personnel should read, review, and follow every resident care plan and assessment.
A record review conducted on 02/27/2023 at 10:12 am revealed a Skilled Chart note dated 2/25/2023 that showed Resident #40 required extensive assistance with 1 person to provide physical support for eating and drinking.
5. Failure to ensure that a resident received treatment for a possible wound infection
On 03/17/23 at 09:48 AM, the surveyor reviewed a complaint MD00168833 which alleged the facility delayed sending the resident out for emergency treatment for pressure ulcers.
Review of medical record at 3/17/23 at 10:00 AM revealed the resident was admitted to the facility on [DATE] for care after a stroke (muscle weakness to one side of the body). Review of labs from June 2021 revealed the facility conducted lab blood tests 6/3/21, 6/5/21, 6/8/21, and 6/10/21 which revealed Resident #359 had increased white blood cells (WBC) levels. Review of skin notes from 6/2/21, 6/9/21, and 6/16/21 revealed no mention of infections. Review of wound notes from 6/2/21, 6/9/21, and 6/16/21 revealed Resident #359 was being treated for several pressure wounds, including a left foot wound, and none of the notes revealed any mention of wound infection.
Additional review of medical records at 3/17/23 at 11:00 AM revealed a Discharge summary dated [DATE] which revealed Resident #359 was admitted to the hospital from [DATE] to 6/28/21 for difficulty in breathing. The hospital diagnosed Resident #359 with an overall systemic infection (sepsis) due to the infection of a left foot wound. Emergency treatment was required including IV antibiotics to treat the overall systemic infection.
On 3/20/23 at 11:00 AM, the surveyor expressed concerns to the Assistant Director of Nursing (ADON).
3. Failure to clarify a physician order for a resident receiving Ensure
On 03/06/23 at 2:30 pm, A review of Resident #19's electronic medical record (EMR) revealed an order dated 02/28/23 at 4:12 pm was written for Ensure Plus three times a day.
On 03/06/23 at 2:29 PM during an interview with LPN #19, he/she stated the resident receives nightly tube feeding and water flushes; the resident also eats by mouth. The Ensure supplement comes from dietary with Resident #19's meals. LPN #19 has cared for Resident #19 multiple times since he/she has been in that unit. After reviewing the order, LPN #19 confirmed the route in which the resident is supposed to receive the Ensure is missing and the staff review orders every 24 hours.
On 03/06/23 at 2:56 pm during an interview with Unit Manager#13, she reported the shift nurses are supposed to check the chart and see if any new orders were taken off. The 11 pm - 7 am shift runs a 24-hour report. She does an order recap every morning Monday through Friday and on the weekend the supervisor does the order recap. Unit Manager #13 was shown the incomplete order written for Resident #19 Ensure.
Based on observation, medical record review, and interview with staff it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice as evidenced by 1.) failure to follow physician orders for 1 of 8 (Resident #155) residents reviewed for pressure ulcers, and 2 of 10 (Resident #40 and #19) residents reviewed for physician orders; 2.) failure of the GNA to notify the nurse after a resident had a fall for 1 of 5 (Resident # 609) residents reviewed for falls; 3.) failure of the facility to ensure that a resident received treatment for a possible wound infection for Resident #359, and 4.) failure to administer a pain medication for Resident #87 as ordered by the physician. This was found to be evident during the facility's annual Medicare/medicaid survey.
The findings include:
1. Failure to follow physician orders regarding pressure ulcer dressing change
On 3/14/23 at 2:30 PM surveyor observed Registered Nurse (RN) #76 doing a dressing change to Resident #155's pressure ulcer. The RN explained to the surveyor that he was cleaning the wound with wound cleaner and then he applied Medi honey, a brand name wound and burn gel made from 100% Leptospermum (Manuka) honey. Manuka honey is unique in that it has antibacterial and bacterial resistant properties.
Review of the physician orders dated 2/23/23 active order reveal the following: Cleanse posterior head wound with wound cleanser, apply hydrogel (a gel in which the liquid component is water) and dry dressing change daily. Further review of the medication administration record (MAR) was the order to cleanse posterior head wound with wound cleanser apply hydrogel and dry dressing, change daily one time a day. The treatment was signed off as being completed.
On 3/14/23 at 2:40 pm RN 76 was interviewed about the current treatment order for hydrogel and not Medi honey, he replied I thought the order was for Medi honey, I'll remove it.
During an interview with the Director of Nursing (DON) on 3/14/23 at 3:00 PM the surveyor informed her of the dressing change observation and what was used versus the physician order. The DON informed the surveyor that the resident was seen early this morning by the wound team and that the order would be changed tonight. The surveyor asked what the current dressing change order was and she replied the nurse should have applied hydrogel and not Medi honey since that was the current order.
The DON, ADON and Corporate staff were made aware at that time of the staff failure to follow the physician order while doing a treatment.
4. Failure of the GNA to notify the nurse after a resident had a fall
Intake MD00184621 was reviewed on 3/15/23 at 10:00 AM for multiple concerns. One of the concerns was an allegation of abuse in which the family reported Resident #609 was pushed from the wheelchair by a staff member.
Further review of the facility's investigation of the fall on 3/15/23 at 12:00 PM revealed the resident had a fall on 10/12/22 while being transported by the GNA #89. The resident abruptly stood up while being pushed in the wheelchair and the resident foot was caught, causing the resident to fall forward. The resident sustained a hematoma to the forehead. The resident was assisted into bed by GNA #89 and a housekeeper staff. According to the facility investigation, the nurse was not notified after the resident fell.
An interview was conducted with the Director of Nursing (DON) on 3/15/23 at 1:20 PM and she stated that the GNA #89 was suspended and then subsequently terminated for not notifying the nurse after the resident fell which delayed the resident assessment by the nurse. The DON went on to say that the GNA was terminated for putting the resident into bed after a fall and not reporting the fall to the nurse. She stated that GNA #89 did not follow the facility policy.
All concerns were discussed with the Administration team at the time of exit on 3/21/23 at 7:45 PM.
6. Failure to administer a pain medication for a resident as ordered by the physician.
Review of the medical record revealed Resident #87 was a resident whose diagnoses included falls with multiple fractures. The resident was cognitively impaired and was totally dependent on staff for care.
On 02/21/23 at 8:25 AM Resident #87 was observed with two white pills sitting in a medication cup on his/her bed side table. The Nurse Manager #49 verified the findings before removing the pills.
During follow-up interview with Nurse Manager #49 on 2/21/23 at 10 am she stated, the medication was Acetaminophen (Tylenol), and the resident was scheduled to receive it at 6 am on 2/21/23. Review of Resident # 87 MAR (Medication Administration record) for 2/21/23 at 11 am revealed the Acetaminophen (Tylenol) was signed off as being administered at 6 am.
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
Based on observation, record review, and staff interview it was determined that the facility staff failed to store, prepare, and serve food and beverages using proper sanitary practices. This deficien...
Read full inspector narrative →
Based on observation, record review, and staff interview it was determined that the facility staff failed to store, prepare, and serve food and beverages using proper sanitary practices. This deficient practice has the potential to affect all residents in the facility.
Findings include:
An initial tour of the facility's kitchen was conducted on 02/21/23 at 08:15 am with the Dietary Manager (DM) #27 present. After surveyors sanitized hands and donned hairnets. Dietary Aid (DA) #34 entered the kitchen, passed surveyors and DM #27, opened, and entered a storage refrigerator without sanitizing their hands.
The DM #27 was alerted to the observation and asked what was the expectation of staff entering into the kitchen. The DM #27 replied that it was expected that all personnel sanitize their hands before entering any area of the kitchen, including the refrigerator.
Observation of the storage refrigerator found and undated, opened partially exposed package of shelved cheese.
Observation of the food preparation area revealed several storage racks with opened spices, seasonings food dyes, and condiments with inconsistent and undated label and shelving dates. Four items were labeled with expired dates from 2022. Two items were labeled expired January 2023. The DM #27 stated that upon arrival to the facility, all food items are dated as received. The items are dated when opened and placed on shelves for use in the kitchen. S/he added that all items were listed with specific used by dates but when asked to show us for review, the DM #27 stated they were not readily available for reference.
Observation of the kitchen equipment storage area noted a meat slicer covered with a white clear wrap. When the cover was lifted, surveyor observed multiple dried pieces of residual meat on the blade, handle, slicer, and tabletop. When asked, the DM #27 stated the slicer was not in use that morning.
At the beverage dispenser area, surveyor observed the dispensing tubing laying on the floor, with dried white, red, and orange tanned residue on and around them. The floor that surrounded the dispensing area was noted with multiple-colored dark stains, debris, and crumbs. Two of the juice base boxes failed to be dated with an opened or expiration date.
Observation of the dry storage area surveyors found on the floor in the far left-hand corner several racks of bagged, sliced bread and hot dog buns. Further observation of the first three shelves surveyors observed on various portions of the bread loaves and hot dog buns a green, white, furry mold were visible through the wrappers. Observation of all bread loaves revealed none were labeled with an expiration date. The DM #27 stated that some of the shelved breads was previously frozen and bought to this area for thawing.
Observation of the right front side of the storage area revealed three storage bins sitting directly on the floor. Two bins one labeled flour the other corn, were noted with cracked, warped, and poor fitted lids. All three containers were noted with dark scratches and stains.
At 08:33 am surveyors observed the facility residents' breakfast service line. During the observation, surveyors noted multiple reusable cups with contents later identified by DM #27 of cranberry, orange and apple juices sat on a multiple tiered railed cart in the absence of ice.
Observation of a beverage chest on the opposite side of the service tray line that contained several milk and supplement drink cartons remained opened during the service. Surveyors watched as the service line staff pulled the juice cups, milk, and supplement cartons to place on resident's trays for distribution to the units. The DM #27 was alerted to observation and a temperature of selected containers and reusable cups was taken and recorded. The temperature of the milk in cartons were found to be 42.8 degrees Fahrenheit. The temperature of the orange juice, was 62.6 Fahrenheit , and a cranberry juice was noted at 60.7 Fahrenheit.
At 08:43 am, surveyors observed as staff #34 retrieved the remaining juice containers and cups from the service area and placed them into the storage refrigerator.
An observation of the kitchen staff's food line tray service and distribution was conducted on 03/08/23 at 12:30 pm accompanied by the facility's DM#27. At 12:33 pm, Staff #34 walked into kitchen, to the food distribution area, retrieved a pushcart with a food tray and attempted to head to the facility's ventilator unit to deliver the tray to a resident without washing their hands.
During an observation of the tray service line at 12:42 pm. Surveyor observed staff #35 retrieve a plate of food from staff #36 observed with the top of their face mask worn on their upper lip. Staff #35 placed the plate on the tray, readjusted their mask on their face with their hand, placed a cup of juice on the tray, pushed it down towards the next person on tray line, grabbed an empty tray and retrieved another resident's plate of food from staff #36. The DM #27 standing next to them was immediately alerted to the observation. Surveyors watched as staff #36 continued to have their mask fall off their nose, without any self-correction or acknowledgement from the kitchen staff.
At 12:50 pm, surveyor observed [NAME] #37 prepare mashed potatoes to replenish the food service line. Without any measuring utensils, the cook #37 poured powdered potatoes into a bowl, shook an unmeasured amount of salt, and another seasoning container, poured liquid out of a pot on the stove, which was later identified as melted butter, was mixed and presented to the tray line for service to the residents.
Cook #37 was interviewed and when asked if she followed a recipe, the cook replied that they held many years of experience and knew how the residents liked their food prepared. The DM #27 approached, informed of the observations, and asked to submit the recipe for the mashed potatoes for review.
On 03/08/23 at 9:45 am, an interview and record review of the submitted mashed potatoes recipe by the DM #27 was conducted with surveyor team. A review of the submitted recipe for the mashed potatoes failed to show that salt, seasoning, or butter was included in the recipe. During the interview, the DM #27 responded that s/he allowed additions/changes to recipe to please the residents.
Apr 2019
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 that facility staff failed to treat residents with respect and dignif...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview it was determined that facility staff failed to treat residents with respect and dignified manner by knocking on resident's room doors before entering. This was evident for 2 out of 53 residents involving (R#105, and #192) observed during dining meal service.
The finding include:
04/02/19 12:20 P.M. during second floor nursing unit lunch meal service observed geriatric nursing assistant (GNA) staff member #3 go in rooms [ROOM NUMBERS] without knocking on resident's doors and not sanitizing hands between rooms with lunch meals trays.
On 04/02/19 12:20 P.M. conducted staff interview with staff member #3 who informed writer the meaning of resident's dignity, and infection control practices. Staff member #3 verbally verified he/she forgot to knock on the resident's room door before entering and didn't wash or sanitized his/her hands between rooms during lunch meal service.
04/02/19 12:25 P.M. conducted staff interview with Nurse Unit Manager staff member #4 with who was present with corporate nurse during surveyor meal service observation and verbally verified writer's observations.
On 4/02/19 at 2:30 P.M. during interview with Director of Nursing (DON) with corporate members was made aware of dining concerns.
Administrator and DON was made aware of dignity and infection control concerns prior and during survey exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with resident, observation of resident and a review of medical records, the facility failed to identify a res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues. This was evident for 1 out of 53 residents with dental issues.
Findings include:
On 3/28/19 at 1:56 PM resident # 358 was interviewed. It was observed that resident had missing teeth and and discolored gums in the upper and lower gums. Resident stated they are decayed. Resident also stated no one here has looked at his/her mouth , nor has she/he had a dental appointment due to fact she/he had no dental insurance. Resident also stated she/he needed to see a dentist. On 3/1/19 when resident was admitted to the facility the admission assessment done by nurse at the time of admission did not identify the condition of resident's dental status. A conversation was on 4/4/19 at 11:38 AM with staff # 1, who is the MDS coordinator. The MDS dated [DATE] section L oral/dental status states there was no issue. (no broken teeth, no tooth fragments, no broken natural teeth. Nursing home MDS (minimal data set) coordinators maintain patient records adhering to state and federal regulations. They work closely with medical and administrative staff to continuously update patient records, and in most cases, handle the RAI (resident assessment instrument) process for patients from admission to discharge. Staff #1 said she would review MDS (Minimum Data Set) and get back to me. Upon her return MDS coordinator confirmed the MDS was coded incorrectly and a change would be made. DON (director of Nursing and Administrator are aware).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with resident, observation of resident and a review of medical records, the facility failed to identify a res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues. This was evident for 1 out of 53 residents with dental issues.
Findings include:
On 3/28/19 at 1:56 PM resident # 358 was interviewed. It was observed that resident had missing teeth and and discolored gums in the upper and lower gums. Resident stated they are decayed. Resident also stated no one here has looked at his/her mouth , nor has she/he had a dental appointment due to fact she/he had no dental insurance. Resident also stated she/he needed to see a dentist. A conversation was had with staff # 1 on 4/4/19 at 11:38 AM who is the MDS coordinator. Nursing home MDS (minimal data set) coordinators maintain patient records adhering to state and federal regulations. They work closely with medical and administrative staff to continuously update patient records, and in most cases, handle the RAI (resident assessment instrument) process for patients from admission to discharge.The MDS dated [DATE] section L oral/dental status states there was no issue. (no broken teeth, no tooth fragments, no broken natural teeth. Staff #1 said she would review MDS (Minimum Data Set) and get back to me. Upon her return MDS coordinator confirmed the MDS was coded incorrectly and a change would be made. DON (director of Nursing and Administrator are aware).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with resident, observation of resident and a review of medical records, the facility failed to identify a res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues and a resident who is on dialysis. This was evident for 2 out of 53 residents without a base line care plan.
Findings include:
1. On 3/28/19 at 1:56 PM resident # 358 was interviewed. It was observed that resident had missing teeth and and discolored gums in the upper and lower gums. Resident stated they are decayed. Resident also stated no one here has looked at the mouth , nor has she had a dental appointment due to fact she has no dental insurance. Resident also stated she need to see a dentist. A conversation was had with staff # 1 who is the MDS coordinator on 4/4/19 at 11:38 AM. The MDS admission assessment reveals that section L oral/dental status states there was no issue. (no broken teeth, no tooth fragments no broken natural teeth. Staff #1 said she would review MDS and get back to me. Upon her return MDS coordinator confirmed the MDS was coded incorrectly and a change would be made. DON (director of Nursing and Administrator are aware). There was no baseline care plan for dental.
2. Resident # 356 was admitted to the facility on [DATE]. He/She had a history of end stage renal disease and went to dialysis on Tuesday, Thursday, and Saturday. Resident has a fistulagram in right upper arm, Communication reports from dialysis are in the chart. Resident is currently on a renal, carb controlled diet and eats 50-100% intake most meals. He does receive a bedtime snack. Weights are 3/28 232#, 3/16 231#, 3/9 230. On 3/28/19 HgA1c was 5.9 which is an improvement. Dialysis communication reports are in the chart. There was no baseline care plan for resident.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with resident, observation of resident and a review of medical records, the facility failed to identify a res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with resident, observation of resident and a review of medical records, the facility failed to identify a resident with Dental issues and a resident who is on dialysis. This was evident for 2 out of 53 residents without a comprehensive care plan.
Findings include:
1. On 3/28/19 at 1:56 PM resident 358 was interviewed. It was observed that resident had missing teeth and and discolored gums in the upper and lower gums. Resident stated they are decayed. Resident also stated no one here has looked at the mouth , nor has she had a dental appointment due to fact she has no dental insurance. Resident also stated she need to see a dentist. A conversation was had with staff # 1 who is the MDS coordinator on 4/4/19 at 11:38 AM. Nursing home MDS (minimal data set) coordinators maintain patient records adhering to state and federal regulations. They work closely with medical and administrative staff to continuously update patient records, and in most cases, handle the RAI (resident assessment instrument) process for patients from admission to discharge. The MDS admission assessment reveals that section L oral/dental status states there was no issue. (no broken teeth, no tooth fragments no broken natural teeth. Staff #1 said she would review MDS and get back to me. Upon her return MDS coordinator confirmed the MDS was coded incorrectly and a change would be made. DON (director of Nursing and Administrator are aware). There was no baseline care plan or comprehensive care plan for this resident. for dental.
2. Resident # 356 was admitted to the facility on [DATE]. He/She had a history of end stage renal disease and went to dialysis on Tuesday, Thursday, and Saturday. Resident has a fistulagram in right upper arm, Communication reports from dialysis are in the chart. Resident is currently on a renal, carb controlled diet and eats 50-100% intake most meals. He does receive a bedtime snack. Weights are 3/28 232#, 3/16 231#, 3/9 230. On 3/28/19 HgA1c was 5.9 which is an improvement. Dialysis communication reports are in the chart. There was no baseline care plan or comprehensive care plan for this resident on dialysis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
Based on observation and staff interviews it was determined that the facility staff failed to develop a care plan for Resident #119 with a diagnosis of dementia. This was evident for 1 out of 53 Resid...
Read full inspector narrative →
Based on observation and staff interviews it was determined that the facility staff failed to develop a care plan for Resident #119 with a diagnosis of dementia. This was evident for 1 out of 53 Residents investigated during the survey process.
The Findings Include:
On 04/05/19 around 09:21 AM, this surveyor was reviewing Resident #119's medical record. It was noted that the Resident has a diagnosis of dementia. Further review of the record revealed that there were no interventions in the care plan for a resident with cognitive difficulties.
A Care Plan is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. This allows nursing to identify interventions to assist the Resident with any barriers that interferes with the Resident's optimal level of health.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or resident representatives were notified in writi...
Read full inspector narrative →
Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or resident representatives were notified in writing that they are being transferred out of the facility to a hospital and the reason why the facility is transferring the resident out. This was found to be evident for 2 out of 5 resident's (R#103 and R#105) reviewed during annual survey the investigative portion of the survey.
The finding includes:
On 4/3/19 Resident #105 medical records were reviewed. This review reveals a nurse's transfer to hospital note written on 12/30/18 which revealed that the resident #105 had an unplanned change in condition the resident was transferred to acute care hospital for medical evaluation.
On 4/9/19 Resident #103 medical records were reviewed. This review reveals a nurse' transfer to hospital not written on 01/07/19 which revealed resident #103 had an unplanned change in condition the resident was transferred to acute care hospital for medical evaluation.
Review of the eINTERACT Transfer Form V5 note revealed that neither the resident's (R#103 and R#105) or resident's responsible person (RP) the facility failed to reveal any documentation that written notification was given in person or mailed out to the resident's or their RP notifying him/her of the transfer and the rationale for the transfer.
On 04/08/17 at 2:30 P.M. during an interview with Director of Nursing reviewed eINTERACT transfer note involving resident's (R#103 and R#105) and verified with surveyor the lack of documentation of written notification was given resident's or RP of reason for hospital transferring resident's out of the facility.
On 04/02/19 at 11:15 A.M. during an interview with responsible party informed surveyor he/she was not notified by facility of change in condition or of hospital transfer involving resident #105 responsible party member stated he/she received a call from admitting acute hospital of resident's admission.
On 04/03/19 at 1:25 P.M. during an interview with R#103 responsible party member informed surveyor he/she not received written notification letter from facility stating reason for R#103 hospital transfer.
On 04/09/19 at 11:35 A.M. during interview with new NHA and Director of Nursing (DON) surveyor informed both staff member of survey concerns.
On 4/09/19 at 11:50 A.M. NHA requested to meet with surveyor to present facility documentation pre-packet for all facility hospital transfers in the presents of corporate staff with DON. During the same date and time, the Assistant Director of Nursing stated the facility gives this packet for all hospital transfers this discharge packet is given to the EMT driver only. Surveyor requested documentation that was provided to the resident's and RP notifying them in writing that the resident is being transferred to the hospital and the reason for the transfer. The facility staff could not provide written documentation that notification was given in writing to resident or RP member.
All findings discussed with the Administrator and the DON and Corporate panel at the time of the survey exit.
Based on facility staff interviews with the DON (Director of Nursing) and record review, the facility failed to provide a written notice to a resident and the responsible party of the transfer for 3 out of 3 people reviewed for transfer out to the hospital.
Findings include:
1. On 3/28/19 at 11:33 AM a record review of resident # 9 was conducted. Resident # 9 was sent to the hospital on 1/13/19 for abdominal fullness and leaking around the supra pubic site. The nursing note stated the supra pubic catheter will need to be changed by interventional radiology at the hospital. An interview with the DON (Director of Nursing) was held on 3/28/19 at 11:33 AM, who showed the survey team a booklet which contained the information sent out with the resident. During this conversation DON stated the packet is given to the EMT (emergency medical team) driver. All paperwork including face sheet, Molst form, Transfer note, labs, Physician note, nurse note, consults and bed hold policy was given to EMT driver. NO care plan was sent out with resident. DON confirmed the Bed hold policy was not given to the resident. DON could not locate or prove that a written note was ever given to the resident or Responsible party regarding the discharge to the hospital. There was no documentation in the chart regarding any transfer note. There was no written note sent to the family or responsible party of the transfer. He returned to the facility on on 1/14/18. A care plan is in place.
2. On 4/8/19 at 10:27 AM a record review was completed on resident # 7. On 2/22/19 resident # 7 was sent out to ER for exacerbation of back pain and positive blood culture.
Vital Signs were: 99.4, 124/77, 78, 18. Responsible Party accompanied resident. Resident sent with transfer package including Molst form Diagnosis, Transfer note, Labs, Physician note and nursing note. No care plan was sent out. Bed hold policy was given to EMT (Emergency Medical Team) not resident. The facility failed to give the resident or responsible a copy of the bed hold policy and a written notice of the transfer. Resident returned to the facility on 3/4/19.
3. On 4/8/19 at 10:04 AM a record review was completed for resident # 5. On 1/23/19 resident was transferred to the hospital feeling very weak and having a blood Pressure of 79/49. She/he returned from the hospital on 1/30/19 with a diagnosis of endocarditis consolidation. Transfer package was sent with resident including package including Molst form Diagnosis, Transfer note, Labs, physician note and nursing note. No care plan was sent with documents. Bed hold policy was given to EMT (Emergency Medical Team) not resident. The facility failed to give the resident or responsible a copy of the bed hold policy and a written notice of the transfer.
A. On 4/3/19 at at 9:59 AM medical chart was reviewed for resident # 5. On 3/25/19 at 22:15 documentation stated resident had dialysis session today. He/She returned to the unit following dialysis. A few hours later AV fistula started to bleed uncontrollable. The facility called 911 and patient was transferred to the ER. All transfer paper work was sent with the resident to the hospital. No care plan was sent out. Bed hold policy was given to EMT (Emergency Medical Team) not resident. The facility failed to give the resident or responsible a copy of the bed hold policy and a written notice of the transfer.
B. April 3, 2019 9:59 AM a review of medical record revealed documentation for hospital transfer: Resident # 5 was transferred to ER via 911 for change of mental status. Resident missed dialysis. A potassium of 6.9, bun 101, CR 11.10, hgb 7.2, hct 23.5, ileus as per abd x-ray and emesis x 2. Resident was sent to the hospital for evaluation. All paperwork went with the EMS (Emergency Medical Team) including bed hold policy, not the resident. No care plan was sent with resident. There was no written notice of transfer sent to the responsible party.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview the facility failed to notify resident/resident representatives in writing of the bed hold policy. This was evident for 2(#103 and #105) of residents...
Read full inspector narrative →
Based on medical record review and staff interview the facility failed to notify resident/resident representatives in writing of the bed hold policy. This was evident for 2(#103 and #105) of residents reviewed that was transferred to an acute care facility.
The findings include:
1). Review of medical records on 4/9/19 for Resident #103 revealed the resident was sent to an acute care facility on 3/17/19 via 911 for shortness of breath with SaO2 range between 98%-88%. SaO2 (oxygen saturation is referred to hemoglobin is saturated with oxygen the body red blood cells that binds together to carry oxygen through the bloodstream to organs, tissues, and cells of the body. Normal SaO2 oxygen saturation is between 96 percent and 98 percent). Further record review failed to produce written notification to resident or resident's representative of bed hold policy.
2. Review of medical records on 4/3/19 for resident #105 revealed on 12/30/18 was sent to an acute care facility for change in condition. Further record review failed to produce written notification to resident or resident's representative of bed hold policy.
An interview with the Nursing Home Administrator (NHA), Director of Nursing (DON) and Assistant Director of Nursing on conducted on 4/09/19 at 11:50 A.M. NHA requested to meet with surveyor to present facility documentation pre-packet for all facility hospital transfers in the presents of corporate staff. During the same date and time, the Assistant Director of Nursing stated the facility gives this packet for all hospital transfers this discharge packet is given to the EMT driver.
Surveyor advised the NHA of the new regulation for all transfers must provide to the resident's and resident responsible party members notifying them written notice of bed hold policy.
Based on facility staff interviews with the DON (Director of Nursing) and record review, the facility failed to provide a written notice to a resident and the responsible party of the transfer for 3 out of 3 people reviewed for transfer out to the hospital.
Findings include:
1.
On 3/28/19 at 11:33 AM a record review of resident # 9 was conducted. Resident # 9 was sent to the hospital on 1/13/19 for abdominal fullness and leaking around the supra pubic site. The nursing note stated the supra pubic catheter will need to be changed by interventional radiology at the hospital. An interview with the DON (Director of Nursing) was held on 3/28/19 at 11:33 AM, who showed the survey team a booklet which contained the information sent out with the resident. During this conversation DON stated the packet is given to the EMT (emergency medical team) driver. All paperwork including face sheet, Molst form, Transfer note, labs, Physician note, nurse note, consults and bed hold policy was given to EMT driver. DON confirmed the Bed hold policy was not given to the resident. DON could not locate or prove that a written note was ever given to the resident or Responsible party regarding the discharge to the hospital. There was no documentation in the chart regarding any transfer note. There was no written note sent to the family or responsible party of the transfer. He returned to the facility on on 1/14/18. A care plan is in place.
2.
On 4/8/19 at 10:27 AM a record review was completed on resident # 7. On 2/22/19 resident # 7 was sent out to ER for exacerbation of back pain and positive blood culture.
Vital Signs were: 99.4, 124/77, 78, 18. Responsible Party accompanied resident. Resident sent with transfer package including Molst form Diagnosis, Transfer note, Labs, Physician note and nursing note. Bed hold policy was given to EMT (Emergency Medical Team) not resident. The facility failed to give the resident or responsible a copy of the bed hold policy and a written notice of the transfer. Resident returned to the facility on 3/4/19.
3
On 4/8/19 at 10:04 AM a record review was completed for resident # 5. On 1/23/19 resident was transferred to the hospital feeling very weak and having a blood Pressure of 79/49. She/he returned from the hospital on 1/30/19 with a diagnosis of endocarditis consolidation. Transfer package was sent with resident including package including Molst form Diagnosis, Transfer note, Labs, physician note and nursing note. Bed hold policy was given to EMT (Emergency Medical Team) not resident. The facility failed to give the resident or responsible a copy of the bed hold policy and a written notice of the transfer.
A.
On 4/3/19 at at 9:59 AM medical chart was reviewed for resident # 5. On 3/25/19 at 22:15 documentation stated resident had dialysis session today. He/She returned to the unit following dialysis. A few hours later AV fistula started to bleed uncontrollable. The facility called 911 and patient was transferred to the ER. All transfer paper work was sent with the resident to the hospital. Bed hold policy was given to EMT (Emergency Medical Team) not resident. The facility failed to give the resident or responsible a copy of the bed hold policy and a written notice of the transfer.
B.
April 3, 2019 9:59 AM a review of medical record revealed documentation for hospital transfer: Resident # 5 was transferred to ER via 911 for change of mental status. Resident missed dialysis. A potassium of 6.9, bun 101, CR 11.10, hgb 7.2, hct 23.5, ileus as per abd x-ray and emesis x 2. Resident was sent to the hospital for evaluation. All paperwork went with the EMS (Emergency Medical Team) including bed hold policy, not the resident. There was no written notice of transfer sent to the responsible party.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
Based on resident observation, responsible party and staff interviews it was determined that the facility staff failed to follow enteral feeding standards of practice. This was evident for 1 out of 2 ...
Read full inspector narrative →
Based on resident observation, responsible party and staff interviews it was determined that the facility staff failed to follow enteral feeding standards of practice. This was evident for 1 out of 2 residents selected for Tube Feeding review involving resident #105 during the investigative portion of the survey process.
When a person cannot eat any or enough food because of an illness. Others may have a decreased appetite, difficulties in swallowing, or some type of surgery that interferes with eating. When this occurs, and one is unable to eat, nutrition must be supplied in a different way. One method is enteral nutrition or tube feeding. Risk of aspiration should be assessed individually and appropriate interventions (e.g., proper positioning, rate of flow) implemented accordingly.
The finding includes:
On 4/3/19 at 10:15 A.M. during resident #105 observation who was admitted to facility with multiple medical diagnosis which includes but not limited to requiring enteral nutrition for daily nutritional needs to be met.
04/03/19 10:15 A.M. during resident #105 observation surveyor observed resident in bed being fed tube feed formula of Nepro with Carbster at rate 45 mL/hr. with 75 ML flush every hour running properly labeled and dated per doctor's order. During the same date and time observed feeding tube infusing, with resident's head of bed (HOB) was not at the required 30-45 degree angle the HOB during tube feeding was observed at a 15-degree angle.
On 4/3/19 at 10:30 A.M. during staff interview with staff member #4 the 2nd floor nursing unit manager surveyor shared tube feeding HOB observation was at 15-degrees verses the required 30- 45 degrees. Second floor unit manager verified surveyor finding and agreed residents #105 HOB was not at 30-45-degree angle during tube feeding.
On 4/3/19 at 11:20 A.M. during interview with responsible party member informed surveyor my mother is always lying in bed with her head in low position. I ask the staff if they can rise my mother head more and it's always at the same position all day.
On 4/3/19 at 2:30 P.M. surveyor accompanied with responsible party member observed resident #105 before receiving care services surveyor observed resident #105 after finishing tube feeding HOB was observed at 15-degrees angle.
On 4/4/19 at 10:00 A.M. during resident third tube feeding observation resident's #105 HOB was observed at 15-degrees angle while receiving enteral nutrition.
On 4/5/19 at 10:00 A.M. during resident #105 fourth tube feeding observation resident #105 HOB was observed at 15-degree angle while receiving enteral nutrition.
On 4/8/19 at 11:28 am during staff interview with Director of Nursing (DON) was made aware of surveyors finding.
The Administrator with DON was informed of care practice concern prior and during survey exit.
Nov 2017
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0243
(Tag F0243)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interviews it was determined that the facility staff failed to provide a private space to support residents right to privacy while conducting their monthly res...
Read full inspector narrative →
Based on observation, resident and staff interviews it was determined that the facility staff failed to provide a private space to support residents right to privacy while conducting their monthly resident council meeting.
The findings include:
This surveyor was invited to attend the Resident Council meeting held on 11/13/17 from 2:15 PM to 3:35 PM. The Activities Director who was also invited assisted the Resident Council President to conduct the meeting. During the meeting four kitchen staff and several Geriatric Nursing Assistants (GNA's) were observed entering the dining room without knocking or receiving permission to enter. The GNA's came to take various residents to activities or appointments and the kitchen staff were walking through the dining room, some to go into the kitchen and others to the lobby.
In an interview with resident council president Resident #12 on 11/1417 at 1:25 PM s/he confirmed that there are frequent interruptions to the meetings with staff walking through the dining room during the resident council meetings. In an interview with the Assistant Administrator and the Activities Director on 11/15/17 at 10:05 AM, the Activities Director stated that this has been a concern and stated that going forward she will be posting a sign on the dining room doors to ensure that everyone will be aware that there is a private meeting in progress.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0329
(Tag F0329)
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 ensure a resident was free of an unnecessary medication (# 135). This was true for 1 out of the ...
Read full inspector narrative →
Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident was free of an unnecessary medication (# 135). This was true for 1 out of the 5 residents selected for a review of medications as part of the survey process.
The findings are:
A review of Resident # 135's clinical record revealed that the resident had an order for Lisinopril (heart medication) 10 mg to be administered once a day. A review of the Medication Administration Record (MAR) for October included parameters for the use of the Lisinopril that included the order to hold the medication if the systolic blood pressure (first number) was below 110. The blood pressure for 10/8/17 was 95/59 but the staff administered the medication.
The Director of Nursing (DON) was interviewed on 11/15/18 at 9:40 AM. The findings were discussed. The pharmacy uses a template for medications that treat blood pressure and as a result it was on the MAR. Since the nurse took the blood pressure it had to be acted upon per the parameters. The DON stated that the facility has already begun to change how parameters are ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0431
(Tag F0431)
Could have caused harm · This affected 1 resident
Based on observation, review of pertinent documentation and interview it was determined that the facility staff failed to ensure an unattended medication cart was locked. This was evident in one medic...
Read full inspector narrative →
Based on observation, review of pertinent documentation and interview it was determined that the facility staff failed to ensure an unattended medication cart was locked. This was evident in one medication cart observed on one of the nursing wings #9.
The findings include:
During a tour of the facility on 11/09/17 at 1:45 PM, this surveyor observed an unlocked medication cart in the hallway of the wing #9. Several Geriatric Nursing Assistants (GNA's), a dietitian, and the Unit Manager were observed walking by the unlocked medication cart.
Nurse # 8 who was responsible for the medication cart was interviewed on 11/13/17 at 1:30 PM. This surveyor asked if the medication cart was locked. She/he stated it was normally locked but she/he had to give Resident # 128 his/her pain medication. Resident # 128 was leaving the facility for the day with his/her family. Nurse # 8 stated that s/he could see the cart from the room. Nurse # 8 then went to Resident # 33's room because s/he put their call light on. Nurse # 8 then left that room with a dietary tray. At that time I informed Nurse # 8 that the cart was unlocked. Nurse # 8 stated that the medication cart is locked that it has a double lock. This surveyor asked Nurse # 8 to open the drawers and at that time the drawers opened and exposed Residents medications. Nurse # 8 then locked the medication cart.
The results of the observation were brought to the attention of the administration on 11/09/17 at 1:50 PM and no further information was provided prior to exit.
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
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 26% annual turnover. Excellent stability, 22 points below Maryland's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s). Review inspection reports carefully.
- • 33 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $15,593 in fines. Above average for Maryland. Some compliance problems on record.
- • Grade F (34/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
✓ Report will be sent to your email
About This Facility
What is Autumn Lake Healthcare Post-Acute's CMS Rating?
CMS assigns AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Autumn Lake Healthcare Post-Acute Staffed?
CMS rates AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 26%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Autumn Lake Healthcare Post-Acute?
State health inspectors documented 33 deficiencies at AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER during 2017 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 32 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Autumn Lake Healthcare Post-Acute?
AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER 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 225 certified beds and approximately 200 residents (about 89% occupancy), it is a large facility located in BALTIMORE, Maryland.
How Does Autumn Lake Healthcare Post-Acute Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER's overall rating (3 stars) is below the state average of 3.0, staff turnover (26%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Autumn Lake Healthcare Post-Acute?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Autumn Lake Healthcare Post-Acute Safe?
Based on CMS inspection data, AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Maryland. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Autumn Lake Healthcare Post-Acute Stick Around?
Staff at AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER tend to stick around. With a turnover rate of 26%, the facility is 20 percentage points below the Maryland average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 23%, meaning experienced RNs are available to handle complex medical needs.
Was Autumn Lake Healthcare Post-Acute Ever Fined?
AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER has been fined $15,593 across 1 penalty action. This is below the Maryland average of $33,235. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Autumn Lake Healthcare Post-Acute on Any Federal Watch List?
AUTUMN LAKE HEALTHCARE POST-ACUTE CARE CENTER 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.