How many inspection deficiencies does COURTLAND, LLC have?

COURTLAND, LLC has 72 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at COURTLAND, LLC?

COURTLAND, LLC has a four-star staffing rating from CMS with 1.03 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is COURTLAND, LLC located?

COURTLAND, LLC is located in BALTIMORE, MD. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does COURTLAND, LLC have?

COURTLAND, LLC has 151 certified beds.

Who owns COURTLAND, LLC?

COURTLAND, LLC is a for profit - limited liability company facility and is part of the FUTURE CARE/LIFEBRIDGE HEALTH chain.

What questions should families ask when visiting COURTLAND, LLC?

Families visiting COURTLAND, LLC should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does COURTLAND, LLC compare to other nursing homes?

COURTLAND, LLC has a 1-star overall rating, which is below average compared to other nursing homes in MD. Families should carefully review inspection findings and consider alternatives.

COURTLAND, LLC

Name: COURTLAND, LLC
Address: 7920 SCOTTS LEVEL ROAD, BALTIMORE, MD, 21208, US
Telephone: (410) 521-3600
Rating: 1.0

7920 SCOTTS LEVEL ROAD, BALTIMORE, MD 21208 · (410) 521-3600

For profit - Limited Liability company 151 Beds FUTURE CARE/LIFEBRIDGE HEALTH Data: November 2025

Trust Grade

40/100

#195 of 219 in MD

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Last Inspection: February 2023

Over 2 years since last inspection. Current conditions may differ from available data.

Overview

Courtland, LLC in Baltimore has a Trust Grade of D, which indicates below-average quality and some concerning issues. Ranking #195 out of 219 facilities in Maryland places them in the bottom half, and #41 out of 43 in Baltimore County suggests limited local competition. The facility is showing improvement, reducing the number of reported issues from 44 in 2023 to just 3 in 2025. Staffing is a strong point, with a 4 out of 5-star rating and turnover at 47%, which is average for the state, indicating that staff generally remain familiar with residents. Although there are no fines recorded, the inspector findings raised concerns about meal delivery practices and infection control, such as lunch trays being left for a resident who was not present and failures in following proper infection prevention measures, which could impact resident safety.

Trust Score: D
In Maryland: #195/219
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Maryland facilities.
Skilled Nurses: Each resident gets 61 minutes of Registered Nurse (RN) attention daily — more than 97% of Maryland nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations: 72 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2023: 44 issues

2025: 3 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, fire safety.

The Bad

1-Star Overall Rating

Below Maryland average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 47%

Near Maryland avg (46%)

Higher turnover may affect care consistency

Chain: FUTURE CARE/LIFEBRIDGE HEALTH

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 72 deficiencies on record

Jul 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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Number of residents sampled: Number of residents cited: Based on review of facility investigation, resident medical records, and interviews, it was determined that the facility failed to ensure that a resident remained free from abuse. This was true for 1 (Residents #2) of 16 residents reviewed for abuse during the annual re-certification survey. The findings include:Nursing Practice Act: 10.27.19.02:D. A nurse may not engage in sexual misconduct. Sexual misconduct includes but is not limited to: (3) Solicitation of a sexual relationship, whether consensual or nonconsensual, with a client.On 7/16/2025 at 8:15 AM the facility reported incident (FRI) was reviewed. Staff #37, GNA (Geriatric Nursing Assistant) and Staff #38, RN (Registered Nurse) walked into the room on 10/6/2024 on evening shift and witnessed Staff#39, GNA touching Resident #2 in their vaginal area and kissing Resident #2's breast. Later the Administrator interviewed Staff #39, the GNA accused of the allegations. Staff #39, GNA stated that they cleaned Resident #2, and the Resident asked them to put barrier cream on their virginal area due to itching, which they did. Staff #39 also denied kissing Resident #2's breast. Staff # 39 did admit to giving Resident #2 a kiss on the lips.On 7/16/2025 at 9:29 AM, Resident #2 was interviewed about the October 2024 incident with Staff #39, GNA. Resident #2 stated that they initiated physical contact and consented to everything, specifically asking Staff #39 to apply cream to their vagina. Resident #2 denied Staff #39 kissing her breast but admitted Staff #39 kissed her on the lips.On 7/18/2025 at 8:30 AM, the facility policy was reviewed. The policy states, Employees shall not become romantically or sexually involved with a resident or a co-worker with whom he/she is in a supervisory position. Further record review revealed that Staff #39 was terminated on 10/11/2024 for violating the company's Standard of Conduct Policy.On 7/18/2025 at 10:05 AM the Administrator was asked about the FRI between Resident #2 and Staff #39. The Administrator recalled that Staff #39 was accused of inappropriate touching Resident #2, which Staff #39 denied, but admitted to kissing Resident #2 on the lips.

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

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, it was determined the facility failed to 1) notify the Ombudsman of resident's transfers, 2) provide the Resident and/or Representative with a written notice of the facility's bed hold policy upon transfer. This was found evident of 2 (Resident #10 & #141) of 4 residents reviewed for hospitalization 3. Failed to provide the resident/family/RP with discharge instructions. (#161) This was evident for 1 of 3 discharge records reviewed during the survey. The findings include: 1a) On 7/16/25 at 9:29 AM, the surveyor reviewed Resident #10’s medical record. The review revealed that Resident #10 was sent to the hospital on 4/25/25 and returned to the facility on 5/2/25. On 7/21/25 at 1:18 PM, the surveyor requested documentation to demonstrate that the Ombudsman was made aware of the hospitalization. On 7/21/25 at 1:42 PM, the surveyor conducted an interview with the Regional Clinical Director of Operations Staff #5. During the interview Staff #5 confirmed that during that time period no one at the facility was providing notices to the Ombudsman of transfers and discharges. 1b) On 7/22/25 at 7:03 AM, the surveyor reviewed Resident #141’s medical record. The review revealed that Resident #141 was hospitalized on [DATE]. On 7/22/25 at 7:56 AM, the surveyor requested documentation to demonstrate that the Ombudsman was made aware of the hospitalization. On 7/22/25 at 8:45 AM, the surveyor interviewed the Regional Clinical Director of Operations Staff #5. During the interview Staff #5 confirmed that during that time period no one at the facility was providing notices to the Ombudsman of transfers and discharges. 2a) On 7/16/25 at 9:29 AM, the surveyor reviewed Resident #10’s medical record. The review revealed that Resident #10 was sent to the hospital on 4/25/25 and returned to the facility on 5/2/25. On 7/21/25 at 1:18 PM, the surveyor requested documentation to demonstrate that the Bed Hold policy was given to Resident #10’s Responsible Party (RP). On 7/21/25 at 1:46 PM, the Regional Clinical Director of Operations Staff #5 stated he was unable to find documentation that the written notice was sent to Resident #10’s Responsible Party (RP). 2b) On 7/22/25 at 7:03 AM, the surveyor reviewed Resident #141’s medical record. The review revealed that Resident #141 was hospitalized on [DATE]. On 7/22/25 at 7:56 AM, the surveyor requested documentation to demonstrate that that the Bed hold policy was given to Resident #141’s Responsible Party (RP). On 7/22/25 at 8:45 AM, the surveyor interviewed the Regional Clinical Director of Operations Staff #5. During the interview Staff #5 stated that he found documentation that stated the bed hold policy sent with the Resident to the hospital. Staff #5 was not able to provide evidence that a written notice was given to Resident #141’s RP. Next the survey reviewed the facility’s bed hold policy. The policy states, The resident and his/her surrogate decision-maker or court appointed legal representative will be provide written and/or verbal information regarding the bed-hold policy at the facility: Upon admission, At the time of transfer to the hospital, at the time of any therapeutic leave and if the bed-hold regulation were to change. 3. During the review of Resident #161’s medical record on 7/21/25 at 8:28 AM discharge planning revealed that there was no documentation of what was provided to the family/resident/representative (RP) at the time of discharge regarding planning, preparation and medications. Resident #161 was being discharged from the facility after rehabilitation from deconditioning and medication management after a kidney transplant. On 7/21/25 this surveyor requested any discharge planning and paperwork that was provided to the family/resident at discharge. On 7/22/25 at 6:42 AM the Regional Clinical Director notified this surveyor that there was no discharge paperwork in the record. The concern was reviewed with him at this time that there was no discharge planning and directions provided to the family of a resident with complex diagnosis' including gastrostomy tube feeding, wound care and anti-rejection medications needed for kidney transplant.

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

Deficiency F0841 (Tag F0841)

Could have caused harm · This affected 1 resident

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Based on medical record, review of a complaint, and interview of facility staff, it was determined that the facility's Medical Director failed to ensure adequate implementation of resident care intervention and/or policy review. This was found evident for 1 (Resident #98) of 1 resident reviewed for insulin use. The findings include: On 7/16/25 at 12:32 PM, the surveyor interviewed Resident #98. During the interview Resident #98 described that when he/she was admitted to the facility he/she was prescribed a glucose monitoring device that was utilized to monitor blood glucose levels without the use of a finger stick. Resident #98 stated he/she was very happy with the use of the device but shortly after the device was ordered it was discontinued. On 7/23/25 at 11:35 AM, the surveyor reviewed Resident #98's medical record. The review revealed an order was placed for 3/27/24 for Resident 98 to have a continuous glucose monitoring device. On further review, Nurse Practitioner (NP) #42 documented, on 4/6/24 in a progress note, that the patient was seen for a follow-up. Patient and patient's daughter are upset that they cannot use the continuous glucose monitoring and now will need to utilize finger sticks. Resident #98 reports a lot of pain in his/her fingertips. On 7/24/25 at 6:06 AM, the surveyor interviewed the Regional Clinical Director of Operations Staff #5. During the interview the surveyor requested the facility's policy for continuous glucose monitoring devices. Staff #5 stated that the facility did not have a policy for the use of this device because it is typically utilized in home settings where patients can self manage the device. Staff #5 confirmed that Nurse Practitioner (NP) #42 wrote the order for Resident #98 to have the device due to the request of the family and that Resident #98 utilized the device for approximately 2.5 days. Staff #5 stated that the previous Director of Nursing (DON) did not request clinical oversight from the Regional Clinical Staff and the device was removed when it was made known to Regional Clinical Staff it sues. Staff #5 further stated that the Medical Director spoke to the provider and informed her the device could not be utilized in the building. The Surveyor asked Staff #5 for the education that was provided by the Medical Director. Staff #5 confirmed that the education was non-formal and there was no documentation. There was also no documentation that any education was provided to other providers. The surveyor reviewed the concern that the facility still did not have a policy or procedure written in regard to the use or non-use of continuous glucose monitoring devices and that there was no formal education to providers after the Medical Director was aware the device was implanted within the facility without a policy or procedure for use.

Feb 2023 44 deficiencies

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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Based on observation and interview with staff it was determined the facility staff failed treat residents with dignity and respect by failing to encourage and assist residents to dress in their own clothing. This was evident for 1 (#90) of 78 residents reviewed during the survey. The findings include: Resident #90 was observed on 1/27/23 at 10:08 AM walking in the hallway toward the nurses' station wearing a hospital gown in his/her bare feet the gown was open in the back and the residents brief was visible. He/She was observed again on 1/31/23 at 12:20 PM sitting on the side of his/her bed wearing a hospital gown and nonskid socks. Review of Resident #90s medical record on 1/31/23 at 12:31 PM revealed an inventory of belongings list dated 9/19/19 which listed 2 shirts. Resident #90 was observed again on 2/3/23 at 8:57 AM sitting on the side of his/her bed wearing a hospital gown and nonskid socks. A blanket was wrapped around his/her shoulders and back. An observation of Resident #90's room was made with Staff #19 on 2/15/23 at 8:49 AM. Resident #90 was in his/her room wearing a hospital gown. 3 shirts were hanging on hangers in the resident's closet. A large black suitcase was standing on the floor against the right side of the closet. Staff #19 partially unzipped the suitcase revealing that it was filled with clothing items. Staff #19 was made aware that the resident was observed on several occasions wearing a hospital gown instead of his/her own clothing. When asked why Resident #90 was not wearing his/her clothing, Staff #19 indicated that Resident #90 was dressed on Friday, that the resident was incontinent of urine and had behavioral issues. She indicated that the residents clothing was kept in the suitcase to prevent him/her from urinating on them. When asked how this prevented the resident from wearing his/her own clothing she stated, sometimes the resident is showered twice a day, he/she has behaviors, and it is easier to just put a gown on him/her. In an interview on 2/15/23 at 9:00 AM Staff #2 the Director of Nursing and Staff #3 the Corporate Nurse were made aware of these findings. Staff #3 indicated that Resident #90 had a Care Plan for refusing care. When asked if it included refusal to dress in his/her own clothing he indicated that it included, medication and treatment, and bath but nothing about dressing/clothing. They were made aware that staff did not indicate that the resident refused to wear clothing but that it was easier to just put a gown on him/her.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of Resident #35s medical record on 2/2/23 at 11:52 AM revealed a Psychiatric Nurse Practitioner progress note dated 9/9/22 at 9:44PM which indicated that Resident #35 was irritable, anxious, loud, yelling at staff and complained of anxiety. The note indicated: Medication intervention with rationale: Start Buspar 5 mg twice per day. Discussed resident's condition and POC (Plan of Care) with CRNP (Certified Registered Nurse Practitioner) and unit manager. There was no indication that the medication increase was discussed with the resident's surrogate decision maker. A Psychiatric NP progress note dated 7/25/22 indicated the History of Present Illness: Resident is calm and pleasant. Staff reports that resident has been noncompliant with Covid 19 isolation. (He/She) was physically aggressive and irritable. Medication intervention with rationale: Increase Effexor to 187.5 mg po (by mouth) qd (daily). There was no indication that the medication increase was discussed with the resident's surrogate decision maker. Staff #2 the Director of Nursing and #3 the Corporate Nurse were made aware of this concern on 2/16/23 at 8:52 AM. Cross reference F 758. Based on reviews of a medical record and staff interview, it was determined that the facility staff failed to 1) notify a resident's physician and family member when a significant weight loss was identified, and 2) notify a resident's Surrogate Decision Maker when changes were made in the residents' psychotropic medications. This was evident for 2 (Resident #35 #93) of 78 residents reviewed during an LTCSP recertification survey. The findings include: 1) A review of the facility Change in Resident Condition, physician notification policy on 02/06/23 at 11 AM revealed the purpose of the policy was to ensure that resident care problems are communicated to the medical staff in a timely, efficient and effective manner, and to ensure that all significant changes in resident condition are assessed and documented in the medical record. The policy for notifying a resident's physician for non-immediate resident changes, that includes a weight change of 5% or more within 30 days, should be minimally notified the next business day. A review of Resident #93's medical record on 01/26/23 at 8:42 AM revealed that Resident #93 was admitted to the facility on [DATE] with diagnoses that include but are not limited to congestive heart failure, polyneuropathy, Atrial fibrillation, diabetes, and chronic obstructive pulmonary disease. A review of Resident #93's medical record revealed the following weights: 1/4/2023 14:34 168.3 pounds 1/4/2023 09:06 167.7 pounds 12/23/2022 14:50 183.6 pounds 10/24/2022 09:40 183.7 pounds 9/14/2022 11:18 187.1 pounds 8/28/2022 15:49 185.2 pounds 8/18/2022 18:24 184.9 pounds A further review of Resident #93's medical record revealed that on 01/04/23 at 9:06 AM, Resident #93 was identified with a 15.9 pound (8.6%) weight loss. The nursing staff also documented a second weight for Resident #93 on 01/04/23 at 2:34 PM that indicated Resident #93 was identified with a 15.3 pound (8.3%) weight loss. Further reviews of the medical record failed to reveal that Resident #93's physician was made aware on 01/04/23 or 01/05/23. Resident #93's physician documented on 01/11/23 an assessment that identified Resident #93's significant weight loss. A review of Resident #93's care plans revealed: Imbalanced Nutrition related to decreased nutrient need, CHO (carbohydrate) as evidenced by LCS (low concentrated sweets) diet for Type II Diabetes that was initiated on 08/22/22 and revised on 11/26/22. Nursing care interventions included: to obtain weight as ordered, review and report to provider as needed. In an interview with the facility dietician on 02/01/23 at 9:45 AM, the facility dietician stated that Resident #93 was identified with a significant weight loss on 01/04/23 and that there was no follow up with the facility nurse practitioner or Resident #93's physician. The facility dietician also stated that the staff had not identified an issue with the facility scales.

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility staff failed to 1) have an effective process in place to protect resident's property from loss or theft. This was evident for 1 (#43) of 3 residents reviewed for Personal Property, and 2) failed to have a safe clean and comfortable environment on 1 of 3 units observed throughout the survey. The findings include: 1) In an interview on 1/24/23 at 11:22 AM Resident #43 was asked if he/she had any belongings go missing. He/she indicated that he/she had clothing go missing over the past 4 years, that he/she had been reimbursed for some things but not everything. The Resident indicated that a [NAME] blanket had been missing for the past month. When asked if it was reported to anyone the resident indicated that he/she had spoken to the Administrator who said that they can't afford to keep replacing his/her items. In an interview on 1/31/23 02:11 PM Staff #19 the Unit Manager was asked to explain the protocol for resident inventory of belongings. She indicated that it is completed on admission, dated, and signed by the staff completing and the resident/representative. Review of the Inventory section of Resident #43's paper medical record revealed 3 pages, the first was an Inventory List dated 10/30/21. Hand written at the top of the page was sent these items home with Grandson on 10/30/2021 the list included: 10 Oriole shirts, 3 Oriole Jacket, 11 Oriole hats, 1 neck cushion, 1 purple bag. There form was signed by a facility representative dated 10/30/21. There was no signature in the space labeled: Signature of Patient/Resp. Party. The second page was a plain white piece of paper with Handwriting: All Winter clothing sent home with resident son. It included the date, 4/9/22 and Resident #43's initials. The page did not list the items sent home nor was it signed and dated by staff. Handwritten on the third page, another white piece of paper was: Inventory List, it included the resident's name, room number, admitted date, and listed: Glasses, cell phone, Bag, 2 Shoes, 1 Jacket, 1 Coat, 2 Hats, 2 Shirts, 1 Scarf, 2 Pants, 1 ring (Gold), 2 Earrings 2 spaces with signatures were labeled Patient signature and Facility signature. There was no date to indicated when this paper was signed by either party. Review of the facility policy/procedure for clothing inventory list on 1/31/23 03:24 PM revealed: The policy was dated 3/2000. The purpose was to protect the resident's personal property. the policy indicated that an inventory list is to be done on all new admissions. Another policy titled FutureCare [NAME] Personal Inventory/Clothing Process was revised 10/19/21 and Approved 10/26/21. It included but was not limited to all clothing brought into the facility must be accepted at the front desk only. Family bringing in clothing Must complete the Inventory List provided at the front desk. The EVS (Environmental Services) director will maintain a copy of All laundered items to ensure that patient clothing is readily labeled and returned to the resident. The EVS director will routinely inspect rooms/wardrobe closets to ensure compliance, and Residents do have the option to deny labeling of clothing, however clothing must still be inventoried and documented as the laundry department cannot be responsible for lost items that are not able to be tracked. An interview was conducted with Staff #45 a laundry aide on 2/1/23 at 10:45 AM. When asked about the process for resident missing clothing she indicated, fill out purple (grievance) paper, describe the item as good as they can. we do our best to find it. When asked about Resident #43's [NAME] blanket. She responded I don't believe he/she is missing a [NAME] blanket. He/she sends a lot of stuff home, it doesn't get marked off of his/her (inventory) list. She initially indicated that the laundry kept a copy of residents' inventory lists but, when the surveyor asked to review the copy of Resident #43's inventory list, she indicated that it would be in the resident's medical record, there wasn't one in the laundry because the resident had been in the facility a long time. She added that the resident's family brings things in and doesn't get them labeled. When asked what happened when she couldn't find a missing item she responded that the administrator takes care of it. Staff #45 went on to say that Resident #43's last missing blanket was about 1 month ago and stated, I took it to him/her, I'm not aware of another, she added that the resident sent a large bag of clothing out with family less than 3 months ago without informing staff to take it off of his/her inventory list. At 11:01 AM Staff #46 the Environmental Services Director joined the interview. She indicated that Resident #43 reported the missing blanket about 1 month ago, but she had not found it and was waiting to see if it came back to the laundry, if it didn't come back then it would be replaced. When asked how long she would wait to see if it turned up, she indicated about 30 days. She added that they usually try to do an inventory, that a list was kept in the resident's chart and also in the laundry. When asked about Resident #43's inventory list she confirmed that they did not have Resident #43's inventory list in the laundry. She indicated that the staff don't always add new items to Resident #43's inventory list because they are not aware of new items coming in. She was asked who was responsible for updating and maintaining the resident's inventory lists and indicated the Charge Nurses. When asked if she kept a list of items that the resident's report missing, she indicated she did not but used the grievance forms. She then added that Resident #43 did not want to fill a grievance form out. She and Staff #45 were asked if they kept a log, or how they track resident's reports of missing clothing items until they are resolved. They indicated there was no log, that they will check the laundry to see if they have the item, if at the end of the day the item is not found, they will check the wardrobes in the residents room, if it is not found, they will check the rooms on either side of the resident's room in case it was delivered to the wrong closet. If it doesn't turn up in about 2 weeks, they will fill out a grievance form. However, they earlier indicated that there was no grievance form for Resident #43's [NAME] blanket. Staff #46 was asked if the facility staff know the process for resident clothing inventory. She indicated that she provided education to facility staff in 2021 and 2022. In an interview on 2/10/23 at 8:43 AM The Administrator was made aware of the above concerns. He indicated that the resident had made numerous allegations and items have been paid for. He indicated that he has met with the Resident's family regarding this issue. When asked if it was part of the resident plan of care, he stated No, we wouldn't typically care plan this. He was asked if the facility had a process for the family and facility to follow for the resident's clothing going in and out since this was a recurring problem. He indicated no. Cross reference F 585. 2)A. On 1/24/23 at 11:13 AM the surveyor observed the handrail located between room [ROOM NUMBER] and 203 was missing the end cap exposing a sharp plastic edge. The wall paint above the handrail was chipped exposing the underlying drywall. Ceiling tiles and an air vent located in the hallway outside of room [ROOM NUMBER] were stained. B. The bathroom shared by the residents in room [ROOM NUMBER] and 207 was observed on 1/24/23 at 11:56 AM. The spigot handle was loose, the tubular metal frame of the toilet riser chair had peeling paint with numerous areas directly under the seat at the front and back had visible rust. The wall behind the toilet had a patch of spackling that was not finished nor painted over. C. On 1/24/23 at 12:09 PM the surveyor observed room [ROOM NUMBER] trashcan by bed A had several long cracks from top edge extending downward. Several stains were observed in ceiling tiles. The wall around the air conditioner/heating unit was cracked. The corner of the wall to left of bathroom door had a deep scuff approximately 12 inches long by 5 inches wide in the wall board exposing the metal beading and another scuffed area approximately 5 inches long 3 inches wide. D. room [ROOM NUMBER] was observed on 1/24/23 at 3:01 PM. The wall behind head of bed A had multiple deep scrapes and areas that were spackled but not finished. The wall across from the foot of the bed had deep scrapes into the wall board. A tubular metal frame toilet riser was located over the toilet in the bathroom. The legs of the riser were rusted. E. On 1/25/23 at 9:55 AM an observation was made of room [ROOM NUMBER]. The trash can had large pieces cracked off and missing around the top. On the floor behind the door to the room was Square of red tape. A large 1 ft diameter patch of spackle was located on wall behind doorknob, unfinished. A ceiling tile located in front of the window had a large tan stain. F. At 12:43 PM on 1/25/23 the plastic below the handrail located to the left of room [ROOM NUMBER] was observed to have a crack approximately 4-5 inches long. The edges were not aligned and could potentially cause a skin injury.

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) In an interview on 1/24/23 at 11:22 AM Resident #43 was asked if he/she had any belongings go missing. He/she indicated that he/she has had clothing go missing over the past 4 years and indicated that a [NAME] blanket had been missing for the past month. When asked if it was reported to anyone the resident indicated that he/she had spoken to the Administrator. The Resident Issue Logs (Grievance Logs) from 2/2022 to 2/1/23 were reviewed on 2/1/23 at 12:56 PM. No entries were found pertaining to Resident #43's report of a missing [NAME] blanket. Review of the Corporate Administrative Manual Concerns/Complaints/Grievances Policy included but was not limited to: A log is to be maintained at the facility of all concerns/complaints/grievances. This form (process must be initiated within two (2) days of receipt of the concern/complaint. The log is used to track status of individual complaints and track and trend complaints for performance improvement. and all staff are responsible for trying to resolve the complaint, if unable to resolve the issue independently the staff is responsible for referring the complaint to the supervisor and ensuring completion of a complaint form. On 2/1/23 at 11:01 AM an interview was conducted with Staff #46 the Environmental Services Director. She indicated that Resident #43 reported the missing blanket about 1 month ago, but she had not found it and was waiting to see if it came back to the laundry, if it didn't come back then it would be replaced. When asked how long she would wait to see if it turned up, she indicated about 30 days. In an interview on 2/10/23 at 8:43 AM Staff #1 the Administrator was made aware that there was no evidence that the facility made prompt efforts to resolve Resident #43's Grievance. Cross reference F 584. Based on complaints, reviews of medical records, and interviews, it was determined that the facility failed to 1) ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued, and 2) promptly resolve resident grievances. This was evident for 2 (Resident #131 and #43) of 3 residents reviewed for the grievance process during the LTCSP recertification survey. The findings include: 1) On 1/30/23, a phone interview was conducted with resident #131's representative at 2:48 PM reporting various concerns with the facility and not receiving written responses/notifications related to grievances filed with the facility on 11/14/22 and 11/28/22. On 1/31/22 complaint intake #MD00188448 was reviewed. The resident representative indicated that He/she was not provided written responses to the submitted concern (grievance) forms originally submitted on 11/14/23 and resubmitted in writing to the nursing home administrator on 11/28/22. On 2/3/23 at 3:16 PM, an interview was conducted with the nursing home administrator (NHA) to discuss the grievance concern forms submitted by the family. The NHA indicated that the facility staff has met with the family representatives of resident #131 multiple times. The NHA was asked to provide credible evidence of how the family was provided written responses to their written grievance concerns that were resubmitted on 11/28/22. A copy of the facility's policy related to Concerns/Complaints/Grievances was provided along with a typed form titled Highlights of conversation based on concern forms:. A review of the written documented responses failed to include the date the grievance was received, a summary statement of the resident's grievance, and the steps taken to investigate the grievance. The form did not fully provide a summary of the pertinent findings or a conclusion regarding the resident representatives' concerns. The first highlight response was written as was seen by the podiatrist on The sentence was incomplete without a date of when resident #131 was seen by the podiatrist. The typed form was hand signed and dated by the director of nursing (DON) dated as 12/12/22. The DON was interviewed on 2/14/23 at 8:53 AM and shown a copy of the written notifications related to the resident representatives' concerns. She acknowledged the incomplete conclusion/summary sentence related to a concern with podiatry care. She indicated that there was a demand for a written response and she failed to complete the response. On 2/15/23 at 2 PM the corporate nurse (staff #3) was asked to provide the grievance logs from November 2022. The corporate nurse revealed that social services maintain the logs. A copy of the November 2022 log was provided with a copy of two incomplete concern forms dated 11/28/22. Review of the grievance log for November 22 did not reveal any entry related to resident #131 on 11/28/22. An entry dated 11-14-22 related to resident #131, was out of sequential order and written after the 11/30/22 entry. An interview was conducted with the director of social services on 2/16/23 at 11:12 AM. She was shown the 2 copied grievance forms dated 11/28/22. She did not provide an explanation of the missing 11/28/22 entries to the grievance logs. The facility did not provide evidence of written documentation provided to the residents' representatives. Review of the facility's grievance policy states upon request the complainant has the right to obtain a written decision regarding the complaint. On 2/16/23 at 12:44 PM, the Director of nursing and corporate nurse were informed of the surveyor's concern related to the facility's non-compliance related to incomplete grievance responses.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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Based on a facility-reported incident, closed clinical record review, staff interview, and reviews of the facility abuse policy, it was determined that facility staff failed to ensure a resident was free of staff abuse. This was evident for 1 (Resident #9) out of 16 residents reviewed for abuse during an LTCSP recertification survey. The findings are: A review of facility-reported incident MD00151687 on 02/06/23 revealed that the facility reported an allegation of staff-to-resident abuse on 02/20/20 which was observed by another staff member. The facility also reported the incident to the local police who conducted an onsite investigation. The resident's physician and responsible party were also made aware of the allegations. A review of the facility abuse and resident reporting policy on 02/01/23 revealed the purpose of the policy was to comply with the entire measure and intent of Article 43, Section 565 A of the Patients' [NAME] of Rights law to ensure the protection of patients entrusted to our care. The first line of the [NAME] of Rights reiterates the resident's right to be free from mental, verbal, or physical abuse. The second line indicates that all cases of suspected or witnessed abuse are required to be reported to the Division of Licensing and Certification by the nursing home administrator or their designee for possible action in accordance with Maryland State Law. The fifth line of the policy indicates that under no circumstances are staff to attempt to resolve such an incident without appropriate channel communications. The Abuse, Resident Reporting failed to reveal signatures of approval and a date when the policy was initiated and/or last reviewed. A review of the 02/20/20, 6:15 PM investigation revealed that Resident #9 alleged that a GNA, staff member #62, doused Resident #9 with water while Resident #9 was in bed. The GNA was immediately suspended and a full investigation was launched. Resident #9's family and physician were made aware at the time. Further review of the facility investigation revealed that the LPN, staff member #63, was a witness to the incident and immediately notified the nursing supervisor. Resident #9 was assessed by his/her physician and received psychiatric services after the incident. Resident #9's plan of care was updated after the incident. The facility terminated the GNA, staff member #62, and report the GNA to the Maryland Board of Nursing for abuse. In an interview with Resident #9 on 02/08/23 at 10:33 AM, Resident #9 stated that s/he did remember the incident where the GNA, staff member #62, threw water on him/her. Resident #9 stated, the GNA got mad and threw water on me. Resident #9 stated that it did not make him/her feel good and I cried. Resident #9 stated that the incident does not affect him/her currently. In an interview with the facility corporate nurse on 02/13/23 at 10:50 AM, the surveyor reviewed the full incident report, staff credentials, abuse training documents, resident and staff interviews, and other pertinent documents. The surveyor determined the facility plan of correction date, for the allegation of staff-to-resident abuse, to be 02/26/20. This citation has been cited as substantiated past noncompliance.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on complaint, reviews of the facility investigation, and staff interview, it was determined that the facility failed to implement abuse prevention polices as evidenced by staff's failure to, 1) immediately notify the facility administrator of an allegation of resident abuse, 2) immediately initiate an investigation into the allegation of resident abuse, and 3) report an allegation of resident abuse to the State Regulatory Agency (Office of Health Care Quality). This was evident for 1 of 16 (Resident #57) residents reviewed for abuse during an annual recertification survey. The findings include: During the initial stages of the LTCSP survey, the surveyor interviewed Resident #57's family member who stated that Resident #57 was kicked in the chest by his/her former roommate 1.5 years ago. Resident #57's family member stated that the facility had taken care of the incident immediately. Review of the facility abuse, resident reporting policy on 02/01/23 revealed the purpose of the policy was to comply with the entire measure and intent of Article 43, Section 565 A of the Patients [NAME] of Rights law to ensure protection of patients entrusted to our care. The first line of the [NAME] of Rights reiterates the resident's right to be free from mental, verbal, or physical abuse. The second line indicates that all cases of suspected or witnessed abuse are required to be reported to the Division of Licensing and Certification by the nursing home administrator or their designee for possible action in accordance with Maryland State Law. The fifth line of the policy indicates that under no circumstances are staff to attempt to resolve such an incident without appropriate channel communications. The Abuse, Resident Reporting failed to reveal signatures of approval and a date when the policy was initiated and/or last reviewed. A review of resident #57's medical record on 02/03/23 at 11:30 AM, revealed a nursing progress note, dated 05/21/21 at 5:03 PM, that stated that the assigned GNA reported to the charge nurse that resident #57 claimed that his/her roommate had hit him on his chest. The progress note indicates that Resident #57 was assessed by the charge nurse and there was no visible bruising and that Resident #57's roommate had denied the allegation. The nursing progress note indicated that Resident #57 had a history of making false accusations. In an interview with the facility corporate nurse on 02/06/23 at 7:34 AM, the corporate nurse stated that the facility did not investigate nor report the allegation of abuse that allegedly occurred between Resident #57 and his/her roommate on 05/21/21 at approximately at 5 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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

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Deficiency Text Not Available

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

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Deficiency Text Not Available

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

Deficiency F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

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Deficiency Text Not Available

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

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Deficiency Text Not Available

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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2) Resident #52 was interviewed on 02/08/23 at 2:40 PM. During the interview, Resident #52 revealed that he/she was blind in the right eye and had poor vision in the left eye. The resident's medical record was reviewed on 02/08/23. A review of the annual MDS assessment with an assessment reference date (ARD) of 07/08/22 revealed a miscoding at B-1000, Vision, (0) was coded as adequate, can see fine print in newspaper/books. A further review of the annual MDS assessment with an assessment reference date (ARD) of 12/16/22 revealed a miscoding at B-1000, Vision, (1) was coded as impaired can see large print but not regular print in newspaper/books. The MDS assessor failed to assess that Resident #52 was blind and had poor vision. Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#48) of 14 residents reviewed for nutrition during the annual survey. The findings include. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) Resident #48 was interviewed on 1/25/23 at 2 PM. During the interview resident, #48 revealed he/she did not have any teeth as he/she wore dentures. The resident's medical record was reviewed on 1/27/23. A review of the annual MDS assessment with an assessment reference date (ARD) of 11/16/22 revealed a miscoding at L0200 (B) as Z none of the above was coded. The MDS assessor failed to assess that resident #48 did not have any natural teeth as the resident was edentulous. The annual MDS assessment with an ARD of 1/20/22 was assessed the same, indicating the resident was not edentulous. The MDS coordinator (staff #58) was interviewed on 2/13/23 at 12:18 PM. During the interview, she reviewed resident #48's MDS assessments and confirmed the inaccurate dental coding of 11/16/22 with an indication that the previous annual MDS assessment was inaccurately coded.

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to screen a resident to determine if the resident had or may have had a mental disorder (MD), intellectual disability (ID), or related condition. This was identified for 1 of (Resident #9) of 2 residents reviewed for pre-admission screening and resident review (PASSR) requirements during an LTCSP recertification survey. The findings include: A review of Resident #9's medical record on 01/25/23 revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that include: end stage renal disease on hemodialysis, hypertension, diabetes, peripheral vascular disease, and anemia. An admission PASSR was not available in the medical record. In an interview with he nursing unit manager on 01/25/23 at 2:14 PM, the unit manager stated that Resident #9's admission PASSR was located on a facility computer hard drive. Further review of Resident #9's medical record revealed that Resident #9 was sent to the hospital and then readmitted on [DATE]. Resident #9 was also diagnosed with Schizophrenia at this time. A PASSR was not completed at this time. In an interview with the facility corporate nurse 01/31/23 and 11:21 AM, the corporate nurse stated that s/he had spoken to the corporate Social Worker who stated that facility staff should have generated another PASSR upon readmission on [DATE]. The corporate nurse stated that there would not have been a different outcome.

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) A review of Resident #9's medical record on 01/25/23 revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that include: end stage renal disease on hemodialysis, hypertension, diabetes, peripheral vascular disease, and anemia. An admission PASSR was not available in the medical record. In an interview with he nursing unit manager on 01/25/23 at 2:14 PM, the unit manager stated that Resident #9's admission PASSR was located on a facility computer hard drive. Further review of Resident #9's medical record revealed that Resident #9 was sent to the hospital and then readmitted on [DATE]. Resident #9 was also diagnosed with Schizophrenia at this time. A PASSR was not completed at this time. In an interview with the facility corporate nurse 01/31/23 and 11:21 AM, the corporate nurse stated that s/he had spoken to the corporate Social Worker who stated that facility staff should have generated another PASSR upon readmission on [DATE]. The corporate nurse stated that there would not have been a different outcome. Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission. The facility did not have records to show the Preadmission Screening and Resident Review (PASARR) Level 1 screening was completed prior to admission. This is evident for 2 (#30, #9) of 34 residents in the initial sample of the annual survey. The findings include: The PASARR level 1 screening is federally mandated and must be completed for all applicants to nursing facilities which participate in the Maryland Medical Assistance Program regardless of an applicant's payment source. The purpose of the screening is to help ensure that residents are not inappropriately placed in nursing homes for long term care. The program assists in the placement and provision of services for individuals with severe mental illness and/or intellectual disability. 1) Resident #30's medical record was reviewed on 1/31/23 at 9:07 AM. During the review, the surveyor noted that Resident #30 was admitted to the facility on [DATE]. A PASARR level 1 screening was found that was dated 8/13/12. The medical record documented psychiatric diagnoses that included Psychotic disturbance, mood disturbances, delusional disorders, major depressive disorder, and anxiety. On 2/1/23 at 3:50 PM, the corporate nurse (staff #3) was interviewed and questioned about the only PASARR level I screen dated 4 years prior to the residents admission to the facility and the resident was determined to have psychiatric diagnoses. On 2/2/23 at 2:00 PM, corporate nurse revealed that he has looked through stacks of files and he did not find an updated Level 1 PASARR screen. He indicated that the facility's social worker will return next week, and she may be able to find an updated PASARR screen for resident #30. On 2/6/23 at 12:18 PM, the corporate nurse revealed that a PASARR screen for resident #30 admitted to the facility on [DATE] was not found. The facility failed to ensure that the resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission.

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on interviews and record review, it was determined that the facility failed to provide residents and or residents' responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications. This was evident for 1 (#131) of 1 resident interviewed about baseline care plans during the annual survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1) On 1/25/23 at 4:15 PM an interview was conducted with Resident #131. When he/she was asked if the facility provided a baseline care plan or medication list, resident #131 responded no. A phone interview was conducted with the resident's responsible party (RP) on 1/30/23 at 2:48 PM. The RP responded that the resident nor the family was provided with a copy of the baseline care plan or a list of medications upon the resident's admission to the facility in August 2022. The resident's medical record was reviewed for a baseline care plan on 2/14/23 at 11 AM. The baseline care plan is documented under the evaluations tab of the electronic medical record. The baseline care plan was dated 9/1/22. A review of both the paper and electronic medical record failed to produce a signed copy of the baseline care plan. A note dated 9/1/22 at 2:10 AM stated 2 copies of baseline care plan printed, will be given to the resident in the morning. The baseline care plan and note were written by a registered nurse (staff #39). Two unsigned copies of the baseline care plan were found tucked into a plastic sheet protector in the paper chart. On 2/14/23 at 11:50 AM, the corporate nurse (staff #3) was asked how the facility documents providing written copies of the baseline care plan. He indicated that the baseline is initiated under the evaluations tab and there is an identified issue with staff not getting signatures and/or lack of documentation in a note. The registered nurse (staff #39) was asked about the procedure for completing the baseline care plan at 3:40 PM on 2/14/23. She indicated that the baseline care plan is to be signed by the resident or family with a signed copy placed in the chart and a copy for the resident. She was asked if the resident or family is given anything else with the baseline care plan and she indicated no. She was informed of the two unsigned copies of the baseline care plan found in resident #131's medical record with no additional comment. The concern of resident #131 not receiving a copy of the baseline care plan and a copy of the medications was shared with the Director of nursing and corporate nurse at 12:44 PM on 2/16/23.

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on complaints, medical record reviews, and interviews with residents and facility staff, it was determined that the facility failed to provide a resident with a shower during the past four weeks of his/her stay. This was evident for 2 (Residents #52, and #195) of 6 residents reviewed for activities of daily living (ADL) during an LTCSP recertification survey. The findings include: 1) A complaint was obtained during the survey regarding Resident #52, on 02/06/23 at 1:30 PM, with an allegation that the nursing staff is not providing showers to Resident #52 for the past four weeks. It was also alleged that the nursing staff is instructing Resident #52 to bathe himself/herself. In an interview with Resident #52 on 02/08/23 at 2:40 PM, Resident #52 stated S/he is to receive a shower once a week and that the last shower that S/he received was 3-4 weeks ago. Resident #52 stated that the facility shower chair is not big enough for/him/her. A review of Resident #52's shower/bathing records on 02/09/23 revealed that the nursing staff documented that Resident #52 did not receive a bath during the evening shift on Wednesdays in January 2023. On 01/11, 18, and 25/23, the facility nursing staff documented Resident #52 only received a bed bath. In an interview with the Director of Nurses (DON) on 02/09/23 at 11:05 AM, the DON stated that Resident #52 shower days are normally Wednesday during the evening shift. The DON also confirmed that Resident #52 only received a bed bath on Wednesday 02/08/23. The DON stated that S/he spoke with the nursing unit manager for Resident #52 as to why Resident #52 did not receive a shower on 02/08/23 but has not received an answer at this time. The DON stated that the facility does have a bariatric shower bed that Resident #52 can use. The DON stated that Resident #52 is not safe to use a shower chair because of his/her bilateral below-the-knee amputations. 2) Review of complaint MD00161773 on 02/14/23, revealed an allegation that the nursing staff did not provide bathing or showers to Resident #195 during his/her residence at the facility. It was alleged that Resident #195 was sent to a physician's appointment on 10/21/20 with an unclean and unkempt appearance. A review of Resident #195's shower/bathing records on 02/14/23 revealed that the nursing staff documented that Resident #195 did not receive a shower from 10/09/20 thru 10/21/20. Further review failed to reveal Resident #195 refused a shower or ADL care during his/her residence in the facility. A review of Resident #195's Self Care Deficit care plan, which was related to Resident #195's diagnosis of lung cancer and having an unsteady gate, was initiated on 10/09/20. The nurse initiating the care plan listed the goals as the Resident will allow staff to perform, toileting, transfers, bed mobility, eating, and ADL tasks. The nursing approaches included: bathing, which will be done with the assistance of one staff member.

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a medical record, and interview, it was determined that the facility failed to provide treatment/services to maintain vision (Resident #52). This is evident for 1 out of 5 residents reviewed for vision/hearing during the annual LTCSP recertification survey. The findings include: A complaint was obtained during the survey regarding Resident #52, on 02/06/23 at 1:30 PM, with an allegation that the nursing staff are not providing any type of vision support. The complainant stated that Resident #52 is blind and that the nursing staff do not assist Resident #52 were his/her personal items are located or where the food items are located on his/her meal tray. A review of Resident #52's medical record on 02/06/23 revealed that Resident #52 was admitted to the facility on [DATE] with diagnoses that include diabetes, unspecified cataracts, hemodialysis, and amputations of the right and left below the knee/lower legs. In an interview with Resident #52 on 02/08/23 at 2:40 PM, Resident #52 confirmed that she was blind in the right eye and had poor vision in the left eye and that S/he suffers from diabetes. Resident #52 stated that S/he has suffered with eye issues for 2-3 years and would like to see the facility ophthalmologist. In an interview with the Director of Nursing on 02/16/23 at 12:05 PM confirmed the surveyor's findings. Cross reference F 641

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A pressure ulcer, also known as a pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. 3) A portion of investigating complaint MD00167882, the surveyor viewed the medical records of Resident #401 on [DATE] at 9:06 AM. The review revealed that Resident #401 resigned from the facility in [DATE] with diagnoses that include but were not limited to congestive Heart Failure, type 2 diabetes, dementia, cerebrovascular disease, and unspecified pressure ulcer multiple lesions. Further review of the medical records revealed that Resident #401 had developed and resloved multiple pressure wound. The wound physician's report dated [DATE] stated that the resident's wounds were resolved. However, the wound physicians report dated [DATE] listed 9 new pressure wounds (posterior neck, Right upper buttock, Right upper ischium, Left upper buttock, left ischium, left heel, right heel, left ear, and right ear). During an interview with the facility wound nurse (RN #52) on [DATE] at 10:47 AM, RN #52 confirmed she was the facility wound nurse who performed daily wound care and assisted wound provider's rounding every Monday. RN #52 recalled Resident #401 developed multi wound after his/her hospitalization from [DATE] to [DATE]. RN #52 consisted at some point after [DATE] the resident was followed up with outside resources for wound care. Also, RN #52 added, Luckily, Resident #401 's wound was almost resolved with an outside resoure. A review of the wound care records on [DATE] at 12:00 PM revealed the facility had weekly skin assessment but there was no documentation from the wound consultant from the end of February 2021 to the beginning of [DATE] (the on-site wound consult restarted on [DATE]). During an interview with the DON and Staff #3 on [DATE] at 11:15 AM, Staff #3 stated, I searched up closed records several times but there was no wound consultant's documentation. 4) A portion of investigating complaint MD00165588, the surveyor viewed the medical records of Resident #405 on [DATE] at 11:37 AM. The review revealed that Resident #405 was admitted to the facility on [DATE] with a past medical history that included, but was not limited to, end-stage renal disease, a status post deceased donor renal transplant, deep venous thrombosis on left upper extremity brachial, recurrent hemorrhagic shock in the setting of lower GI (gastrointestinal) bleeding. Further review of the medical records revealed that a facility nursing staff documented that Resident #405 had had pressure ulcers on the sacrum, Right hip, Right sacrum, and a skin tear on the Right wrist on the admission date. However, there was no documentation by the wound team until the resident's discharge on [DATE]. During an interview with a Registered Nurse (RN #19) on [DATE] at 2:30 PM, RN #19 explained that if a newly admitted resident had a wound, the nurse would contact the provider for orders and wound consult. RN #19 added, a nurse who initially assessed the resident would put his/her name on the wound sheet for the wound doctor ' s rounding. Then the wound doctor will do the assessment every Monday. The surveyor shared the above concerns with the Director of Nursing (DON) on [DATE] at 11:15 AM. Based on complaints, observation, reviews of medical records, and interviews, it was determined that the facility staff failed to 1) cleanse a wound with the prescribed solution, 2) implement measures to minimize the residents' risk of injury, 3) ensure a wound consult was completed timely, and 4) monitor and document treatments and services to promote healing of pressure ulcers. This was evident for 2 (Residents #65, #401, and #405) of 10 residents reviewed for pressure ulcers during an LTCSP recertification survey. The findings include: 1) On [DATE] at 9:23 AM the surveyor observed Staff #52 the Wound Nurse perform wound care for Resident #65. Staff #52 gathered supplies including Optiform dressing, Aquacel, skin prep, cotton tipped swabs, sterile 4 x 4 gauze pads, a drape, and a 16 ounce spray bottle of Skintegrity wound cleanser. Upon entering Resident 65's room, Staff #52 placed the supplies onto the drape on the residents overbed table. She cleansed her hands and applied gloves. She removed the old dressing revealing a quarter size deep pressure wound at the resident's lower midline sacrum/coccyx (tailbone) area. Staff #52 removed her gloves, sanitized her hands, and donned clean gloves. She then sprayed the wound with the Skintegrity wound cleanser and used a 4 x 4 gauze to clean the wound. She repeated this process a second time. She again sanitized her hands while changing gloves, packed the wound with Aquacel using the sterile swab, changed gloves, sanitized her hands, and applied an Optifoam dressing which she had dated and initialed, over the wound. She then changed gloves and sanitized her hands, removed Resident #65, heel protector and non-skid sock revealing a small red spot approximately 2 millimeters diameter on the residents right heel. The skin was intact and dry. Staff #52 applied skin prep to the heel then replaced the sock and heel protector, discarded her gloves, and sanitized her hands. Staff #52 then exited the room and placed the bottle of Skintegrity wound cleanser onto the treatment cart located outside of the door. The bottle was dated [DATE] in black marker but did not have a resident's name on it. Review of Resident #65's medical record on [DATE] at 11:12 AM revealed plans of care for impaired skin integrity to sacral area, the approaches included but were not limited to Apply treatment as ordered. Monitor for effectiveness. A physician order was written [DATE] to: Cleanse sacral wound with NSS (Normal Sterile Saline), gently pat the wound then apply Aquacel AG and cover Allevyn foam daily and as needed (every day shift for wound care. Do not scrub or use excessive force). Another order was written [DATE] for: Cleanse right lateral heel wound with NSS, gently pat dry and apply skin prep every shift. Staff #52 failed to follow the plan of care and the physicians wound care orders by failing to cleanse the resident's right heel with NSS prior to applying skin prep, by cleansing the residents sacral wound with Skintegrity wound cleanser instead of NSS as ordered, and using Optifoam dressing instead of the Allevyn foam dressing as ordered by the physician. Skintegrity wound cleanser contains several ingredients. It does not contain NSS. Optifoam Adhesive is a hydropolymer adhesive foam island dressing that is waterproof and has a high fluid-handling capacity and thin film backing. Allevyn Foam Dressing is a 3 layer Hydrocellular foam dressing designed for use on wounds with moderate exudate levels. Staff #2 the Director of Nursing and Staff #3 the Corporate Nurse were made aware of these findings on [DATE] at 8:52 AM. Cross reference F 880. 2) Resident #65 was observed on [DATE] at 10:08 AM lying in his/her bed. His/her bed was in an elevated position approximately 3 feet above the floor, no fall mats were observed in the room. Another observation on [DATE] at 12:35 PM revealed the resident was again observed in his/her bed which was elevated approximately 3 feet above the floor. When asked at that time if he/she adjusted the height of the bed, the resident stated I don't do shit with it. Another observation was made on [DATE] when the surveyor entered Resident #65d room with Staff #52 the wound nurse and #53 a GNA (Geriatric Nursing Assistant) to observe a dressing change. The bed was observed in an elevated position upon entry to the room. After completion of resident care and the dressing change, the staff failed to lower the bed before leaving the room. Review of Resident #65s medical record on [DATE] at 12:47 PM revealed that the resident was identified as having a risk for falling related to a neurological disorder and a plan of care was developed on [DATE]. The approaches staff were to implement included: Keep bed in low position except when rendering care. Additional observations were made of the resident in his/her bed on [DATE] at 2:10 PM and[DATE] at 9:43 AM, the bed was not in a lowered position. Staff #2 the Director of Nursing and Staff #3 the Corporate Nurse were made aware of these findings on [DATE] at 8:52 AM.

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

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

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Based on medical record review, and staff interview, it was determined facility staff failed to follow up on Podiatry consultation report recommendations. This is identified for 1 (resident #131) of 1 resident reviewed for foot concerns. The findings include: Podiatry is a branch of medicine devoted to the study, diagnosis, and medical and surgical treatment of foot, ankle, and lower extremity disorders. A review of resident #131's medical record on 2/13/23 revealed a physician's order for Podiatry Consult was written on 10/19/2022. A review of the medical record did not reveal if resident #131 had been seen by a Podiatrist. An interview was conducted with the unit manager/nurse (staff #37) at 11:45 PM on 2/13/23. When asked if the resident was seen by podiatry, she indicated that the resident was seen. She was informed that the podiatry consultation report was not in the medical record. She looked in a binder and found the original Health Dive initiation on the podiatry consult dated 10/19/22. She could not find the podiatry consult or documentation of when resident #131 was seen by the Podiatrist. She indicated that she would have the scheduler/secretary call to have the consult sent. The unit manager provided a copy of the podiatry consult at 1:15 PM on 2/13/23. A review of the consultation report revealed the resident was examined on 12/8/22. The podiatrist documented a progress note describing the evaluation and treatment performed with recommended new orders. The unit manager was interviewed and asked if the recommendations will be followed up. She proceeded to look in the resident's paper chart and read the consult recommendations. She confirmed the recommendation to apply Lac Hydrin 12 % cream daily to both feet was not ordered. The podiatrist documented that the resident's family member accompanied the resident during the examination. The podiatrist revealed the resident is walking in therapy with just slipper socks. The podiatrist indicated that the resident had arthritis in the right foot and doing physical therapy in just socks on is probably exacerbating symptoms. The podiatrist recommended a good athletic shoe for all walking. A review of the surveyor's notes revealed a documented therapy observation on 2/2/23 at 12:42 of the resident standing with a specialized walker and two staff assisting the resident to ambulate while the resident was wearing non-slip socks. On 2/15/23 at 12:45 PM, the unit manager confirmed that she followed up with the resident's attending physician related to the podiatry recommendations that were written on 12/8/22. On 2/16/23 at 12:44 PM, the Director of nursing and corporate nurse were informed of the surveyor's concern related to the missing podiatry consultation form, with a noted delay in follow-up to the recommendations and ongoing therapy with the resident not wearing shoes. The facility had failed to timely follow up on the podiatry recommendations of 12/8/22 as the facility failed to obtain the podiatry consultation report until surveyor intervention.

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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Based on a medical record review and staff interview, it was determined that the facility failed to monitor a resident's body weight, who had potential nutritional risks due to tube feeding. This was evident for 1 (Resident #33) of 14 residents reviewed for nutrition during the annual survey. The findings include: A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. Parenteral and enteral feedings are considered in patients with insufficient oral intake or contraindications to anything by mouth. A review of the medical record for Resident #33 on 01/31/23 at 11:30 AM revealed that the resident had a PEG tube since his/her origin admission in August 2022 for Resident #33's history of poor oral intakes. Resident #33 had an order of 1800ml total volume of nutrients and a regular texture thin liquids consistency diet. A review of Resident #33's care plan revealed that the intervention, obtain/ monitor/document weight as ordered, was placed under risk for a deficient fluid volume-related history of poor oral intakes as evidenced by a PEG tube. On 1/31/23 at 1:00 PM, a review of Resident #33's order revealed no active order for a monthly weight check. The monthly weight check order was placed on 9/14/22 and discontinued on 9/29/22; another one was placed on 10/27/22 and discontinued on 11/17/22. A further review of the medical record revealed that the most recent body weight for Resident #33 was on 11/29/22. Also, nutrition/dietary notes written by the Director of Dietary (Staff #5) on 11/30/22, 12/08/23, 1/12/23, and 1/20/23 used the same weight recorded on 11/29/22. During an interview with Staff # 5 on 02/01/23 at 09:50 AM, Staff #5 stated that for managing tube feeding residents' nutrition, she would regularly follow up on residents' body weight and monitor residents' status through her routine rounding. Staff #5 also explained that she expected the body weight to be recorded weekly. If it were not recorded, she would follow up. The surveyor shared Resident #33's medical records that the resident's body was not checked for two months. There was no documentation that the facility staff attempted to check Resident #33's body weight. The surveyor shared the above concerns during an interview with the Director of Nursing (DON) on 2/16/23 at 11:15 AM.

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

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

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Based on review of residents medical records and interview with staff, it was determined that the facility failed to develop a plan of care that addressed the needs of a resident with dementia. This was evident for 1 (#129) of 2 residents reviewed for dementia care. The findings include: Dementia is a general term that describes symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function caused by the permanent damage or death of the brain's nerve cells. Resident #129's electronic and paper medical record was reviewed on 1/30/23 at 2:02 PM. During the review, it was found that the resident was diagnosed with unspecified dementia without behavioral disturbance, Parkinson's disease. Resident #129 was receiving medications such as Carbidopa-Levodopa or Nuplazid (discontinued on 11/23/22) that were used in treating those diagnoses. Further review of the resident's care plan and interventions revealed that the care plan failed to address the needs of a dementia resident to achieve the highest practicable physical, mental, and psychosocial well-being. During an interview with the Activity Director (Staff #12) on 02/02/23 at 12:25 PM, Staff #12 stated the facility did not have specific activity programs or evaluation tools for residents who have dementia disease. On 02/03/23 at 9:36 AM, the surveyor asked the Director of Nursing (DON) how the facility evaluated residents to maintain the highest practicable physical, mental, and psychosocial well-being. The DON stated, maybe providers have documentation, but we do not have typical evaluation tools. During an interview with the DON On 02/16/23 at 11:15 AM, the surveyor shared the above concerns about dementia care. No additional supporting documentation was submitted to the time of the exit conference performed on 2/16/23 at 2:00 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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff it was determined the facility staff failed to ensure adequate rationale for increasing antianxiety and antidepressant medications and monitoring of behaviors, behavior interventions and effectiveness for a resident receiving psychotropic medications for anxiety and depression. This was evident for 1 (#35) of 5 residents reviewed for Unnecessary Medications. The findings include: Review of Resident #35s medical record on 2/2/23 at 11:52 AM revealed diagnoses which included but were not limited to Dementia, Psychotic disturbance, Mood disturbance and Anxiety. A Psychiatric Nurse Practitioner (NP) progress note dated 9/19/22 at 9:44 PM indicated that Resident #35 was irritable, anxious, loud, yelling at staff and complained of anxiety. The note indicated: Medication intervention with rationale: Start Buspar (also known as Buspirone, an anxiety medication) 5 mg (milligrams) twice per day. The physicians' orders reflected an order written on 9/19/22 for Buspirone 5 mg twice a day for anxiety. A Psychiatric NP progress note dated 1/16/23 10:31 PM Stated: History of Present Illness: Resident is calm and pleasant. (He/she) denies depression, anxiety, hallucinations, or delusions. No SI/HI (Suicidal/Homicidal Ideations).He/she is not combative. The record failed to reveal documentation by the practitioner to support why Resident #35's Buspirone dose was increased on 1/23/23. However, on 1/23/23 Resident #35s Buspirone was increased to 7.5 mg two times a day. Review of Resident #35s Behavior record revealed that staff were monitoring the resident for: Verbalizing exit seeking, Wandering in the hallway exit seeking, and Wandering in the hallways. The record did not reflect that staff were monitoring the resident for anxiety, or that staff identified and provided behavioral interventions to assist the resident in managing anxiety. A Psychiatric NP progress note dated 7/25/22 included the History of Present Illness: Resident is calm and pleasant. Staff reports that resident has been noncompliant with Covid 19 isolation. (He/She) was physically aggressive and irritable. (He/She) complains of denies depression and anxiety. (He/She) denies hallucinations or delusions. No SI/HI. Treatment Plan: Behavior Management Plan: Staff to provide structured ADL care; Staff to approach patient respectfully and be clear about upcoming nursing care. Medication intervention with rationale indicated: Increase Effexor (an antidepressant medication) to 187.5 mg po (by mouth) qd (daily). It did not include the practitioner's rationale to increase the antidepressant. Resident #35s behavior record for July 2022 included monitoring for: Throwing stuff at staff, using profanities toward staff, Wandering on the hallways, and Hoarding. The behavior record did not reflect that staff monitored the resident for symptoms of depression, that staff provided any non-pharmaceutical interventions to assist the resident in managing his/her depression nor the effectiveness of the approaches. There was no evidence that the staff included the behavior management plan in the resident's plan of care for Depression as indicated in the NP progress note. In an interview on 2/7/23 at 9:25 AM Staff #59 a facility LPN was asked where Resident #35's behavior and interventions were monitored and documented. He indicated that they were documented on the behavior sheets in the EMR (Electronic Medical Record) and showed the surveyor that the resident was monitored for wandering in the hallway, verbalizing exit seeking, wandering in the hall and exit seeking and psychotropic medication side effects. The facility staff were no longer monitoring for throwing things, using profanities toward staff nor were they monitoring for other displays of agitation, depression, or anxiety. There was no documentation on the behavior sheets of resident specific interventions and their effectiveness. He confirmed that there was nowhere else where behavior monitoring was documented. Staff #3 the Corporate Nurse was made aware of these concerns on 2/7/23 at 10:58 AM. In an interview on 2/8/23 at 9:35 AM Staff #19 the 2nd floor Unit Manager indicated that resident had exit seeking behaviors, that he/she became agitated, screamed profanities and refused care. She was asked to identify the interventions staff implemented when the resident displayed these behaviors. She indicated if he/she is aggressive he/she will respond to redirection at times, or walk away and reapproach later, sometimes the same person, sometimes he/she responds better if a different person reapproaches. When asked how staff know what to do, she indicated, we will let staff know in report if the resident has been having behaviors on the previous shift. When asked if interventions were documented somewhere for staff to follow if Resident #35 became agitated, she indicated that for the nurses the behaviors were in the Care Plan and that for the GNA's it was in the Point of Care. A plan of care was in place for Non-adherence to plan of care related to consistent wandering hallways, Mood disturbance related to Depression, and Safety risk (Elopement) related to wandering. However, there was no plan of care related to agitated or aggressive behavior or anxiety with measurable objectives and resident centered approaches. Resident #35s Point of Care ([NAME]) included: provide reassurance leave and return 5-10 minutes later and try again, Behavior monitoring for verbalizing exit seeking, Distract from wandering by getting resident involved with activities and try to redirect resident to reality when he/she I stating that they want to leave an go home. There were no interventions related to agitation, anxiety, or depression. These concerns were reviewed again with Staff #2 the Director of Nursing and #3 the Corporate Nurse on 2/16/23 at 8:52 AM.

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interviews, it was determined that facility staff failed to ensure residents were free from significant medication errors, as evidenced by administrating overdose of psychotropic medication with the same ingredient but different forms (tablet and sprinkles capsule) for two days. This was evident for 1 (#49) of 5 residents reviewed for an unnecessary medication review during the annual survey. The findings include: The medication Depakote (divalproex sodium) is an anticonvulsant. It is prescribed to treat seizure disorders and to manage the manic phase of bipolar disorder. Depakote has three different forms: Depakote (delayed-release tablets), Depakote ER (extended-release tablets), and Depakote Sprinkle Capsules (delayed-release Capsules). Depakote Sprinkle Capsules work the same way as Depakote Delayed-Release tablets, although they are in capsule form instead of a tablet. Some patients (for example, those with difficulty swallowing) may find it easier to take Depakote Sprinkle Capsules because they can be swallowed whole or opened and the contents sprinkled on soft food. On 02/01/23 at 10:46 AM review of Resident #49's medical record revealed that Resident #49 had diagnoses that include but were not limited to schizophrenia, bipolar disorder, dementia, and depression. Further review of Resident #49 ' s medical record revealed the resident had been taking Depakote tablets 500mg three times per day from October 2022 to 01/21/2023. Also, there was an order for Resident #49, Depakote Sprinkles Capsule 500mg three times per day from 01/19/2023 to 1/31/2023 (since the resident transferred to the hospital, the order was discontinued). On 02/01/23 at 12:40 PM, a review of the Medication Administration Record (MAR) for Resident #49 revealed that the facility nursing staff documented Resident #49 received Depakote tablet 500mg at 9 AM, 8 PM, and 9 PM on 01/19/23 and Depakote Sprinkle Capsules 500mg at 4:30 PM and 10 PM on 01/19/23. Also, on 01/20/23, the resident took Depakote tablet 500mg at 9 AM, 8 PM, and 9 PM, and Depakote Sprinkle Capsules 500mg at 6:30 AM. These records stated Resident #49 administrated Depakote total doses of 2500mg on 1/19/23 and 2000mg on 1/20/23. During a phone interview with Psychiatric Nurse Practitioner (Staff #22) on 02/01/23 at 01:30 PM, Staff #22 stated, on my record, Resident #49 is taking Depakote tablet 500mg BID (twice a day) due to bipolar disorder. I don ' t know about the HS (take at bedtime) dose. Staff #22 said the facility attending physician and herself discussed residents ' medication for adding, reducing, or changing, but it was not required. Also, Staff #22 explained that Depakote was used to manage bipolar disorder, it could be used in high doses as 2000-3000mg/day based on the patient 's condition. Staff #22 stated that Depakote 2000-2500mg per day was not dangerous for Resident #49. A blood draw should do the toxic level of Depakote, but it was not required. On 02/02/23 at 08:42 AM, an interview was conducted with an attending Nurse Practitioner (Staff #23). Staff #23 recalled Resident #49 had been prescribed Depakote 500mg BID and HS (total dose 1500mg per day) for managing bipolar disorder. Staff #23 said she also discussed residents ' status with psychiatric providers. The surveyor reviewed Resident #49 ' s orders and MAR with Staff #23. Staff #23 confirmed that she did not mean to give Depakote tablets and Sprinkles simultaneously. Staff #23 said, I didn ' t want Resident #49 to miss her/his medication due to a delivery issue. I meant to administrate Depakote tablets before Depakote Sprinkles were delivered. On 02/02/23 at 10:40 AM, the Director of Nursing (DON) and Staff #23 brought a copy of the clinical incident report and employee education form dated 02/03/23 about the 01/19/23 Depakote Sprinkle administration. The DON and Staff #23 stated that one of the facility nursing staff (Registered Nurse #39) signed off on the MAR for Depakote Sprinkle on 1/19/23 at 4:30 PM and 8 PM, which was not given. On 02/02/23 at 11:02 AM, during an interview with the DON, the surveyor asked about another signed-off Depakote Sprinkle by RN #47 on 1/20/23 at 6:30 AM. The DON did not provide any documentation about this record. On 2/16/23 at 11:15 AM, the surveyor shared the above concerns with the DON and Regional Registered Nurse (Staff #3).

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

Deficiency F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

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Based on a complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to obtain a STAT urine sample when a resident was observed with a change in condition. This was evident for 1 (Resident #195) of 36 complaints reviewed during an LTCSP recertification survey. The findings include: A review of complaint MD00161773 on 02/14/23 revealed an allegation that Resident #195 was not provided with care while residing in the facility. A review of Resident #195's closed medical record on 02/14/23 revealed that Resident #195 was observed with increased confusion on 10/20/20 at 4:48 PM. The nurse notified Resident #195's physician who instructed the nurse to obtain a STAT urinalysis and urine culture. Bloodwork was also ordered at this time on a routine basis. Further review of Resident #195's closed medical record revealed a nurse's progress note, dated 10/20/20 at 5:31 PM, that indicated the nurse was unable to obtain a STAT urine specimen to send to the lab. In an interview with Resident #195's 10/20/20 evening shift charge nurse, staff member #61, on 02/15/23 at 10:55 AM along with the facility DON, staff member #61 stated that s/he recalled Resident #195 on 10/20/20 during the evening shift. Staff member #61 stated that when s/he went to obtain a urine sample on Resident #195 on 10/20/20, staff member #61 recalled that Resident #195's brief was soaked so s/he placed a urinal between Resident #195's legs to try to obtain a urine sample. Staff member #61 stated that s/he was unable to obtain a urine sample for Resident #195 and that if this occurs, s/he would notify Resident #195's physician for an order to straight catheterize a resident for the urine sample. Staff member #61 stated that a call was not placed to Resident #195's physician for an order to straight catheterize Resident #195 for the urine sample. Staff member #61 stated that s/he did notify the nurse for the oncoming shift. A review of Resident #195's closed record did not reveal a STAT urinalysis result for 10/20/20.

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected 1 resident

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Based on observation and interview with staff it was determined the facility failed to have sufficient dietary support personnel to provide social dining services in the dining room. This was evident throughout the survey and had the potential to affect all residents. The findings include: 1) Observations were made of the facility's only dining room, located on the first floor of the building, from approximately 7:00 AM - 3:00 PM on 1/23/23-1/27/23 and 1/30/23-2/3/23. Group activities were observed taking place however no dining services were provided during that time frame. Review of the Resident Council meeting minutes on 1/26/23 at 10:31 AM revealed that the Administrator shared with the council on 1/4/23 that dining room service would return ASAP when the new director starts in the beginning of January. Minutes from a Special Resident Council Meeting held 1/19/23 to discuss Food complaints revealed that the new Food Service Manager, Staff #20 indicated that service in the main dining room would resume when staffing allows. In an interview on 2/3/23 at 10:10 AM Staff #20 indicated she started working for the facility 1/10/23 and had been in orientation on and off. When asked why the dining room was not used for meal service, she indicated that she did not know why it was not used and stated: we are in the process of setting it up. In an interview on 2/3/23 at 10:35 AM Staff #1 the Administrator was asked why the staff were not providing meal service in the dining room. He stated, because we did not have the staff to run it. When asked which staff he stated: Dietary staff. When asked when the facility stopped using the main dining room he stated we haven't used the dining room for about a month, month, and a half, we lost some personnel, we were short staffed. We are looking forward to using it again. Continued observations of the dining room revealed that food service had not resumed by the end of the survey on 2/16/23. 2) Resident #48 was interviewed on 2/9/23 at 8:20 AM. When asked she could not remember the last time the facility had served lunch in the dining room. He/she indicated that it had been a while. Resident #48 indicated that the residents had not eaten in the dining room this year. He/she went on say everybody loved it because of the variety. Providing comments such as you get to choose, and you get to pick what you want like options such as getting potatoes instead of noodles or whatever else they may be serving. We all miss not being able to eat in the dining room. 3) Resident #17 was interviewed on 2/14/23 at 1:30 PM. He/she indicated that they have not eaten in the dining room for over two months. When they did eat in the dining, it did not happen every day; it was only for lunch. He/she revealed that the residents were given choices and were able to select what they wanted that was the best. Additionally resident #17 indicated that it was good to be with the other residents.

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on complaint, observation, resident, and staff interviews, it was determined that the facility staff failed to develop, prepare, distribute, and serve menus that reflect a resident's nutritional wishes. This was evident for 1 (Resident #96) of 78 residents reviewed during the recertification survey. The findings include: In an interview with Resident #96 on 1/25/2023 at 12:36 PM, Resident #96 complained that the food was usually cold, and s/he was not given a menu to choose from. Resident # 96 added that what was served did not match what they had on the meal ticket, and they don't give you alternate food choices. While the surveyor was in the resident's room, Geriatric Nursing Assistant (GNA #27) brought in Resident #96's lunch tray. Surveyor observed that the food items on the lunch tray did not match what was written on the meal ticket. Resident #96 refused the meal and stated that s/he did not like the food. GNA #27 took the tray out without offering the resident any alternate food choice or substitute. Surveyor immediately interviewed GNA #27 who confirmed that the meal on the resident's lunch tray did not match the meal ticket and acknowledged that the resident was not offered any substitute. Registered Nurse (RN #25) and GNA #26 who were both in the hallway confirmed that what was served on the lunch tray did not match what was written on the meal ticket on the tray. When asked what the process was for when a resident refused a meal because s/he did not like it, GNA #26 and RN #25 stated that the resident would be given an alternate meal. All three (3) staff members (GNA #27, GNA #26, and RN #25) stated that Resident #96 usually ordered food from the outside because s/he did not like the food that was served in the facility. On 2/3/2023 at 9:45 AM: In an interview with the Corporate Clinical Dietician (Staff #5), she stated that she goes to the residents on admission and get their food preferences which is entered into PCC (electronic record). This generates a menu slip which is printed out in the kitchen prior to meal service. She stated that stable long term care residents were reassessed every 3 months and/or on as needed basis. Staff #5 added that the nurses on the floor could also put in a request for the dietician to see the resident. Regarding menu selection, Staff #5 stated she would get the food service director to answer the question. On 2/3/23 at 10:10 AM, an interview was completed with the Food Service Director (CDM #20), who stated that Resident #96 shouldn't be getting food items that were different from what was printed on the meal ticket. CDM #20 was shown a copy of the meal slip taken from the resident's tray with the items that were not on the tray. She stated she was going to follow up with the resident to get more details of the resident's concerns about food. Regarding meal substitutes, CDM #20 stated that there should a ticket on the meal tray to show whatever was substituted and sometimes the dietary staff would tell the residents verbally when the kitchen was out of certain food items. Regarding Menu selection, the food service director stated that the menus were posted on TV and given to the residents once a week by the activity staff who help them to make their selections. Regarding resident's concerns about the food being cold, CDM #20 stated that they were aware of that concern and have gotten new heating pellets to help keep the food warm. She added that they had a meeting with the residents prior to the surveyors coming into the building and the residents stated that the food had improved both in quality and heat (temp). CDM #20 added that she was constantly on the floors talking with the residents and taking note of their concerns. A review of the Resident Council minutes dated 1/19/2023 revealed that resident food complaints were a common issue and included Cold food/meal temps and Items listed on tray card missing from meal. On 2/10/23 at 1:19 PM, in a follow up interview with CDM #20, she stated that the activities department staff were supposed to be giving a weekly menu to each resident in their rooms. Surveyor notified the food service director that some residents have not been getting the weekly menu. She stated she was going to follow up with the activities department staff.

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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Based on complaint, observation, resident, and staff interviews, it was determined that the facility staff failed to provide food that accommodates resident preferences and/or appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice. This was evident for 2 (#96, #342)) of 78 residents reviewed during the recertification survey. The findings include: 1) In an interview with Resident #96 on 1/25/2023 at 12:36 PM, Resident #96 complained that the food was usually cold, and s/he was not given a menu to choose from. Resident # 96 added that what was served did not match what they had on the meal ticket, and they don't give you alternate food choices. While the surveyor was in the resident's room, Geriatric Nursing Assistant (GNA #27) brought in Resident #96's lunch tray. Surveyor observed that the food items on the lunch tray did not match what was written on the meal ticket. Resident #96 refused the meal and stated that s/he did not like the food. GNA #27 took the tray out without offering the resident any alternate food choice or substitute. Surveyor immediately interviewed GNA #27 who confirmed that the meal on the resident's lunch tray did not match the meal ticket and acknowledged that the resident was not offered the opportunity to receive substitutes. Registered Nurse (RN #25) and GNA #26 who were both in the hallway confirmed that what was served on the lunch tray did not match what was written on the meal ticket that was on the tray. When asked what the process was for when a resident refused a meal because s/he did not like it, GNA #26 and RN #25 stated that the resident would be given an alternate meal. GNA #27 added that he did not ask to give Resident #96 something else when the resident refused to eat lunch because the resident had told staff earlier that s/he was going to order food from outside. All three (3) staff members (GNA #27, GNA #26, and RN #25) concurred that Resident #96 usually ordered food from the outside because s/he did not like the food that was served in the facility. On 2/3/2023 at 9:45 AM: In an interview with the Corporate Clinical Dietician (Staff #5), she stated that she goes to the residents on admission and get their food preferences which is entered into PCC (electronic record). This generates a menu slip which is printed out in the kitchen prior to meal service. She stated that stable long term care residents were reassessed every 3 months and/or on as needed basis. Staff #5 added that the nurses on the floor could also put in a request for the dietician to see the resident. On 2/03/23 at 10:10 AM, an interview was completed with the Food Service Director (CDM #20), who stated that Resident #96 shouldn't be getting food items that were different from what was printed on the meal ticket. CDM #20 was shown a copy of the meal slip taken from the resident's tray with the items that were not on the tray. She stated she was going to follow up with the resident to get more details of the resident's concerns about food. Regarding meal substitutes, CDM #20 stated that there should be a ticket on the meal tray to show whatever was substituted and sometimes the dietary staff would verbally tell the residents when the kitchen was out of certain food items. 2) In an interview with Resident #342 on 1/25/2023 at 10:14 AM, the resident stated I don't like the food. They just give you what they want. Resident #342 added that whenever s/he told the nurse that s/he did not like the food that was served, they usually came back and told her/him that they did not have anything else. In a follow up interview with CDM #20 on 2/10/2023 at 1:19 PM, she stated that the residents were supposed to get alternate food choices when they refused and/or did not like the meal that was served. CDM #20 stated she was going to follow up with the resident and staff.

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

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to correctly evaluate and provide a resident with a full cognitive workup as recommended by a speech-language pathologist (SLP). This was evident for 1 (Resident #195) of 36 complaints reviewed during an LTCSP recertification survey. The findings include: A review of complaint MD00161773 on 02/14/23 revealed an allegation that Resident #195 was not provided with care while residing in the facility. A review of Resident #195's closed medical record on 02/14/23 revealed that Resident #195 was admitted to the facility on [DATE]. At that time, Resident #195's physician instructed the staff to obtain a Speech-Language Pathology screen and to treat as indicated. A review of the 10/08/20 SLP, staff member #60, screening criteria noted that Resident #195 had a mental status change, having problems with memory, orientation, or problem-solving, and a change in the resident's condition. The 10/08/20 SLP therapist identified Resident #195 with some cognitive impairment and recommended an SLP full cognitive evaluation. A cognitive test checks for problems with your mental function (how your brain processes thoughts). The test involves answering simple questions and performing simple tests. The test is also called a cognitive screening test or cognitive assessment. Cognitive speech therapy is a type of therapy that works and focuses on a wide variety of speaking & communication skills, and is not only for those having difficulty speaking. Some of the areas cognitive speech therapy targets are language and improving one's general cognitive skills. Further review of Resident #195's closed record revealed that on 10/19/20 Resident #195 was observed on the floor, on 10/20/20 Resident #195 was observed with an increase in confusion which Resident #195's physician requested laboratory studies be obtained, and that Resident #195's was consuming 0 - 50 % of his/her meals between 10/08/20 and 10/21/20. Resident #195 was sent to an oncology appointment on 10/21/20 and did not return to the facility. On 10/22/20, a second SLP therapist, staff member #32, reevaluated and rescreened Resident #195. On 10/22/20, staff member #32 indicated that Resident #195 did not have a mental status change, did not have a new onset of falls, and did not have problems with memory, orientation, or problem-solving and that Resident #195 was not consuming less than 75% of meals or snacks. Staff member #32 recommended that no speech services were indicated at this time and that Resident #195 was at his baseline. In an interview with staff member #32 (SLP) on 02/15/23 at 10:08 AM, staff member #32 stated that s/he did the SLP screen on Resident #195 on 10/22/20 and documented the assessment. Resident #195 was screened by the facility's Speech-Language Therapist on 10/08/20 upon admission to the facility. The therapy staff failed to initiate and complete a full cognitive evaluation as recommended on 10/08/20. Resident #195 did not receive any speech-language services during his/her residence in the facility. Resident #195 was admitted to the hospital on [DATE] after being sent to see his/her oncologist.

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on observations, record review and interview it was determined the facility staff failed to ensure 1) accurate documentation of oxygen administration for 1 (#111) of 1 resident reviewed for respiratory care, and 2) failed to maintain complete and accurate inventory of belongings for 3 (#70, #137, and #90) of 78 residents reviewed during the survey. The findings include: 1) Review of Resident #111's medical record on 2/13/24 at 8:37 AM revealed a physician order written 12/27/22 for Oxygen via Nasal Cannula at 2-3 LPM (liters per minute) Goal O2 saturation greater than 95%. Review of the TAR (Treatment Administration Record) for January and February 2023 revealed the physicians order for oxygen. The spaces provided for administration times were labeled PRN (as needed). The oxygen was not signed off by the nursing staff as administered to the resident nor did it reflect how many liters of oxygen were administered. Staff #19 the 2A Unit Manager was interviewed on 2/13/23 at 12:41 PM. She was shown the TAR and made aware that the order indicated a range of 2-3 liters, the TAR indicated that it was PRN, and that staff were not signing off to indicate that the oxygen was being administered nor how much. She indicated that the order should indicate how much oxygen the resident was to receive and then stated I see what you mean, they should not have it on the TAR as PRN. They should have it listed for each shift and should be signing off that they are administering it. Staff #3 the Corporate Nurse was made aware of these findings on 2/13/23 at 12:47 PM and indicated that he would follow up on it. 2) B. On 1/31/23 at 12:20 PM Resident #90, Resident #70 and Resident #137 were observed wearing hospital gowns. Review of the residents' records revealed inventory of belongings lists for all 3 residents. Resident #90's list was dated 9/19/12. The only entry was 2 shirts. Resident #70's list included 1 radio, 1 furniture (did not specify) and handwritten at the bottom was Pajama top-1 and Pajama pants-1. The inventory list was not signed nor dated. Resident #137's inventory of belongings list was blank and was not signed nor dated. In an interview on 1/31/23 02:11 PM Staff #19 the Unit Manager was asked to explain the protocol for resident inventory of belongings. She indicated that it is completed on admission, dated, and signed by the staff completing and the resident/representative. Review of the facility policy/procedure for clothing inventory list on 1/31/23 03:24 PM revealed: the purpose was to protect the resident's personal property. the policy indicated that an inventory list is to be done on all new admissions. The procedure indicated to check all clothing and possessions with resident and/or responsible party. Record all items on the inventory list and store all items in appropriate place. Request resident/responsible party to sign the completed inventory list. the individual completing the inventory list is to witness the signature by singing complete name and title. Notify Social Service if the resident needs clothing. Upon discharge or transfer, an inventory of all resident's property is to be listed. Account for all property. All valuables from the safe are to be included in the list. A copy of the inventory list is given to the resident/responsible party. In an interview on 2/1/23 at 11:01 AM Staff #46 the Environmental Services Director confirmed that she supervised the laundry services. She was asked if the facility staff know the process for resident clothing inventory. She indicated that she provided education to facility staff in 2021 and 2022. Observation of Resident #90, #70 and #137's rooms were made with Staff #19 the 2A Unit Manager on 2/15/23 at 8:49 AM. Resident #90's closet contained 3 shirts on hangers. A large black suitcase was standing on the floor against the right side of the closet. Staff #19 partially unzipped the suitcase revealing that it was filled with clothing items. During observation of Resident #70's room Staff #19 confirmed that there were several bed/bath linens and other items in the closet and that the closet contained no clothing. Resident #137s closet contained 2 thin fabric, black and white print, items of clothing folded on the floor of the closet. Staff #19 confirmed that no other items of clothing were present. In an interview on 2/15/23 at 9:00 AM Staff #2 The Director of Nursing (DON) and Staff #3 the Corporate Nurse were made aware of these findings. Staff #2 indicated she had gone to the laundry and gotten 2 outfits - 2 tops and 2 pair of pants, for Resident #137 soon after his/her admission. She confirmed that she did not add the clothing to Resident #137's inventory.

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

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2) A dry erase staffing assignment board on Unit 2A was observed on 1/27/23 at 9:47AM. The board included the label Feeders and identified 6 residents by room and bed number. Staff #19 the 2A Unit Manager was interviewed at that time and indicated that Feeders referred to the residents who required staff to feed them. Additional observations of the 2A assignment board on 1/30/23 at 9:15 AM, 1/31/23 9:41 AM, 2/1/23 11:15 AM, 2/2/23 10:15 AM revealed the label feeders written at the bottom left corner with residents identified by room/bed numbers listed across the bottom of the board. These findings were reviewed with the Director of Nursing and the Corporate Nurse on 8/16/23 at 8:52 AM. 3) A. On 1/21/23 at 12:20 PM Resident #70 was observed sitting on the side of his/her bed eating lunch wearing a hospital gown. Review of the residents record at 12:33 PM revealed an inventory list which identified that the resident had 1 Pajama top and 1 Pajama pants. The record revealed that Resident #70 was admitted to the facility in October 2022. On 2/3/23 at 8:57 AM Resident #70 was observed sitting in a wheelchair in his/her room wearing a hospital gown and non-skid socks. When asked, the resident indicated that he/she will put on whatever they give him to wear. He/she was not sure if he/she had clothing in his/her closet. The 2 closets in the room were observed. The 1st closet had 4-5 empty hangers, bed and bath linens, incontinence briefs and hospital gowns piled in the bottom. 1 pair of balled up slipper socks was in the top drawer below the closet. The second closet was empty. 2) B. On 1/31/23 at 12:20 PM Resident #137 was observed propelling himself/herself in a wheelchair in the hallway and into their room wearing a hospital gown and nonskid socks. Observation of Resident #137's closet revealed that it contained no clothing. 1 sweatshirt was lying on the foot of the resident's bed. The resident indicated that they did not have any clothing with them because they had only been in the facility for 1 or 2 days. Review of Resident #137's medical record on 1/31/23 at 12:32 PM revealed the resident had been in the facility approximately 3 months. Resident #137's inventory of belongings list revealed no clothing items for Resident #137. Review of the facility policy/procedure for Clothing Inventory List included Notify Social Service of the resident needs clothing. An interview was conducted on 2/1/23 at 10:45 AM with Staff #45 a laundry worker. She was asked to explain the process for resident clothing. She indicated that clothing is brought to the receptionist desk by the family. The clothing is listed on an inventory sheet by the receptionist then the clothing and inventory sheet are sent to the laundry. She indicated that she was responsible for reconciling the inventory list with the clothing brought in and applying labels to the residents clothing. When asked what happened if a resident didn't have clothing, she explained that the facility had a rack of donated clothing, appropriate items would be picked out to give to the resident, labeled with their name and it became theirs. When asked how she would know if a resident needed clothing, she indicated that when she delivered the resident's laundry to their rooms she would see if someone was wearing a hospital gown or didn't have their own clothing. In an interview on 2/1/23 at 11:01 AM Staff #46 the Environmental Services Director confirmed that she supervised the laundry services. She was asked if the facility staff know the process for resident clothing inventory and labeling. She indicated that she provided education to facility staff in 2021 and 2022. Observation of Resident #137 and #70's rooms were made with Staff #19 the 2A Unit Manager on 2/15/23 at 8:49 AM. Resident #137s closet contained 2 thin fabric, black and white print, items of clothing folded on the floor of the closet. Staff #19 confirmed that no other items of clothing were present. When asked why Resident #137 had no other clothing staff #19 indicated she was not sure but stated sometimes we call family. During observation of Resident #70's room Staff #19 confirmed that there were several bed/bath linens and other items in the closet and that the closet contained no clothing. Staff #19 was made aware of the surveyors' prior observations and that the residents inventory lists revealed that Resident #137 had no clothing and that Resident #70 had 1 pair of pajamas but no other clothing. When asked what was done to obtain clothing for these residents, she indicated that if residents don't have clothing, the family would be called, if there was no family, then donated clothing could be obtained from the laundry. Staff #19 indicated that Resident #137 had no family. She was asked what had been done to obtain clothing for the resident. She indicated that nothing had been done. In an interview on 2/15/23 at 9:00 AM Staff #2 The Director of Nursing (DON) and Staff #3 the Corporate Nurse were made aware of the above findings. Staff #2 indicated that she did not understand why Resident #137 had no clothing, that she had gone to the laundry and gotten 2 outfits - 2 tops and 2 pair of pants, for the resident soon after his/her admission. She confirmed that she did not add the clothing to Resident #137's inventory list nor have the clothing labeled for the resident. Based on surveyor observation and interview with staff it was determined the facility staff failed to treat each resident with respect and dignity by 1) ensuring residents were treated with respect and dignity by labeling residents who required physical assistance with meals as feeders and this was evident for 11 residents listed on 2 of 3 posted staffing assignment boards in the facility, 2) identifying, labeling and posting the residents level of dependency on others on 1 of 3 nursing units in the facility, and 3) failing to have an effective process in place to assist the residents to obtain and wear personal clothing for 2 (#70 and #137) of 78 residents reviewed during an LTCSP recertification survey. The findings include: 1) A lunchtime meal test tray observation was conducted with the Food Service Director staff #20 in the 1st-floor unit on 2/3/23. A review of the unit staffing assignment board revealed the word feeders at the bottom left corner, with room numbers (indicating the residents requiring assistance with eating) listed across the row under each GNA assignment. On 2/3/23, an agency Licensed Practical nurse (LPN) was observed to be assisting with the delivery of meal trays to residents in their room. At 12:28 the LPN (staff #29) was in the hallway next to a food cart when she yelled out I don't know who the feeders are. The surveyor shared with the Food Service Director of the derogatory remark the LPN had shouted. For the next week on 2/6, 2/7, 2/8, and 2/9/23 on the 1st-floor staff assignment board and on the 2A unit remained the label Feeders on the boards to identify the nursing assistant assigned to assist the resident identified by room number and bed. On 2/9/23 at 8:34 AM an interview was conducted with the assistant unit manager (staff #36) of the 2A unit. She collaborated on the label feeders written on the assignment board and proceeded with a discussion related to maintaining residents' dignity in dining and labeling residents as feeders is considered a disrespectful term. On 2/9/23 at 8:40 AM the same conversation was held with the unit manager (Staff #9) on the 1st-floor nursing unit. He collaborated on the labeling of feeders written on the assignment board. A follow-up discussion was held with the unit manager at 9:30 AM. Questions related to agency staff and supervision related to the sufficient and competency survey task. He was informed of him of the surveyor's observation of the agency LPN (staff #29) on 2/3/23 shouting that she did not know who the feeders are.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) Medical record review on 2/14/2023 revealed Resident (R) # 199 was admitted to the facility on [DATE] with diagnoses that included but not limited to End Stage Renal Disease, Unspecified Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Type 2 Diabetes with diabetic neuropathy. On 2/14/2023 at 12:15 PM, review of change in condition form dated 6/5/2021 at 21:21 (9:21 PM) revealed documentation that GNA ( Geriatric Nursing Assistant) on shift reported lowering Resident #199 on the floor while transferring him/her to bed, according to GNA, Resident #199 did not hit his/her head. R # 199's Care Plan was reviewed on 2/14/2023 at 12:45 PM. During the review, surveyor noted a care plan initiated on 12/11/2020, revision on 2/4/2022, and cancelled on 2/4/2022 that revealed a care plan problem entitled Risk for fall r/t CVA as evidenced by Right sided weakness. The goal was that Resident will remain free of falls through review period. The care plan approaches developed included the following interventions: Anticipate toileting needs, and Apply floor mat to (Specify right/left/bilateral sides) of bed. However, it did not specify the side (s) of bed for the floor mat. The care plan was not comprehensive and interventions not resident centered. There were no interventions addressing resident education or cueing, evaluate for fall risk, keep bed in low position, physical therapy/occupational therapy screen, eval and treat as indicated, or other interventions designed to address the resident's risk of - and actual - fall. Additional review of the care plan revealed a care plan problem for Actual fall r/t resident lowered to the floor initiated on 6/7/2021, revised on 2/4/2022 and cancelled on 2/4/2022. The goal was Resident risk of injury will be minimized through the review date. The approaches included ensuring that the resident has appropriate footwear when ambulating or mobilizing in wheelchair, use sit to stand for transfer instead of 1 person assist, Perform frequent rounds each shift, and resident will be screened by rehab to decrease risk of future falls. However, this care plan was not comprehensive and lacking some of the interventions addressed under the risk for fall care plan. The surveyor reviewed Resident #199's care plans with the Director of Nursing (DON) during an interview on 2/15/2023 at 1:45 PM. The DON confirmed that the risk for fall and/or actual fall care plans were lacking some interventions. 4) In an interview on 1/26/23 at 8:40 AM Resident #51's family member indicated that he/she had to provide instruction to new and agency staff regarding Resident #51's care. He/She indicated that there is often a discrepancy regarding bathing times on dialysis mornings and provision of meals on dialysis days. Review of Resident #51's Plan of Care revealed that the facility failed to develop a resident specific plan of care that identified Resident #51's individualized care needs related to dialysis including but not limited to dialysis schedule, provision of care and meals on dialysis days, pre/post dialysis care/assessments, schedule for provision of ADL (Activities of Daily Living) care, meals, location and assessment of dialysis access site, which arm to avoid for procedures, any related laboratory tests, what to do for bleeding at access site. The Bedside [NAME] is a tool used by the Geriatric Nursing Assistants (GNA's) to identify and provide individualized resident care it is generated from the Plan of Care. Resident #51's [NAME] included: Ensure resident is prepared for dialysis sessions PER ORDER. The [NAME] failed to identify the resident's dialysis schedule, it failed to include guidance for the GNA's to provide resident specific care related to dialysis and resident choices such as timing of ADL care and meals on dialysis days, location of the resident's dialysis access site and or any specific care restrictions. On 2/15/23 at 9:17 AM Staff # 2, the Director of Nursing, and #3 the Corporate Nurse were made aware of these concerns. Cross reference F 812. An observation of Resident #51 on 1/26/23 at 9:07 AM revealed that the resident had a urinary catheter. The resident's spouse was present and indicated that it was a suprapubic catheter and that Resident #51 had it for approximately 8 years. A suprapubic catheter is a urinary catheter that is placed into the urinary bladder through a hole in the abdomen it is used to drain urine. Further review of the medical record revealed that the resident had a physicians order written 3/15/22 for the Urologist to change the residents catheter, additional orders were written to irrigate the catheter for patency, change the catheter tubing and bag for malfunction, contamination, odor or sedimentation as needed and to utilize a leg strap to anchor the tubing. A plan of care was developed on 10/5/21 and revised on 3/16/22 for impaired urinary elimination. The residents goals were identified as: Residents continence level will be improved through the review period, and Resident will be free from odors and dignity will be maintained through review period. The goals were not resident centered and did not include measurable objectives. The approaches staff were to implement to assist Resident #51 to reach his/her goal included: change catheter per order and PRN (as needed) for leakage/blockage, it included the size catheter. The plan of care failed to identify that the resident was followed by the Urologist, that only the Urologist should change the catheter, that the resident was prescribed medication for bladder spasms. It failed to reflect irrigation, tubing change, bag change, and leg strap interventions or that the resident was being considered for a potential urethroplasty procedure. 5) Review of Resident #35's medical record on 2/6/23 at 10:12 AM revealed a plan of care for the problem: Nonadherence to plan of care r/t (related to) Constant Wandering on hallways. Refusing daily weight. Refusing staff to assist with ADL's (Activities of Daily Living). Refusing hipsters. Refusing showers. Removes wanderguard. The residents Goal was identified as : Resident will collaborate with healthcare team regarding plan of care through review period. The goal was a staff goal and did not include resident specific measurable objectives. A plan of care was developed for Mood disturbance related to depression. The resident goals did not include measurable objectives. No plan of care was developed to address the residents individualized care needs related to his/her diagnoses of anxiety including the use of antianxiety medication. A Psychiatric Nurse Practitioner progress note dated 7/25/22 included Treatment Plan: Behavior Management Plan: Staff to provide structured ADL care; Staff to approach patient respectfully and be clear about upcoming nursing care. The plan of care did not reflect a behavior management plan. In an interview on 2/8/23 at 9:35 AM Staff #19 the 2nd floor Unit Manager indicated that resident had exit seeking behaviors, that he/she became agitated, screamed profanities, and refused care. There was no plan of care related to agitated or aggressive behavior including measurable objectives and resident centered approaches. These concerns were reviewed with Staff #2 the Director of Nursing and #3 the Corporate Nurse on 2/16/23 at 8:52 AM. Cross reference F 758 4) A complaint was obtained during the survey regarding Resident #52, on 02/06/23 at 1:30 PM, with an allegation that the nursing staff are not providing any type of vision support. The complainant stated that Resident #52 is blind and that the nursing staff do not assist Resident #52 were his/her personal items are located or where the food items are located on his/her meal tray. A review of Resident #52's medical record on 02/06/23 revealed that Resident #52 was admitted to the facility on [DATE] with diagnoses that include diabetes, unspecified cataracts, hemodialysis, and amputations of the right and left below the knee/lower legs. In an interview with Resident #52 on 02/08/23 at 2:40 PM, Resident #52 confirmed that she was blind in the right eye and had poor vision in the left eye and that S/he suffers from diabetes. Resident #52 stated that S/he has suffered with eye issues for 2-3 years and would like to see the facility ophthalmologist. Review of Resident #52's care plans on 02/08/23, failed to reveal nursing care plan for poor vision/blindness with specific interventions to assist Resident #52 with ADL's, meals, and activities. Based on observation, medical record reviews, and staff interviews, it was determined that facility staff failed to develop and initiate comprehensive, resident-centered care plans with measurable objectives and goals for residents residing in the facility. This was evident for 6 (#14, #30, #131, #52, #51, #35) of 78 residents reviewed during the LTCSP recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) Resident #131's care plans were reviewed on 2/10/23. A care plan problem initiated on 2/6/23 related to functional maintenance was reviewed. Two goals were written as resident will be able to make basic needs known with use of GoTalk device, and Resident will demonstrate effective use writing skills with use writing skills with use of white board to copy letters/simple words. The only intervention was written as communication 3 x a week for 53 weeks The one written intervention did not include the specified care and services that was to be implemented. The intervention written would not enable the resident to meet his/her goals. The rehabilitation director (staff #15) was interviewed on 2/10/23 at 3:15 PM. He collaborated the finding and initially did not recognize that the only written intervention was not specific to meeting the resident's goals. He indicated that there was a glitch in the system. Review of the most recent MDS assessment dated [DATE], revealed resident #131 was assessed to require extensive assistance with assist of 1 person to move in bed. Resident #131 was dependent on staff for bed mobility. A care plan problem initiated on 1/31/23 related to bed side rail use was reviewed. The goal for the utilization of bed siderails was written as, resident will remain independent with positioning through next review. The resident was not independent and was prescribed by the attending physician to be turned and repositioned every two hours. The goal for this care area was not specific to resident #131. On 2/13/23 at 11:33 AM resident #131's care plans were reviewed with the unit manager nurse (Staff#37). Review of a care plan problem related to self-care deficits revealed a care intervention written as Toileting 1 person assistance from w/c using wall rail. The unit manager was asked if the resident uses the toilet, and she indicated the resident does not as the resident is always incontinent. The unit manager was asked how the nursing assistant and agency staff know how to care for each resident. She indicated that the [NAME] has the information. She was asked to show the resident's [NAME] in the electronic medical record. Review of the [NAME] displayed the some of the same information as the care plan. The [NAME] shown the resident was to be toileted with the assistance of 1 person from w/c using wall rail. With discussion the unit manager acknowledged that the resident written care plan was not specific for resident #131. There was not any care planning related to the resident's assessed incontinence. There were not any interventions related to wearing of briefs or how often the resident should be check as examples of potential interventions to provide resident centered care to resident #131. 2) Resident #14's care plans were reviewed on 2/6/23. Review of a care plan related to mood disturbance did not reveal a resident-specific goal with measurable objectives in order to evaluate the resident's progress toward his/her goal. The goal for this care area was simply written as Resident will have improved mood state through next review. A care area for a problem/care area related to resident #14 having Impaired cognition was reviewed to not have measurable goals. The goals were written as Resident will maintain current level of functioning and the other goal was written as Resident will participate in leisure activities via one-to-one interventions, live broadcast programs and/or group programs when available to maintain current level of functioning through the review period. On 2/6/23 at 3:00 PM an interview was conducted with the activity's director (staff $#12). She was asked how the facility documents resident participation in activities. She indicated that resident #14 has been spending greater amounts of time in bed. Resident #14's care plans were reviewed with the activities director and she acknowledged that the goals as stated above were not measurable. 3) Resident #30's care plans were reviewed on 2/6/23. Review of a care plan related to mood disturbance did not reveal a resident-specific goal with measurable objectives in order to evaluate the resident's progress toward his/her goal. The goal for this care area was simply written as Resident will have improved mood state through next review. Resident #30's care plans were reviewed with the activity's director on 2/6/23 at #:00 PM and she acknowledged that the goal as stated above was not measurable. Review of the most recent MDS assessment dated [DATE], revealed resident #30 was assessed to require extensive assistance with assist of 2 persons to move in bed. Resident #30 was dependent on 2 staff for bed mobility. A care plan problem initiated on 1/31/23 related to bed side rail use was reviewed. The goal for the utilization of bed siderails was written as, resident will remain independent with positioning through next review. The resident was not independent with bed mobility and was prescribed by the attending physician to be turned and repositioned every two hours. The goal for this care area was not specific to resident #131. On 2/7/23 at 3:30 PM, the concern related to some of the new care planning written in relation to F700 were not resident centered for residents that were dependent on staff for bed mobility. Cross-reverence to F700

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Review of Resident #35's record on 2/2/23 at 10:56 AM revealed plan of care notes dated 11/29/22. 1 note was transcribed by Staff #12 the Activities Director. The remainder of the care plan notes from that date were transcribed by Staff #36 a Licensed Practical Nurse. Review of Resident #111's record on 2/13/23 at 8:37 AM revealed Plan of care notes dated 1/17/23 transcribed by Staff #12. Both Resident #35 and #111's plan of care notes included notations and POC (Plan of Care) continue. However, the notes failed to reflect that staff evaluated and measured the residents' progress or lack of progress toward reaching their goals. None of the notes indicated that either Residents' care plan goals or approaches were revised in an attempt to better assist the resident in reaching his/her goals if they were not met. Staff #2 the Director of Nursing and #3 the Corporate Nurse were made aware of these concerns on 2/6/23 at 8:52 AM. 3) Heparin injection is an anticoagulant. It is used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels. Review of Resident #23's medical record on 01/31/23 revealed that Resident #23 was admitted to the facility on [DATE] with diagnoses that include: traumatic brain injury, stroke, contractures of muscles, spastic hemiplegia and seizures. On 08/01/22, Resident #23's physician instructed the nursing staff to administer the anticoagulant, Heparin, 5000 units, subcutaneously, three times a day for deep vein thrombosis prophylaxis. Further review of Resident #23's medical record failed to reveal a care plan for anticoagulant therapy. Based on medical record reviews and interviews with facility staff, the facility failed to update residents' care plans after each assessment and failed to consistently conduct quarterly care plan meetings. This was found to be evident for 4 (Resident #48, #131, #23, #35) of 78 residents reviewed during an LTCSP recertification survey. Findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements. The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents (regardless of payer) of long-term care facilities certified to participate in Medicare or Medicaid. Each care plan provides a framework for guiding the review of trigger areas and clarifying a resident's functional status and related causes of impairments. It also provides a basis for additional assessment of potential issues, including related risk factors. These thorough assessments provide the interdisciplinary team additional information to help them develop a comprehensive plan of care. By modifying the care plans provided in this resource, you'll fit the individual needs of your residents while satisfying the requirements of the new assessment process. 1) Resident #48's medical record was reviewed on 1/30/23 at 10 AM. Review of most recent MDS assessments reference dates revealed a quarterly assessment was dated 7/21/22, followed by quarterly assessment 10/21/22 and an annual comprehensive assessment was dated 11/16/22. Review of the electronic and paper chart revealed that the last documented care plan meeting was on 8/2/22. Documentation was not found to show a care plan meeting with the resident was not held within 7 days after the 10/21/22 assessment or the 11/16/22 assessment. An interview was conducted with the unit manager nurse (staff #19) on 1/30/23 at 10:30 AM. The unit manager was asked when the last care plan meeting was held for resident #48. She reviewed the electronic and paper chart and collaborated the findings in the medical record. The facility failed to have a care plan meeting for resident #48 after the 10/21/22 and 11/16/22 MDS assessments. 2) On 2/13/23 at 11:33 AM resident #131's care plans were reviewed with the unit manager nurse (Staff#37). Review of a care plan problem related to self-care deficits revealed a care intervention written as Toileting 1 person assistance from w/c using wall rail. The unit manager was asked if the resident uses the toilet, and she indicated the resident does not as the resident is always incontinent. The unit manager was asked how the nursing assistant and agency staff know how to care for each resident. She indicated that the [NAME] has the information. She was asked to show the resident's [NAME] in the electronic medical record. Review of the [NAME] displayed the some of the same information as the care plan. The [NAME] shown the resident was to be toileted with the assistance of 1 person from w/c using wall rail. With discussion the unit manager acknowledged that the resident written care plan was not specific for resident #131. There was not any care planning related to the resident's assessed incontinence. There were not any interventions related to wearing of briefs or how often the resident should be check as examples of potential interventions to provide resident centered care to resident #131. Further review of the resident's medical record revealed that a care plan meeting was held on 12/7/22. Only two care plan evaluations were found, one related to activities and a documented evaluation by the registered dietician related to a focus on nutrition. Evaluations of care planning were not found for the care plan related to resident #131's documented self-care deficits.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) A portion of investigating complaint MD00142756 on [DATE] at 1:03 PM, the surveyor reviewed Resident #403's medical record. The review revealed that the resident was admitted to the facility for recovery from a recent left tibial bypass. Per the progress note written by the facility nurse dated [DATE] said, Resident #403 went for vascular follow-up, suture was removed, dressing to be changed daily to the groin and left knee, continues on ABT (antibiotic), to return on [DATE] Further review of the resident's vascular surgery visit summary note on [DATE] stated the instructions; apply ABD pad over groin incision and incision along the medial aspect of the knee, double tubi-grip to below the knee. Change dressing daily. However, a review of Resident #403's order on [DATE] at 1:20 PM showed that the left knee daily dressing order started on [DATE]. No other documentation was found for dressing changes from [DATE] to [DATE]. During an interview with Resident #403 on [DATE] at 11:15 AM, the surveyor shared concerns about the dressing change issue. 4) A portion of investigating complaints MD00175015 and MD00175059, the surveyor reviewed medical records of Resident #297 on [DATE] at 12:57 PM. The review revealed that Resident #297 was admitted to the facility on [DATE] for his/her continuation of care related to lengthy and complicated hospitalization. Also, the medical records showed that the resident had had episodes of worsening dyspnea and severe hypoxemia (intubated and BiPAP, a type of ventilator that helps with breathing, required) while his/her hospitalization prior to being admitted to this facility. Further review of the medical records revealed that a Registered Nurse (RN #42) wrote a progress note on [DATE] at 2:09 AM as Resident #297 had difficulty breathing, his/her O2 sat dropped to 86%, O2 / 2 L administered and the O2 sat increased to 97%. Provider orders chest X-ray. However, no X-ray result was found in Resident #297's medical records. No additional assessments regarding the resident's symptoms were documented; only one vital sign was recorded when he/she reported shortness of breath. During an interview with the Director of Nursing (DON) on [DATE] at 1:30 PM, the DON confirmed that the facility had a contracted vendor for an urgent x-ray and expected to take a STAT order within 2 hours by them. The surveyor interviewed RN #42 on [DATE] at 3:38 PM. RN #42 said, STAT radiology order taken time was varied. If it were not done by my duty, I would hand it over to the next shift nurse to follow up. RN #42 also added that if a resident had difficulty breathing, she would monitor closely and document the resident's condition. On [DATE] at 09:00 AM, the DON confirmed that Resident #297's chest X-ray was not completed until the resident transferred to the hospital on [DATE] at 10:45 AM due to chest pain. The radiology service person arrived at the facility on [DATE] at 11:00 AM after the resident transferred. 5) A portion of investigating complaint MD00165588, the surveyor viewed the medical records of Resident #405 on [DATE] at 11:37 AM. The review revealed that Resident #405 was admitted to the facility on [DATE] with a past medical history that included, but was not limited to, end-stage renal disease, a status post deceased donor renal transplant, deep venous thrombosis on left upper extremity brachial, recurrent hemorrhagic shock in the setting of lower GI (gastrointestinal) bleeding. Further review of the medical records revealed that Resident #405's blood test was completed on [DATE] at 3:00 PM. The lab result had a critical level of Hemoglobin 6.2 g/dL (normal range: 11.0-14.5), which was called to and read back by the facility's Registered nurse (RN # 56) on [DATE] at 6:35 PM. During an interview with RN #56 on [DATE] at 3:05 PM, RN #56 stated that if he received a call from lab he would call the doctor immediately, document, and assess the resident. However, a review of medical records for Resident #405 on [DATE] at 3:30 PM revealed that Resident #405's vital signs were checked at 8:30 PM on [DATE], 2 hours later than he received the call. The critical lab result (hemoglobin 6.2g/dL) was notified to the provider on [DATE] at 8:45 PM and transferred to the hospital at 9:10 PM on the same day. During an interview with the DON on [DATE] at 11:15 AM the surveyor shared concerns that immeidate care was not provided to the resident who had critical lab result. Based on complaints, reviews of medical records, and interviews, it was determined that the facility failed to 1) ensure staff followed physician orders as evidenced by failing to apply Multi Podus boots and hand splints to a resident, and 2) to ensure ordered consults were addressed, 3) follow a consult physician's dressing change orders, 4) provide care for a resident who had shortness of breath, including failing to ensure the resident's x-ray was taken STAT (immediately) per the Physician's order, and 5) delay care regarding critical lab results. This was evident for 5 (Resident #53, #199, #297, #403, #405) of 78 residents reviewed during an LTCSP recertification survey. This noncompliance resulted in no actual harm to the residents, it has a potential for more than minimal harm if the practice is not corrected. The findings include: 1) On [DATE] at 12:00 PM, Resident # 53 was observed in room and not wearing hand splints and/or Multi podus boots. A follow-up observation was made on [DATE] at 12:26 PM. Resident #53 was observed in bed with legs elevated on a pillow, and not wearing hand splints and/or Multi podus boots. A review of Resident #53's medical record on [DATE] at 2:18 PM revealed the resident was admitted to the facility on [DATE] with diagnosis that included but not limited to Cerebral Infarction, Nontraumatic Intracranial hemorrhage, Functional Quadriplegia, Contracture of muscle (unspecified site), Bed confinement status. Review of the order summary on [DATE] at 8:42 AM Review of physician revealed the following orders: Wear multi podus boots during the daytime only with regular skin checks start date [DATE], and Splint order: Make sure B hands are clean/dry, passively extend fingers from palm, place modified palm protectors in hands after AM care start date 810/2021.Review of Treatment administration Record (TAR) for [DATE] on [DATE] at 10:00 AM revealed staff documentation that resident was wearing bilateral palm protectors in both hands as tolerated, and they were removing them in the evening, and performing passive range of motion (prom) and checking skin integrity. There was also documentation on the TAR for Multi podus boots with check mark on some days and the number 9 on others. On [DATE] at 10:45 AM, review of progress notes revealed staff notes on [DATE] indicating that the resident declined to wear the palmar guards and multi podus boots. However, there were no notes regarding the [NAME] guards and/or multipodus boots prior to that date. On [DATE] at 11:20 AM, in an interview with Registered Nurse (RN # 13), she was asked to show the surveyor the resident's Multi podus boots and hand splints. The hand splints were observed on the resident's bedside table; however, RN #13 searched the resident's room but could not find the multi podus boots, she stated that the multi podus boots may have been sent to laundry and she was going to follow up. She further stated that the resident sometimes refused to wear the hand splints and the boots. On [DATE] at 11:25 AM, in an interview with the resident ' s Geriatric Nursing Assistant (GNA #14), she stated she did not see the multi podus boots in the resident's room when she came on duty. GNA #14 stated that she has taken care of the resident before but has never seen and/or put on the multi podus boots. However, both RN #13 and GNA #14 confirmed the multipodus boots were not in the resident's room. On [DATE] at 11:30 AM, an interview was completed with the first-floor unit manager, RN #9. RN #9 was made aware of the Multi podus boots not being in Resident #53's room. He stated he was going to follow up. A review of the resident's TAR for [DATE] was done with RN #9. He stated that the check mark on top of staff initials on the TAR meant the task was performed and the number 9 on top of staff initials meant Other / See progress notes. Further review of the TAR revealed staff documentation that the resident had on the Multi podus boots on most of the days in January including [DATE] and [DATE]. There was also corresponding documentation that staff were removing the multi podus boots as ordered. However, most of the slots that had 9 documented did not have a corresponding progress note to indicate if the resident declined having the boots put on her/his legs. On [DATE] at 9:41 AM, in an interview with the Rehab Director, staff #15, he stated that Resident #53 was supposed to be wearing bilateral hand splints and multipodus boots during the daytime. 2) Medical record review on [DATE] revealed Resident (Resident #199) was admitted to the facility on [DATE] with diagnoses that included but not limited to End Stage Renal Disease, Unspecified Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Type 2 Diabetes with diabetic neuropathy. Review of order summary report on [DATE] at 11:00 AM revealed orders for a follow up with vascular for a bilateral carotid duplex and bilateral lower extremity duplex on [DATE]. Further review revealed another order: F/U ON [DATE] AT 9:00 AM AT 2411 W. [NAME] AVE, SUITE 304, BALTIMORE MD 21215. 443 640 4827 that was put in on [DATE]. On [DATE] at 2:15 PM, review of resident ' s closed records revealed a Vascular Surgery Associate LLC consultation report for office visit dated [DATE] at 11:00 AM. A review of the report revealed the Resident needed a follow-up appointment in 6 months for bilateral lower extremity duplexes that was scheduled for [DATE]. On [DATE] at 9:25 AM, review of progress notes was completed. However, there was no documentation to indicate that the facility had made arrangements for the resident to keep the follow-up visit with Vascular surgery on [DATE] and/or reasons why the appointment was not kept. On [DATE] at 12: 35 PM, surveyor requested vascular consult notes from [DATE] up to discharge. The Director of Nursing (DON) gave the surveyor copies of the Vascular surgery consultation notes dated [DATE] and stated she could not find any notes of a vascular consult for [DATE] or then after. On [DATE] at 1: 37 PM, an interview was conducted with the Second Floor Unit Manager, Registered Nurse (RN #19). Regarding residents ' appointments, RN #19 stated that the facility had a scheduler who set up transportation with an Escort to take the residents to their appointments. She added that sometimes the residents were transported to their appointments by family. When asked if Resident #199 kept the follow-up vascular appointment on [DATE], RN #19 stated she could not tell off hand but will investigate. On [DATE] at 2:25 PM, in a follow-up interview with RN #19, she stated that the resident did not keep the appointment with vascular surgery on [DATE]. RN #19 added that she called the vascular center, and they told her that [DATE] was the last time the resident was there. RN #19 further stated that she could not find any progress notes from nursing staff to indicate why the resident did not go for the follow up appointment. An interview was conducted with Unit Secretary, Staff #41, who was responsible for scheduling residents' appointments/transportation on [DATE] at 10:15 AM. Staff #41 verified that Resident #199 had no scheduled transportation for [DATE] and did not keep the [DATE] follow-up vascular appointment. On/16/2023 at 11:00 AM, a review of the electronic appointment/transportation calendar with the Unit Secretary, Staff #41, and the DON, revealed the resident was not scheduled transportation for [DATE]. However, the resident was scheduled for transportation on [DATE] to NW hospital for an Ultrasound (US).

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) A review of Resident #129's medical record on 1/24/23 at 11:51 AM revealed that the resident was admitted to the facility on [DATE] with diagnoses that include but were not limited to unspecified dementia without behavior disturbance, Parkinson's disease, depression, anorexia, dysphagia, oropharyngeal phase. A further review of Resident #129 ' s progress note written on 12/25/22 at 7:41 AM showed that he/she had a fall which was discribed as Staff found resident sitting on the floor next to his/her bed. Alert and oriented to self with baseline confusion. Observe no injury noted. Active ROM within resident baseline noted in all extremities. Neuro check initiated per facility protocol. Dr. XX made aware and left a voice message for spouse. Also, the surveyor verified that the care plan was updated after the fall incident to anticipate toileting needs and perform frequent rounds each shift on 12/26/22. However, the record review showed that the facility was failed to implement interventions to reduce hazard and risks. During an interview with the Director of Nursing (DON) on 2/16/23 at 11:15 AM, the surveyor reviewed Resident #129 ' s care plan with the DON. The DON agreed that the care plan was not specific interventions to reduce a resident's risks from environmental hazards. Based on observation, reviews of medical records, and staff interviews, it was determined that the facility staff failed to 1) initiate nursing interventions to prevent further falls, and 2) implement measures to minimize the residents' risk of injury. This was evident for 2 (Residents #65, and #129) of 11 residents reviewed for accidents during an LTCSP recertification survey. The findings include: 1) Resident #65 was observed on 1/25/23 at 10:08 AM lying in his/her bed. His/her bed was in an elevated position approximately 3 feet above the floor, no fall mats were observed in the room. Another observation on 1/27/23 at 12:35 PM revealed the resident was again observed in his/her bed which was elevated approximately 3 feet above the floor. When asked at that time if he/she adjusted the height of the bed, the resident stated I don't do shit with it. Another observation was made on 1/30/23 when the surveyor entered Resident #65d room with Staff #52 the wound nurse and #53 a GNA (Geriatric Nursing Assistant) to observe a dressing change. The bed was observed in an elevated position upon entry to the room. After completion of resident care and the dressing change, the staff failed to lower the bed before leaving the room. Review of Resident #65s medical record on 1/30/23 at 12:47 PM revealed that the resident was identified as having a risk for falling related to a neurological disorder and a plan of care was developed on 7/18/22. The approaches staff were to implement included: Keep bed in low position except when rendering care. Additional observations were made of the resident in his/her bed on 1/30/23 at 2:10 PM and1/31/23 at 9:43 AM, the bed was not in a lowered position. Staff #2 the Director of Nursing and Staff #3 the Corporate Nurse were made aware of these findings on 2/16/23 at 8:52 AM.

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) A portion of investigating complaints MD00175059 and MD00175015, Resident #297's medical records were reviewed on 02/10/23 at 12:57 PM. The review revealed that the resident was admitted to the facility on [DATE] with a past medical history that included, but was not limited to, chronic kidney disease stage 4 with hemodialysis therapy, SVT (supraventricular tachycardia) likely from hypovolemia post hemodialysis on 3/22/22, Liver transplant (2015), and Kidney transplant (2016). Further review of the Dialysis communication record (part of the medical record) revealed that Resident #297 had hemodialysis on 04/01/22. The record contained the resident ' s vital signs checked on 4/01/22 at 09:57 AM by the facility nurses. However, Post Dialysis Data session documented the same vital sign as 04/01/22 at 09:57 AM without filing pre-dialysis weight and post-dialysis weight. Post Dialysis Assessment obtained by a facility nurse had vital signs of 4/01/22 at 10:05 PM. During an interview with a Registered Nurse (RN #42) on 2/13/23 at 9:45 AM, RN #42 confirmed that nurses are required to check vital signs, assess the hemodialysis site, and head to toe assessment before and after hemodialysis therapy. Also, nurses must document nursing notes and dialysis communications under electronic medical records. The surveyor asked RN #42 about the case of Resident #297's post-hemodialysis vital sign, which was recorded 10 hours later than the pre-hemodialysis one. RN #42 said, I check dialysis residents immediately after therapy. This was something wrong. An interview with the Director of Nursing (DON) on 2/16/23 at 11:15 AM, the surveyor shared concerns regarding hemodialysis residents' assessment. Based on reviews of the medical records and interviews with staff, it was determined that the facility staff failed to 1) conduct accurate ongoing assessments and oversight of the resident before and after dialysis treatments, and also failed to develop a resident-centered plan of care for a resident receiving dialysis. This was evident for 2 (Residents #51, and #297) of 5 residents reviewed for Dialysis during an LTCSP recertification survey. The findings include: 1) Dialysis Communication Forms are utilized by the facility and dialysis center to assess and communicate the residents status before, during and after dialysis treatments. The facilities Dialysis Communication form consisted of 3 sections. The first section FN1, provided space for the facility nurse to document any communication to the dialysis nurse, and space to record the residents most recent vital signs and blood glucose with the date and time each were obtained. The second section DN provided space for the dialysis nurse to post dialysis vital signs with the date and time they were obtained, pre and post dialysis weights, most recent weight, and the amount of fluid added and removed. It also had space to record communication from dialysis to the facility nurse including medication that was administered during dialysis. The third section FN2 provided a space for the facility nurse to record post dialysis assessment of the residents' vital signs, and dialysis access site dressing, and to indicate that they reviewed the communication from the dialysis nurse. All 3 sections included space for the nurse completing the section to sign and date. Resident #51 received Hemodialysis every Tuesday, Thursday, and Saturday. Review of the Resident's Dialysis Communication forms on 2/14/23 at 12:00 PM revealed that on 1/3/23, 1/5/23, 1/7/23, 1/13/23, 1/19/23, 1/31/23, 2/2/23, 2/4/23, 2/7/23, and 2/11/23 the facility nurses failed to assess Resident #51's vital signs after dialysis. Section FN2, post dialysis contained the same set of vital signs that were assessed and documented in section FN1, pre dialysis. Additionally, the facility nurse failed to sign Section FN2 on 1/7/23, 1/21/23, and 2/7/23 and sections FN1 and FN2 on 1/13/23. In an interview on 2/14/23 at 11:28 AM Staff #18 a Licensed Practical Nurse was asked to explain the routine when Resident #51 returned from dialysis. He indicated that he would call for the resident's lunch tray, would assess the access site to make sure it was not bleeding, he would assess the residents vital signs and the residents level of consciousness and documents his findings on the Dialysis Communication form in the Electronic Health Record (EHR) and electronically signs it. On 2/15/23 at 9:17 AM Staff # 2, the Director of Nursing, and #3 the Corporate Nurse were made aware of these concerns. Staff #3 confirmed these findings and indicated he would look into it.

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, administrative policy review, and interviews, it was determined that the facility failed to have a system in place to ensure that appropriate alternatives are attempted prior to installation of side rails, assess residents for risk of entrapment from bed rails, obtain informed consent, and ensure bed rails were properly installed prior to the utilization of side rails for any resident. This was evident for 3 (Resident #30, #48, #131) of 3 residents reviewed for accident hazards during the annual survey. The findings included. The intent of this requirement is to ensure that prior to the installation or use of bed rails, the facility attempts to use alternatives. If the attempted alternatives were not adequate to meet the resident's needs, the resident is assessed for the use of bed rails, which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative. The facility must ensure the bed is appropriate for the resident and that bed rails are properly installed and maintained. 1) Resident #30 was observed in bed on 1/24/23 at 11:28 AM with bilateral (1/2) upper side rails in the up position. Resident #30's medical record was reviewed on 1/30/23 at 2:28 PM. The most recent side rail assessment dated [DATE] was reviewed and revealed the recommendation indicating Siderails/assist handles are indicated and serve as an enabler to promote independence. The assessment indicated Left and Right side Grab bars. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of the MDS assessment with an assessment reference date (ARD) of 12/11/22 documented resident #30 required extensive assistance with 1-person physical assistance for bed mobility. There was no documentation in the medical record of an evaluation of the alternatives that were attempted prior to the use of the side rails. There was no signed consent from the resident representative prior to the use of side rails. There was no physician's order for the side rails and no care plan for the side rails. There was no assessment of the risk of entrapment. The 'grab bars identified in the last siderail assessment was not observed as the resident's bed was equipped with two bilateral upper rails extending from the mid-point of the bed to the top end. 2) Resident #48 was observed in bed on 1/24/23 at 8:45 AM with bilateral (1/2) upper side rails in the up position. Resident #48's medical record was reviewed on 1/27/23 at 11:40 AM. The most recent side rail assessment dated [DATE] was reviewed and revealed the recommendation indicating Siderails/assist handles are indicated and serve as an enabler to promote independence. The assessment indicated Left and Right side 1/4 rails. The siderail assessment at question 1A stated to aide in mobility. Review of the MDS assessment with an assessment reference date (ARD) of 12/11/22 documented resident #30 required extensive assistance with 1-person physical assistance for bed mobility. There was no documentation in the medical record of an evaluation of the alternatives that were attempted prior to the use of the side rails. There was no signed consent from the resident representative prior to the use of side rails. There was no physician's order for the side rails and no care plan for the side rails. There was no assessment of the risk of entrapment. The resident was prescribed to be turned and position every 2 hours as he/she was unable to independently move in bed. 3) Resident #131 was initially observed on 1/23/23 at 2:27 PM in bed with bilateral upper bedrails in the up position. Review of resident #131's medical record on 1/26/23 at 12:13 PM revealed the resident was admitted to the facility on [DATE]. Continued review of resident #131's medical record did not reveal documentation of an evaluation of the alternatives that were attempted prior to the use of the side rails, or an assessment for the risk of resident entrapment. There was not a signed consent by the resident or the resident representative prior to the use of side rails. There was no physician's order for the side rails and no care planning for the use side rails. An interview was conducted on 1/30/22 at 10:30 AM with the unit manager (Staff #19) with questions related to the completion of a siderail assessment and if the facility gets informed consents prior to use of the bed rails. She initially indicated that the siderail assessment was in the Nursing admission data base. She did not provide a response to how a resident is assessed for at risk for entrapment. She did not have an example of a signed bedrail consent form. The corporate nurse (staff #3) was interviewed at 11:40 AM on 1/30/23 for a discussion related to the use of bed siderails. He referred to a siderail as a grab bar. Discussion related to whatever the staff names a siderail there should be alternatives attempted and documented prior to installation of siderails, and an assessment related to risk for entrapment. Findings shared as to concerns of how the facility's siderail assessment is conducted, lack of informed consents, and lack of care planning for residents appropriately assessed to utilize siderails. The corporate nurse was asked to provide facility policies related to siderail assessment, how to perform the assessment, and how to assess for a risk for entrapment. On 01/31/23 at 7:50 AM, Staff #3 provided a copy of the facility's use of bedrails policy. The policy provided did not include any Approved by names or signatures nor was there an original date of the policy. The latest revision date was 8/12/10. He did not provide additional information as to how the clinician is to perform an assessment for use of siderails. The policy included residents utilizing bedrail/assist handles will have care plans reflecting the use, and .consents for use shall be obtained from the resident/healthcare decision maker and documented in the clinical record. There was not documentation of how to assess for risk of entrapment. Additionally, the policy did not include language to indicate siderails are properly inspected and maintained.

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

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected multiple residents

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2) On 02/01/23 at 10:46 AM review of Resident #49's medical record revealed that Resident #49 had diagnoses that include but were not limited to schizophrenia, bipolar disorder, dementia, and depression. A review of Resident #49's current order revealed that the resident had been taking Depakote tablets 500 mg BID (two times a day) and at HS (take at bedtime) from October 2022 to 01/21/2023. Further review of Resident #49's Medication Administration Record (MAR) from November 2022 to January 2023 revealed that the resident had been taking Depakote 500 mg three times a day. On 2/01/23 at 10:40 AM, the surveyor reviewed Psychiatric Nurse Practitioner's (Staff #22) notes from November 2022 to January 2023 (11/07/22, 1/23/23, and 1/30/23). The notes stated that Resident #49 had taken Depakote 500 mg BID. Also, a note was written by physician #51 (one of the physicians in the primary care group) on 12/07/22 stating the resident took Depakote 500 mg BID. During a phone interview with Psychiatric Nurse Practitioner (Staff #22) on 02/01/23 at 01:30 PM, Staff #22 stated, on my record, Resident #49 is taking Depakote tablet 500 mg BID due to bipolar disorder. I don't know about the HS (take at bedtime) dose. The surveyor informed Staff #22 that Depakote 500 mg bedtime dose was added in October 2022, and MAR verified as resident #49 had been taking Depakote 500 mg three times a day. Staff #22 said the facility attending physician and herself discussed residents' medication for adding, reducing, or changing, but it was not required. During an interview with the Director of Nursing (DON) on 2/16/23 at 11:15 AM, the surveyor shared concerns about Staff #22's inaccurate note. Based on record review and interview it was determined that the Physician failed to 1) review the resident's total plan of care as evidenced by the physician continuing to write orders related to a condition no longer existed, and 2) reconcile the correct dose, or the amount of the medication the resident received per day, of Depakote. This was evident for 2 (Resident's #35, #49) of 5 residents reviewed for Unnecessary Medications during an LTCSP recertification survey. The findings include: 1) Resident #35's medical record was reviewed on 2/2/23 at 11:52 AM. The review revealed a physician order written 11/26/22 for Enhanced Barrier Precautions (EBP) every shift. In an interview on 2/2/23 at 1:28 PM the Director of Nursing (DON) who was also the acting Infection Preventionist, was asked why the resident was on EBP. She indicated that the resident had a wound on their leg and thought that the wound was resolved in December. Resident #35's most recent Skin and Wound record dated 12/5/22 revealed that a left calf wound was resolved on 12/5/22. Further review of Resident #35's physician orders revealed that after Resident #35's wound was documented as healed, the physician continued to review and electronically sign the orders for Enhanced Barrier Precautions on 12/12/22, 1/6/23 and 1/30/23.

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) On 01/30/23 at 12:27 PM, a review of Resident #129's medical records was conducted. The Pharmacist's Medication Regimen Review of the resident dated 9/08/22, recommended updating the supporting diagnosis for Nuplazid to hallucinations associated with Parkinson's disease psychosis. Further review of the order history revealed Resident #129 had order of Nuplazid 34mg capsule to administer one capsule by mouth once a day for Hallucinations from 8/25/22 to 9/21/22; Nuplazid 34mg capsule for administering one capsule by mouth once a day in the morning for Parkinsons' disease/psychosis from 9/30/22 to 11/23/22. During an interview with the Director of Nursing (DON) on 01/31/23 at 12:48 PM, the DON stated the Pharmacist's medication Regimen Review would be reviewed by the physician and filed under the resident's medical records. However, there was no documentation of the physician's response to the pharmacist's recommendation. 6) A review of Resident #33's medical records on 01/31/23 at 11:06 AM revealed that Pharmacist Medication Regimen Review was conducted monthly by consultant pharmacist. On 09/08/22 and 10/12/22 consultant pharmacist recommended as below: - On 09/08/22: adding a hemoglobin parameter to Procrit (a prescription medicine used to treat anemia) to determine when to hold a dose -On 10/12/22: a) to reduce the resident's pill burden, please consider changing the order to Sertraline 100mg take one tablet daily instead of 50mg take 2 tablets once a day. b) adding a hemoglobin parameter to Procrit to determine when to hold a dose However, there was no documentation of physician/prescriber response to the recommendations to agree, disagree, or other comments. On 02/16/23 at 11:15 AM, the surveyor shared the above concerns with the DON. 4) Review of Resident #35s medical record on 2/3/23 at 8:28 AM revealed a monthly pharmacy review was conducted by the clinical pharmacist on 8/8/22 which indicated: See report for any noted irregularities and/or recommendations. The Residents paper record was reviewed on 2/3/23 9:00 AM. The pharmacist report from 8/8/22 was not found in Resident #35s Paper or Electronic Medical Record (EMR). On 2/3/23 at 9:33 AM Staff #2 the Director of Nursing (DON) was made aware that the surveyor was unable to find the pharmacy recommendation from 8/8/22. At 10:10 AM on 2/3/23 The DON provided a copy of the pharmacist recommendation from 8/8/22. It requested that the physician review the residents PRN (as needed) Aspercream, ProAir Inhaler and Senna-S prescriptions for possible discontinuation due to non-use. The copy did not include the physicians response to indicate that it was reviewed and addressed nor was it signed by the physician. On 2/3/23 at 11:33 AM the DON with Staff #3, the Corporate Nurse present, was asked where she found the pharmacist review from 8/8/22. She indicated that she printed it out from the pharmacy. When asked for a copy with the physicians response, date and signature she confirmed that there was none. Further review of the Resident's record revealed the resident's current physicians' orders included but were not limited to Aspercreme Lidocaine Cream 4% every 8 hours as needed for pain, Albuterol Sulfate inhaler every 6 hours as needed for wheezing and Senna S oral tablet 2 tablets twice a day for bowel regimen. 3) Review of Resident #93's medical record on 01/26/23 revealed that Resident #93 was admitted to the facility on [DATE] with diagnoses that include but that are not limited to: cerebral vascular attack (stroke), Atrial fibrillation, anemia, difficulty walking and polyneuropathy. On 08/20/22, Resident #93's physician placed Resident #93 on the anticoagulant Lovenox, 40 mg, subcutaneously, daily, for the prevention of blood clotting. Enoxaparin sodium, sold under the brand name Lovenox among others, is an anticoagulant medication. It is used to treat and prevent deep vein thrombosis and pulmonary embolism including during pregnancy and following certain types of surgery. Further review of Resident #93's medical record failed to reveal and Consultant Pharmacy reviews from October 2022 thru January 23, 2023. In an interview with the facility Director of Nurses (DON) on 01/31/23 at 1:45 PM, confirmed the missing 4 months of Consultant Pharmacy reviews from Resident #93's medical record. The DON stated that S/he did speak to the facility Consultant Pharmacist who stated there were no medication irregularities for Resident #93 during the 4 months (October 2022 through January 2023). The DON stated S/he was waiting for consultant pharmacist to fax/send the monthly reports for Resident #93. On 01/31/23, the DON presented the 4 monthly Consultant Pharmacist reviews to the nurse surveyor. On 12/07/22 the consultant pharmacist recommended that Resident #93's physician review the continued need for the rescue inhaler, Albuterol. Resident #93's physician was able to address the consultant pharmacist 12/07/22 recommendation on 01/31/23. Based on reviews of medical records and staff interviews, it was determined that the facility staff failed to 1) have a process to ensure the clinical pharmacist's monthly medication reviews were reviewed by the physician with a documented response in the resident's medical record, 2) to ensure that monthly medication regimen review was completed by the facility pharmacist, and 3) ensure the physician reviewed and addressed irregularities identified by the clinical pharmacist. This was evident for 6 (Residents #48, #30, #93, #35, #129, and #33) of 6 residents reviewed for unnecessary medications during an LTCSP recertification survey. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough monthly evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. 1) Resident #48's medical record was reviewed on 1/30/23 at 1:17 PM. The pharmacist's monthly medication regimen reviews (MRR) were documented under the evaluations tab in the electronic health record (EHR) and reviewed for monthly compliance. The MRR dated 4/6/22 indicated that there was an irregularity. Recommendation made see report. A review of both the electronic and paper versions of resident #48's medical records did not reveal a report. The director of nursing was informed of the missing pharmacist report dated 4/6/22 on 1/31/23 at 8:57 AM. She returned at 9:44 AM and stated she could not find the recommendation. There was not any evidence that the attending physician took action as the see report was not found. 2) Resident #30's medical record was reviewed on 1/31/23 at 9:07 AM. The MRRs dated 4/6/23, 10/4/22, and 1/5/23 indicated there were irregularities Recommendations made see report. Review of both the electronic and paper versions of resident #30's medical records did not reveal a report from the pharmacist. The director of nursing was interviewed at 10:20 AM on 1/31/23 to inform her of the months the pharmacist identified an irregularity and a separate pharmacist report was not found. She returned at 11:00 AM with a pharmacist report related to the 10/4/22 recommendation. The report was signed by a nurse practitioner and validated the concern was addressed. She stated that the nurse practitioner was reviewing the 1/5/23 recommendation. The director of nursing did not have the pharmacist report from April 2022. Therefore, the facility failed to follow up on the recommendation made on 4/6/22.

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2, 3, 4) On 1/27/2023 at 12:10 PM, Observation was made of the medication room located behind the nursing station on Unit 1 A. The following multi-dose vial floor stock medications were found in the refrigerator greater than 28 days after they had been opened: Multi-dose vial Influenza vaccine opened on 10/11/2022. Multi-dose vial Influenza vaccine opened on 10/6/2022. Multi dose vial Influenza vaccine opened on 11/2/2022. Also found in the refrigerator were the following: One opened but not dated multi- dose vial of Lorazepam injection with expiration date 8/2023, and Two (2) vials of Lorazepam Oral Conc 2 mg/ml vials that expired on 12/2022 On 01/27/2023 at 12:15 PM an interview was conducted with the 1st floor unit manager, Registered Nurse (RN) #9 who confirmed the above findings. On 1/27/23 12:45 PM, observation was made of the medication room located behind the nursing station on Unit 2 A with the covering unit manager, RN #9. One vial of opened/accessed but not dated Epogen Injection 10, 000 units/ml was observed in the refrigerator. RN # 9 confirmed the finding. On 1/27/23 1:45 PM, the medication storage rooms observations were reviewed with the Director of Nursing (DON). The DON stated she was going to follow up. Based on observation, staff interview, and documentation review it was determined that facility staff failed to 1) keep medication carts locked when unattended, 2) discard multi-dose vials which have been opened or accessed (e.g., needle-punctured) within 28 days, 3) label medications upon opening, and 4) dispose of expired medications. This was evident in 2 of 3 nursing units observed during the annual recertification survey. The findings include: 1) 01/31/23, at 12 noon, during an observation of the lunch meal on the 100 hall, an observation was made of an unlocked medication outside room [ROOM NUMBER]. The surveyor waited approximately 5 minutes for the nurse to return and lock the medication cart. 02/13/23, at 10:05 AM, during an observation of the second floor nursing unit, an observation was made of an unlocked medication outside room [ROOM NUMBER]. The surveyor notified the charge nurse who locked the medication cart. 02/13/23, at 2:01 PM, during an observation of the second floor nursing unit, an observation was made of an unlocked medication outside room [ROOM NUMBER]. The surveyor notified the charge nurse who locked the medication cart. A review of the facility Medication Storage policy on 02/13/23 at 3 PM, revealed the following: Medications and biological's are stored safely, securely and properly following the manufacturer's recommendations or those of the supplier. A review of the procedure included: 2. Only licensed nurses, the consultant pharmacist, and those authorized to administer medications (e.g., medication aides) are allowed to access medications, medication rooms, and medication supplies are locked or attended by persons with authorized access.

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Parties (RPs) were provided education regarding the benefits, risks, and potential side effects of Influenza and Pneumococcal vaccines before requesting consent, and document residents' vaccination consent form including agree to receive the vaccine or refuse it. This was evident for 4 (Resident #51, #128, #133, and #142) of 5 residents reviewed who were eligible for Influenza and Pneumococcal vaccines during the annual survey. The findings include: Pneumococcal vaccine helps prevent pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people 65 years and older, pregnant people, and people with certain health conditions or a weakened immune system are at the greatest risk of flu complications. Influenza (Flu) vaccines can prevent influenza. (Centers for Disease Control and Prevention- vaccines and preventable disease) PCC (Point Click Care) is a cloud-based healthcare software provider helping long-term care. The PCC has an immunization tab which showed vaccination status (immunization name, date given, and consent status). The surveyor reviewed randomly selected 5 residents ' immunization records on 01/25/23 at 01:45 PM. Resident #142 was admitted to the facility on [DATE], and the electronic medical record (PCC) immunization tab showed that the resident refused the Flu and pneumococcal vaccines. Also, the resident ' s paper chart contained a signed refusal form for Flu and Pneumococcal vaccine. However, there was no documentation that Resident #142 received education regarding the benefits, risks, and potential side effects of Influenza and Pneumococcal vaccines before requesting consent. The medical record of Resident #133, who was admitted in October 2022, was reviewed on 1/25/23 at 2:30 PM. The PCC immunization tab for the resident showed that the resident refused the Flu vaccine. Also, the paper chart had a signed refusal form for Resident #133. However, no documentation for Resident #51 received education related to the Flu vaccine. A review of the medical record of Resident #51 revealed that the resident was admitted to the facility in August 2021. The PCC immunization tab showed that the resident refused the Flu vaccine in 2021 and 2022. Further review of Resident #51 ' s paper chart showed the resident had a signed declined form for Flu in September 2021. However, no documentation for Resident #51 received education related to the Flu vaccine. A review of the medical record of Resident #128 revealed that the resident was admitted to the facility in August 2022. The PCC immunization tab showed that the resident refused Flu vaccine. However, there was no consent or education documentation regarding the Flu vaccine in his/her medical records (including PCC and paper chart). During an interview with the Director of Nursing (DON) on 01/26/23 at 11:28 AM, the DON stated that the facility staff provided the CDC's (Center for Disease Control and Prevention) fact sheet as vaccination education but did not write any specific data (including who received education by whom and when) on it. The surveyor shared the above concerns during an interview with the Director of Nursing (DON) on 2/16/23 at 11:15 AM.

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected multiple residents

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Based on medical record review and staff interview, it was determined the facility failed to document providing education regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents. This was evident for 2 (Resident #51 and #128) of 5 residents reviewed for COVID-19 vaccination during the annual survey. The findings include: On 01/25/23 at 01:45 PM, randomly selected five residents COVID-19 vaccination medical records were reviewed. Resident #51 has resided in the facility since August 2021 and received the first dose of COVID-19 vaccines on 03/08/22. The second dose of COVID-19 vaccine was documented as consent refused under the electronic medical record immunization tab. However, no COVID-19 vaccine refusal form was filed under his/her medical records. Also, no documentation was found to support the facility educating the resident regarding the vaccine. A review of Resident #128's medical records on 01/25/23 at 2:00 PM revealed that the resident has resided in the facility since August 2022 and had been refused COVID-19 vaccine. However, the resident's medical records documented no signed refusal form or education record. During an interview with the Director of Nursing (DON) on 01/26/23 at 11:28 AM, the surveyor shared concerns related to COVID-19 refusal form and education was not documented. The DON submitted no further supporting documentation.

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

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

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Based on documentation review and interview, it was determined that the facility failed to ensure nurse aide competency training (including dementia management and resident abuse prevention training) occurred no less than 12 hours per year. This was evident for 3 (GNAs #48, #49, and #50) of 3 employee training records reviewed and had the potential to affect all residents. The findings include: A review was conducted of GNA personnel files on 2/14/23 at 11:25 AM. A review of GNA #48's personnel file revealed GNA #48 was hired on 1/9/19. A review of GNA #49's personnel file revealed GNA #49 was hired on 8/16/19. A review of GNA #50's personnel file revealed GNA #50 was hired on 9/17/19. An interview was conducted with the Human Resources director (staff #38) on 2/14/23 at 11:35 AM. She was asked about education transcripts and the process of monitoring. She indicated that the facility does not control the electronic system that is utilized for employee education. She indicated that employees are sent emails to notify each employee of due education requirements and the expected date that communication is to be completed. She was asked if she could run education transcript reports based on an employee's hire date/month to the following year. She indicated that she could run the reports to reflect all the online education an employee has completed since their hire date. She ran a Relias Transcript report for the three employees that were under review. The printed transcripts were reviewed with the Human Resources director and revealed that all three employees did not meet the minimum training requirements for the past year. All three files did not show any completed training for 2022 and a few completed educational trainings completed in 2021. There was no documentation showing abuse and dementia management was educated in the past 2 years. A review of the employee files revealed. GNA #48 last documented competency skills clinic was dated 1/22/19. GNA #49 last documented competency initial skills competency was dated 10/9/19. GNA #50 last documented competency skills clinic was dated 10/1/19. The facility failed to demonstrate sufficient training to ensure continuing competencies of the nurse aides.

CONCERN (F) 📢 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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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2) On 1/25/23 lunch trays were observed being delivered to the residents on Unit 2A at approximately 11:50 AM. On 1/25/23 at 12:49 PM the surveyor observed 2 meal trays on an overbed table beside bed B, Resident #111's bed. Resident #111 was not in the room. Resident #111's roommate and spouse, Resident #51 was lying in bed A. The meal tickets on the trays indicated that the trays belonged to Resident #111 and Resident #51. Both trays contained Beef Stroganoff, buttered noodles, cauliflower, chocolate pudding and Resident #111's tray also contained a bowl of soup. The food on the trays and utensils appeared untouched. Staff #36 a Licensed Practical Nurse was interviewed at that time and was asked why the trays were left on Resident #111's overbed table. She explained that Resident #111 was in dialysis and would return about 3:45 PM. When asked how Resident #111 was to get his/her lunch meal, she indicated that Resident #111 asked that it be kept at his/her bedside but that sometimes it was kept in the kitchen. She then went on to say that Resident #51's tray was also held at the bedside per Resident #111's request. She added that Resident #111 likes to eat their meals with Resident #51, that Resident #51 needs help with eating and Resident #111 did not want staff to feed Resident #51. She indicated that dialysis won't let the residents eat due to risk of upset stomach. When asked if she was familiar with the safe holding temperature for food, she stated: no. Staff #56 an Agency GNA (Geriatric Nursing Assistant) indicated she was caring for Residents #111 and #51 and that this was her first time working in this building. She indicated that Resident #111 and #51's breakfast trays came up at 8 AM and that Resident #111 asked to hold it till 11 AM and that they both ate that time. She added that Resident #111 asked that both lunch trays be held until he/she returned from dialysis. In an interview on 1/26/23 at 8:57 AM Resident #111 explained that there was an issue with meals on dialysis days, that he/she starts dialysis between 10AM & 12 PM on Monday, Wednesday and Friday, and Resident #51 received dialysis on Tuesday, Thursday and Saturday starting between 5-6 AM. He/She explained that he/she likes to eat his/her meals with Resident #51 and assist him/her with eating, so they eat their meals late in order to eat together. When asked why the trays were left in their room, she explained that there used to be a process in which a separate cart was sent from the kitchen with trays for the resident's receiving dialysis. He/she indicated that sometime last year the process stopped and that there is some kind of disconnect now. He/She explained that meals are often missing, and he/she has had to go to the other units looking for their trays. He/She explained that he/she requested that the trays be left in their room to ensure that he/she and Resident #51 would get their meals. Resident #111 indicated that while in dialysis on 1/25/23 2 ladies came and told him/her that they would be sending bagged meals, that there was an issue and that trays will no longer be sitting in their room as before. An interview was conducted on 2/3/23 at 10:10 AM with Staff #20 the Certified Dietary Manager and Staff #5 the Corporate Dietician. Staff #20 confirmed that she started with the facility on 1/10/23, was in orientation and had started in the facility on approximately 1/23/23. She was asked to explain the process for obtaining meals for the residents who go to dialysis. She indicated that some residents want breakfast prior to going to dialysis, a GNA will come down and pick up their tray. If they want it afterward, staff will call and pick it up when the resident returns. She went on to explain that a list of dialysis residents is sent to the kitchen the night before, that the tickets are pulled from the tray line for that meal. A GNA or transporter will pick up the resident's tray. She confirmed that this process had started about a week and a half ago. Staff #20 and #5 both confirmed that they did not find it acceptable for a lunch tray to be left at the bedside for several hours. They were made aware of the above concerns and that Resident #111 indicated that there was no other option if they and Resident #51 wanted to eat their lunch. Based on observations, interviews, and reviews of facility documents and medical records, it was determined that the facility staff failed to 1) ensure that the dishwasher hot water temperatures are frequently checked to ensure cleanliness and sanitation of dishware, and 2) store food in accordance with professional standards for food service safety, and 3) ensure meals were provided in a manner that maintained safe quality control temperatures to meet the individual needs of dialysis residents. This was evident for 2 (Residents #51 and #111) of 17 residents reviewed during an LTCSP recertification survey for food quality and kitchen practices. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen. The findings include: 1) An initial environmental kitchen food services inspection was conducted on 1/23/23 at 8:15 AM. Dishwasher temperature logs were not found/observed in the dishwashing machine area or any other area in the kitchen. A male dietary worker (staff #28) was asked about the dishwashing temperature log, and he responded, there is no log. On 1/24/23 at 9:30 AM a second tour of the kitchen was conducted. A dishwasher temperature log was not observed. There was an empty clear plastic envelope stuck on the dishwashing machine. The certified dietary manager (CDM) (staff #20) was asked to provide the January 2023 dishwashing machine water temperature log. She could not find it in her office. The surveyors left her office to observe the dishwashing machine in operation with two dietary workers emptying breakfast carts and stacking dishes and loading dishwashing trays for the dishwasher. The CDM came out of her office with a dishwashing temperature log with documented dishwashing temperatures for 1/23/23 she said that the dishwashing log got wet. She was asked to provide the December 2022 dishwashing log she checked in multiple binders and then proceeded to look at stacks of papers grouped by the preceding months. The stacks of paper had shown to have other temperature logs including the multiple refrigerators and freezer temperatures. Each group stack of temperature logs did not have a dishwashing water temperature log. No dishwashing log for December 2022, November 2022, or October 2022, and the September dishwashing log only had documented water temperatures for the last three dinner times for the month. The log for August 2022 was shown to be filled out appropriately. Observation of the dishwashing machine on 1/24/23 shown to be operating at a wash temperature greater than the minimum of 160 degrees Fahrenheit (F) and the rinse temperature was above the minimum temperature of 180 degrees F. The CDM was asked to provide a copy of the last county health department kitchen inspection. A review of the county health department kitchen inspection dated 10/18/22 revealed that the dishwasher was not in working order at the time of the inspection. On 2/7/23 at 9:32 AM, an inspection of the walk-in refrigerator/freezer revealed items stored on the floor of the refrigerator part of the walk-in. A netted 10-pound bag of onions and two juice boxes one on top of the other were on the floor. The CDM was not in the kitchen at the time of discovery. She returned a few minutes later and was informed of the stored food items found on the floor of the refrigerator.

CONCERN (F) 📢 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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, reviews of medical records, and staff interviews, it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by;1) failing to screen tuberculosis (TB) for new admit residents, this was evident for 2 (Resident #125 and #142) of 5 residents TB screening reviewed; 2) failing to order contact precautions for a resident who diagnosis E. coli infection, this was evident for 1 (Resident #343) of 6 residents review for infection disease; 3) failing to follow infection control practices in residents' rooms, this was evident for 2 (Resident #2 and #205) of residents reviewed; 4) failing to implement Enhanced Barrier Precautions (EBP), and 5) failed to implement measures to prevent contamination of resident care products for 1 (#65) of 8 residents reviewed for Pressure Ulcer/Injury. These practices had the potential to affect all residents. The findings include: Tuberculosis (TB) is a disease caused by germs that are spread from person to person through the air. Each resident must have a health assessment upon admission, including significant past or present infectious diseases and signs and symptoms of tuberculosis (TB). Skin tests should be administered to all new residents and employees as soon as their residency or employment begins unless they have documentation of a previous positive reaction. A two-step procedure (administering 2nd skin test within 1-3 weeks) is advisable for the initial testing of residents and employees. Each skin test should be administered and read by appropriately trained personnel and recorded (in mm induration) in the person's medical record. A record of all reactions of greater than or equal to 10 mm should be placed in a prominent location in order to facilitate the consideration of tuberculosis if the person develops signs or symptoms of tuberculosis, such as a cough of greater than 3 weeks' duration, unexplained weight loss, or unexplained fever. All persons with a reaction of greater than or equal to 10 mm should receive a chest radiograph to identify current or past disease. [Center for Disease Control and Prevention] Escherichia coli (abbreviated as E. coli) are bacteria found in the environment, foods, and intestines of people and animals. E. coli are a large and diverse group of bacteria. Although most strains of E. coli are harmless, others can make you sick. Some kinds of E. coli can cause diarrhea, while others cause urinary tract infections, respiratory illness and pneumonia, and other illnesses. Contact precautions have been recommended for hospitalized patients colonized or infected with extended-spectrum ?-lactamase-producing Escherichia coli. [Center for Disease Control and Prevention] Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high-contact resident care activities. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO (Multidrug-resistant organism). [Center for Disease Control and Prevention] 1a) On 01/25/23 at 01:45 PM, randomly selected 5 residents' medical records were reviewed for Immunization. Resident #125 was admitted to the facility on [DATE]. The resident's TB screening was done on 11/23/22. The test result was negative under the PCC (electronic medical record) immunization tab. However, no record was found for the second test. On 01/25/23 at 2:00 PM, Resident #142's medical record review revealed that the resident was admitted to the facility on [DATE]. However, there was no documentation of the TB screening under the resident's medical records (including electronic records and paper charts). During an interview with the Director of Nursing (DON) on 01/26/23 at 11:28 AM, the DON confirmed that the facility had screening new admission residents for TB with a 2-step skin test which would be documented under the PCC immunization tab. On 02/16/23 at 11:29 AM, the surveyor reviewed the facility's infection Control Manual of Tuberculosis Control Plan. The plan stated all residents shall receive a tuberculin skin test within 10 days following an initial admission unless the resident has had a documented negative skin test within the previous month, a previous positive test, history of preventive therapy or treatment of tuberculosis. No documentation of previous TB skin testing resident needed 2- step TB skin test. Above TB screening concerns were discussed with the DON on 2/16/23 at 11:15 AM. 2) A portion of investigating complaint MD00177483 on 2/13/23 at 11:54 AM revealed that Resident #343 was diagnosed with E. coli infection on 5/21/22 by blood culture. Further review of medical records revealed that Resident #343 had a contact precaution order from 5/24/22 to 5/28/22 without any indication listing. During an interview with the corporate Registered Nurse (Staff #3) on 2/13/23 at 3:47 PM, Staff #3 stated that Resident #343 already had had contact and droplet precaution for PUI (people under investigation) COVID-19 PCR pending results from 5/19/22 to 5/22/22. However, Staff #3 verified that no precautions were provided to the resident on 5/23/22 when he/she had already been diagnosed with E. coli infection. 3a) On 02/13/23 at 9:24 AM, the surveyor observed on the second floor of the nursing unit, 2A. room [ROOM NUMBER] door with three precautions signs (Enhanced Barrier Precaution, Contact precaution, and Droplet precautions) posted was opened. No active care or therapy was ongoing in the room. At 9:33 AM on 2/13/23, the surveyor observed that an agency Registered Nurse (RN # 43) administrated medication to Resident #19 without PPE (personal protective equipment). Right after the observation, RN #43 was interviewed. RN #43 said, I did not receive any report related to precaution, I will double-check on the order. She found only Enhanced barrier precautions without any detailed reasons. She also confirmed that she didn't have PPE when she entered the room. Further review of Resident #19's medical record revealed that the resident was under enhanced barrier precaution due to G-tube. 3c) During Resident #65's dressing change procedure on 1/30/23 at 9:23 AM Staff #52 the Wound Nurse was observed spraying Skintegrity Wound Cleanser directly onto the resident's open sacral wound then wiping the wound with a 4 x 4 gauze pad and repeated this action a second time. The bottle was date labeled 1/30/23 in black marker but not labeled for Resident #65, nor did the resident have an order for its use. Staff #52 failed to protect the bottle of wound cleanser from becoming contaminated with potentially hazardous organisms by spraying it directly onto Resident #65's open wound exposing it to potential splash back. Staff #2 the Director of Nursing/Infection Preventionist and Staff #3 the Corporate Nurse were made aware of these findings on 2/16/23 at 8:52 AM. Cross reference F 686. 4) On 1/30/23 at 9:23 AM the surveyor observed Staff #52 the Wound Nurse, perform a dressing change to Resident #65's sacral wound. Resident #65 also had an indwelling urinary catheter. Prior to the dressing change, Staff #53 a GNA (Geriatric Nursing Assistant) washed and dried the resident's groin area, buttocks, and posterior thigh areas while Staff #52 held the resident in place to facilitate the process. Staff #53 then took Staff #52's place and assisted Resident #65 to remain on his/her left side as Staff #52 performed the dressing change. Afterward a clean brief was applied to Resident #65. Both staff were wearing gloves and surgical masks, Staff #52 was wearing a face shield. However, neither staff member wore a protective gown. Review of Resident #65's medical record on 1/30/23 at 11:12 AM revealed a physician order written 1/6/23 for Enhanced Barrier Precautions - wound/foley (urinary catheter) every shift. Resident #65's TAR (Treatment Administration Record) included the physicians order for Enhanced Barrier Precautions and was signed off for Day shift 1/30/23. Observation of Resident #65s room on 1/30/23 at 2:10 PM revealed a sign posted on the outside of the door which indicated Enhanced Barrier Precautions. 3 Carts labeled Isolation gowns, with drawers labeled for PPE (Personal Protective Equipment) were located in the hallway between rooms 209/211, 219/221, and 229/231. In an interview on 1/30/23 at 2:30 PM Staff #53 was asked what she does when a resident is on EBP she indicated wear a gown, gloves, N95 mask and a face shield. She confirmed that she did not wear a gown when providing care and assisting Staff #52 with Resident #65s dressing change earlier that the morning. When asked what Enhanced Barrier Precautions were for, she stated for infections then, precautions for if they have a cold or flu symptoms. The DON was asked for the Education In-Service Attendance Sheets for staff education for EBP. 2 sign in sheets dated 10/19/22 were provided. 1 sheet listed 11 Environmental Services (Housekeeping) staff, the other sheet listed 12 staff, 11 were identified as Nursing Department staff and 1 had no department identified. Both sheets revealed that the listed staff received EBP Education from Staff #54 The Regional Educator. Staff #52 and #53 were not listed on either attendance sheet. An interview was conducted with Staff #2 the Director of Nursing (DON)/Infection Preventionist (IP) on 2/2/23 at 1:31 PM. She indicated that she was the IP for the facility. However, Staff #54, the Regional Nurse Educator, was the facility's previous IP and provided the staff education regarding infection control. When asked about Enhanced Barrier Precautions she stated it's basically for PEGs (feeding tubes), wounds, HIV, MRSA (Methicillin Resistant Staph Aureus), or previous MRSA; put signs on doors to let them know to wear masks, gloves, and gowns. Any resident with wounds should have Enhanced Barrier Precautions. Unit Managers put signs up. When asked if audits were done for EBP, she indicated that Unit Managers did an audit at the beginning of the month to make sure the signs were still up. When asked if audits were done to ensure staff were following proper precautions, she indicated that she and the Unit Managers just watch on the floor, but don't document their findings. When asked who provided education to the staff regarding EBP she indicated the Regional Educator. She indicated that any staff who enter the resident's rooms should be educated. She was made aware that the education sign in sheets reflected that only 23 staff received EBP education, 11 of which were Environmental Services staff. She indicated that she had more sign in sheets somewhere on her desk but could not find them. Staff #2 was asked what education was provided to the EVS staff. She indicated that they were told what enhanced barriers were and about the signs then stated, I wasn't there so I can't say for sure. She indicated that approximately 20% of the staff in the facility were agency staff. She indicated that they were educated along with the facility staff and identified that 2 of the staff on the education sheets were possibly agency staff. She indicated that anyone providing care, touching the resident should put on a gown and gloves. She was asked how staff would know which resident was on EBP if there was a sign on the bedroom door. She indicated by the position of the EBP sign - a sign placed in the center would indicate that both residents were on EBP, a sign close to the hinged side of the door would indicate bed B, a sign close to the open side of the door would indicate bed A. She was made aware that Staff #52 and #53 were observed providing care to Resident #65 without Enhanced Barrier Precautions. An interview was conducted on 2/8/23 at 9:49 with Staff #54 the Regional Educator, Staff #55 the Regional RN was present. Staff #54 was asked to describe her role. She indicated that she came on board in May, that she was spread among 15 buildings, her responsibilities included new employee orientation, employee orientation, new hires, and skills fairs. She indicated that she tries to be in this facility as often as she can. She indicated that she did not attend the facility's QAPI (Quality Assurance, Performance Improvement) meetings. Staff #54 indicated the DON had the main role of education in the facility. When asked if she did facility training for Enhanced Barrier Precautions, Staff #54 indicated that she did some, and that she educated the department heads and risk managers in the morning meeting which included Unit Managers, supervisors and EVS staff. She indicated that the Unit Managers and the DON were responsible for educating their staff. She added that she was not here to cover staff. Staff #54 indicated that she was not sure if Staff #52 was present at the training she conducted adding that the wound nurse was generally not in the morning meeting. She indicated that the Administrator and the DON were responsible for ensuring that the rest of the staff were educated. The facility failed to provide any additional Education In-Service Attendance sheets to the surveyor. 3b) On 2/2/23 at 9:45 AM, wound nurse (staff #52) was observed to provide wound care to resident #8. There was a sign on resident #8's door indicating the resident was on Enhanced Barrier Precautions. The wound nurse performed a dressing change to a buttock wound without PPE to include a gown. Review of resident #8's medical record after wound round observation revealed a doctors order for Enhanced Barrier Precautions due to wounds. At 01:26 PM on 02/02/23 the director of nursing was informed of the wound nurse not wearing additional PPE during wound rounds for resident #8.

MINOR (C) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

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Based on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Geriatric Nurse Aides (GNA) per shift, and failed to have the staff data requirements available in an accurate, clear and readable format. This was evident for the initial 4 days of the annual survey beginning on 1/23/23. The findings include. An initial tour of the facility on 1/23/23 did not reveal a facility-wide staff posting indicating the total number and actual hours worked by categories of Registered nurses (RN), Licensed practical nurses (LPN), and Certified nursing aides (CNA) per shift. Each subsequent survey day did not reveal the Federal requirements for the posting of nursing staffing. An interview was conducted with the nursing home administrator (NHA) on 1/26/23 at 2:34 PM. The Nursing home administrator was asked the whereabouts of the Federal requirements for the posting of staffing. The NHA showed a document located in the Lobby, with information that did not meet the requirements for the Federal posting of staff. The document displayed two categories 11 FTEs of License staff and 20 FTEs of unlicensed staff. A discussion was held to review the current Federal requirements for the posting of staff. A revision of the staff posting was reviewed on 1/27/23. The form was changed to show the total actual hours but not the total number by categories as the staff numbers were divided between the three units. Other noted modifications to the posting displayed additional categories of staff including CMAs (certified medication aides) and unit clerks. On 1/31/23 at 11:13 AM, an interview was conducted with the NHA to review the noted revisions with concerns about the additional categories and the divisions of the total numbers of staff that appeared to not be clear and easily readable. At 1:50 PM on 1/31/23, the NHA showed the surveyor a copy of a 2003 regulation related to the posting of staff. The current Federal requirements for the posting of staff were shown to the NHA for his review. Included in the regulatory requirements was the retention of posted daily staffing data for a minimum of 18 months.

Dec 2018 18 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

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2. During observation of unit 1A on 12/11/18 at 1:30 PM surveyor noted Nurse (Staff #6) exit out of a resident's room. The nurse walked across the hallway, opened the door and entered Resident #31's room without knocking or receiving permission from the occupants in the room. At 1:45 PM during an interview in the room of Resident #31 with their responsible party (RP) present, surveyor observed Housekeeper (Staff #4) walk in, sweep the floor, and exit the room without speaking. Staff #4 failed to knock on the door, announce herself, or wait to receive permission to enter. Resident #31 responded that it was not uncommon for staff to enter their room without knocking. The RP added that during their visits they have experienced staff who fail to knock or gain permission to enter resident's rooms. An interview with the Unit Manager (Staff #5) was conducted on 12/11/18 at 2:15 PM. He stated that it was expected of facility staff to knock, make themselves known, and gain permission from residents before entering rooms. The Director of Nursing was made aware of surveyor's findings at 2:47 PM. Based on observation, medical record review and interview with facility staff, it was determined that the facility staff failed to: 1) promote care for a resident in a manner and in an environment that maintained or enhanced the resident's dignity and respect by failing to provide a privacy cover to a resident with Foley drainage bag and 2) failure to knock and wait for permission to enter a resident room. This was found to be true for 2 out of 4 residents (Resident #44 and Resident #31) reviewed for dignity. The findings include: A Foley catheter is a urinary collection system consisting of a tube inserted into the bladder. The urine then drains through the tubing into a drainage bag that is attached to the side of the bed or chair. A privacy cover is placed over the drainage bag to hide the contents thus ensuring privacy and preventing embarrassment for the resident, roommate or visitors. 1. During a tour of unit 2 on 12/10/18, Resident #44 was observed from the hallway with his/her Foley drainage bag exposed. Review of the medical records on 12/10/18 revealed that Resident #44 was admitted to the facility in 2016 for long term care and with a diagnosis which includes neurogenic bladder. Neurogenic bladder is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition requiring long term Foley catheter use. During an interview with the Director of Nursing on 12/10/18 she revealed that any resident that has a Foley catheter with a drainage bag the expectation of staff is to place a privacy cover over the drainage bag. She acknowledged that Resident #44 did not have a privacy bag, after surveyor intervention a privacy bag was placed on the resident's Foley drainage bag. All findings discussed during the survey exit on 12/18/18.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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Based on observations and staff interview it was determined the facility failed to promote care for a resident in a manner that would ensure the resident's dignity. This was found to be evident for 1 out of 44 residents (Resident #44) reviewed during the survey. The findings include: An observation was made on 12/12/18 at 12:50 PM of Staff #21, a Geriatric Nursing Assistant (GNA), assisting Resident #44 with his/her lunch in their room. The GNA stood above the resident and fed him/her their lunch. Staff #22, a nurse, walked into the resident room at that time to check on the resident. As Staff #22 exited the room, at 12:52 PM, the surveyor asked Staff #22 if there was a reason why the GNA was standing and feeding Resident #44 and s/he responded that there was no chair in the resident room. The nurse, Staff # 22, went into another room and retrieved a chair and took it into Resident #44's room and the GNA, Staff #21 sat down and continued to assist the resident with his/her meal. During the interim while the nurse retrieved the chair, the GNA Staff #21 continued to stand above the resident and feed him/her. After the nurse gave the chair to the GNA and left the resident room, s/he stated to the surveyor that that was a dignity concern and that was why s/he gave the GNA a chair to sit in. The Director of Nursing was made aware of this concern on 12/12/18 at 2:30 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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2. A family interview was conducted on 12/10/18 at 9:30 AM with Resident #2's spouse and child. Family members stated that for months they have talked to the laundry staff and the unit manager and repeatedly requested that the facility not do the resident's laundry. Family members directed surveyor's attention to two signs posted in the resident's room stating Please do not send clothes to the laundry family takes them home. Put them in the drawer. Resident #2's spouse explained to surveyor that the facility continues to launder Resident #2's clothes and that clothes have been missing. When surveyor asked if he/she had filed a report for the missing items he/she stated that they were unaware of how to file a complaint. The Unit Nurse Manager (Staff #5) interview on 12/13/18 at 11:30 AM revealed that staff members were aware of family member's concerns. Surveyor asked Staff #5 if an incident report or grievance was filed at any time for the family member's concerns and staff member stated no, it wasn't that kind of situation it was more of a spoken thing between staff and the family. Staff #5 also stated that he/she explained to the family that any heavily soiled items would have to go to the laundry at the facility. A record review of nursing notes conducted on 12/14/18 at 9:10 AM revealed that no nursing notes had been entered by staff regarding the laundry preferences of Resident #2's family. During a second interview on 12/17/18 at 1:45 PM with Resident #2's family it was revealed that the family has had the same complaint when the resident was on another floor however he/she stated it has become worse since the patient moved to this unit a short time ago. Review of the complaint report log books dating back 6 months on 12/17/18 at 2:45 PM did not reveal any entries for Resident #2's missing items. Director of Nursing was made aware of these concerns on 12/18/18 at 9:50 AM. He/she stated they would talk with Resident #2's family and the unit manager to further investigate the situation. Based on observation, record review and interview with staff and family members, the facility failed to ensure that resident bathing areas were free of hazards that may cause injury to the residents. This has the potential to affect any resident that utilized the shower in Hall 1A. The facility also failed to provide reasonable accommodation of resident needs and preferences for Resident #2. This was evident for 1 out of 45 Residents reviewed during the survey. The findings include: 1. On 12/18/18 at 1:40 PM during an environmental tour of Hall 1A with Staff #23, the residents' shower area floor (first shower stall) had a 4 inch x 2 inch area of cracked and peeling paint with raised edges that may cause injury to a resident while barefoot. Staff #23 and the administrator did acknowledge the surveyor's concerns during the tour.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected 1 resident

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Based upon resident interviews, record review and staff interview it was determined that facility staff failed to consider or act upon Resident Council's grievances regarding food service. This deficient practice has the potential to affect all residents receiving food/meal services in the facility. The findings include; Resident Council is a group of residents that meets regularly on behalf of all residents in the facility to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life. Facility staff are required to consider residents' views and act upon grievances and recommendations. Facility staff must consider these recommendations and attempt to accommodate them, to the extent practicable. On 12/13/18 at 9:21 AM a meeting with the facility's Resident Council was conducted. Members stated that they have expressed concerns in several council meetings regarding the temperature, appearance, taste and timeliness of meals. Residents stated that for the past several months, the meal trays and service carts arrived late to the units and dining rooms resulting in cold food. They added that the dinner meal services have arrived at least 1 to 2 hours late and that the previous evening (12/12/18) the 1st of the delivery carts for the 2nd floor unit did not come until 6:30 PM. Because of the delays, the servers in the dining room are rushed which resulted in food served cold, and/or burnt, and messily plated. The residents added that the dietary department's response to their concerns has always been that trays/food are served late due to nursing staff and the new Food Service Director (FSD) has given the same reply since his arrival late fall of 2018. However, later that morning during an interview with the FSD and the Administrator at 11:00 AM on 12/13/18, the FSD admitted that originally, he believed the concerns about cold food were because of the nursing staff, but soon determined that most of the occurrences were due to the slow service line in the kitchen. Although the Administrator added that he knew of the FSD's findings, neither he or the FSD had relayed this information to the Resident Council. Review of the facility's scheduled meal times revealed that facility's dinner service is at 5:15 PM. However, a facility observation conducted on 12/14/18 at 6:41 PM revealed that there were no meal delivery or service carts on the units or in the dining rooms. An observation of the kitchen at 6:48 PM by surveyor found 2 food service staff present. The Dietician (Staff #30) was found at the doorway donning a hair net. Surveyor asked Dietician if she knew the expected time the dinner service would start for the residents. The FSD entered the area, acknowledged that there was a delay in food preparation, and stated that he and the Dietician would help get the meals to the units and dining areas. (Cross Reference F 800, F 804, F 809, and F 812)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview with staff it was determined that the facility failed to ensure that residents and/or resident's representative were notified in writing of the resident's transfer and the rationale for the transfer. This was found to be evident for 2 of 4 residents (Resident #103 and Resident #119) reviewed for hospitalization during the investigative stage of the survey. The finding includes: 1. Review of the medical record for Resident #103 on 12/12/18 at 2:45 PM revealed that the resident was admitted to the facility in November 2018 and then discharged to the hospital within the first few weeks of admission to the facility. During an interview with the resident on 12/12/18 the surveyor asked if he/she received any documentation from the facility indicating why the resident was being transferred/discharged to the hospital. The resident's response was that they did not give me anything. Further review of the medical records failed to reveal any documentation that the facility provided a copy of the notice of reason for transfer/discharge to the resident with the date and reason of the transfer. During an interview with the Director of Nursing (DON) on 12/12/18, the surveyor asked if the facility provided any documentation to the resident regarding the transfer/discharge. The DON revealed that the facility staff documents an e-transfer note, but the residents are not given a copy. The DON acknowledged that written transfer/discharge notice was not given to the resident. 2. On 12/12/18 Resident #119's medical records were reviewed. This review revealed that the resident had a responsible party making all decision due to his/her mental status. Further review of the medical records revealed the resident was transferred out to the hospital in March 2018. Review of the medical record failed to reveal any documentation that the responsible party (RP) had been provided with written notification of the transfer or the rationale for the transfer. During an interview with the DON the surveyor requested documentation indicating that the RP was given notice about the transfer and the rationale. As of survey exit on 12/18/18 no documentation had been provided to the surveyor. All findings discussed during the survey exit on 12/18/18

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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Based on administrative manual review, medical records review and interview with staff and residents, it was determined that the facility failed to provide residents and or their resident representative (RP) with the documentation of the facility's bed-hold policy. This was evident for 2 of 4 residents (Resident #103 and Resident #119) reviewed for planned and unplanned hospitalizations during the investigative stage of the survey. The findings include: Review of the facility bed-hold policy revealed that the resident and his/her surrogate decision maker or court appointed legal representative would be provided written and or verbal information regarding the bed-hold policy at the facility 1. On 12/12/18 Resident #103's medical records were reviewed. This review revealed that the resident had an unplanned transfer to the hospital 2 weeks after admission. Further review of the medical records revealed that the facility failed to provide the resident or RP with a copy of the bed-hold policy upon transfer/admission to the hospital. During an interview with the Director of Nursing(DON) on 12/12/18 the surveyor asked who was responsible to ensure that the resident or RP are given a copy of the bed-hold policy? The DON informed the surveyor that she believes it is the business office. The surveyor requested any documentation indicating that when the resident went to the hospital the resident was given a copy of the bed-hold policy. As of survey exit no documentation had been provided to the survey team indicating that resident or RP were given a copy of the bed-hold policy. 2. Review of Resident #119's medical record revealed a hospitalization in March 2018. Further review revealed that the resident and or RP was not given a copy of the facility bed-hold policy. As of survey exit on 12/18/18 no additional documentation was provided to the survey team indicating that resident or their RP were given a bed-hold notification.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**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 develop a care plan for a resident at risk for pressure ulcers. This was found to be evident for 1 of 4 residents (Resident #99) reviewed for pressure ulcers. The findings include: Resident #99 was admitted to the facility on [DATE] and has the following but not limited diagnosis: Peripheral Arterial Disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A medical record review was conducted for Resident #99 on 12/14/18 at 10:45 AM. Review of the resident care plan revealed the resident had a care plan in place for actual pressure ulcer related to disease process, history of ulcers and immobility that was initiated on 5/18/18. Another care plan for an actual arterial ulcer related to history of ulcers, limited joint mobility and peripheral arterial disease that was initiated on 9/26/18. Further review revealed the facility failed to have a potential for pressure ulcer care plan with preventative measures in place. An interview was conducted with the Director of Nursing (DON) on 12/14/18 at 11:30 AM and s/he was asked if there was a preventative care plan for Resident #99 who was at risk for pressure ulcers. The DON stated that the staff does weekly skin checks based upon physician orders. Review of physician orders revealed an order for weekly skin checks to be completed every Monday with a start date of 4/16/18 and Heel boot to be worn at all times while in bed. In another interview with the DON on the same date at 2:00 PM s/he was made aware that the orders for skin checks were not started until 4/16/18. The DON confirmed that the facility did not have a preventative care plan for the resident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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2. Blood glucose level is the amount of glucose (sugar) in the blood. The amount of glucose in the blood is measured in units of mg/dl or mmol/l. Blood sugar levels that are too high or too low can be a dangerous condition and without immediate treatment can cause serious complications. A review of the medical for Resident #96 was conducted on 12/10/18 at 10:00 AM. Review of a physician order dated 10/17/18 stated to check the resident's blood sugar level twice a day and notify the physician if the resident's blood sugar level was below 80 mg/dl or above 250 mg/dl. However, review of the October 2018 Treatment Administration Record (TAR) conducted on 12/13/18 indicated that the order was started on 10/22/18. Further review of the resident's TAR revealed that from October 2018 to December 2018, there were five entries by staff that indicated blood sugar levels above 250 mg/dl and one entry the level was below 80 mg/dl. However, there was no documentation to support that the physician was notified about the levels as ordered. The Director of Nursing was made aware of surveyor's findings on 12/17/2018 at 4:00 PM. Based on observation, record review, staff and resident interview it was determined that the facility staff failed to identify and provide needed treatment and care in agreement with standard of practice, goals, and residents' choices for 1)skin health and 2) the monitoring of blood sugar levels. This was found to be true for 2 of 45 residents (Resident #31 and Resident #96) reviewed during the investigative portion of the survey. The findings include: 1. An interview was conducted with Resident #31 and their Resident Representative (RR) on 12/11/18 at 1:41 PM. During the interview the resident alerted surveyor to an area on the right side of their cheek near the mouth that irritated them. Surveyor noted several small white raised bumps clustered reaching from the corner fold of the mouth to just under the right nostril. Also observed were 5 to 6 clusters of flat white circles and numerous short strands of thick hair along the cheek, jawline, and upper neck of the resident. Several of the strands were curled toward their skin. Resident #31 indicated that the bumps were ingrown hairs arising from being shaved by staff. The Resident's Representative (RR) added that the resident had very short facial hair before admission and had noticed the bumps and ingrown hairs but did not know that the resident was routinely shaved. The RR added that if they would have been made aware that the facial hair had grown, they would have discussed the matter with the resident to consider the resident's choice to remove the hair. Resident #31 replied that he/she did not want to be shaved. Review of the resident's medical record was conducted on 12/13/18 at 3:30 PM. Review of the care plan revealed no indication that the resident had any skin issues or addressed facial skin care preferences. Review of care plan meeting notes revealed that although the resident had a diagnosis of Dementia and short term memory loss, the resident had participated in decisions regarding activities but no documentation was found to indicate that the resident was questioned regarding facial hair care. An interview with the Resident's Unit Manager (UM) (Staff#5) on 12/13/18 at 3:30 PM revealed that it was staff's preference that the resident is shaved and although he could not verify that the resident was consulted before today, the family had been made aware and consented to the procedures. The UM was made aware of the RR's statement that they were not aware that the resident was being shaved and was requested to submit documentation to support that the RR consented for the resident to be shaved. Observation and interview with Resident were conducted on 12/13/18 at 3:35 PM with the Unit Manager (Staff #5) present. Surveyor noted that the cluster of bumps on the right face now resembled the flat white circles and curled hair noted earlier on the other areas of their face. In addition, under the chin were several new raised clusters of bumps that Resident #31 shared had begun to itch. The resident then stated to the UM that he/she did not want to be shaved anymore. The UM asked him/her to confirm the statement and Resident #31 repeated that they did not want to be shaved and to allow the facial hair to grow. On 12/13/18 at 5:05 PM the Director of Nursing (DON) was made aware of surveyor's findings and the documentation request to the UM. The DON returned at 6:01 PM to state that there was no evidence that indicated the RR was informed or gave permission for Resident #31 to be shaved. The DON added that she also spoke with resident earlier and confirmed that the resident did not want to be shaved because it causes irritation. The DON stated that they will honor the resident's wishes, notify the RR, and create a plan of care based on the resident's preferences. (Cross Reference F 656)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on record review, staff and family interview, it was determined that the facility failed to adequately monitor behaviors for a resident who was prescribed antipsychotic medication. This was evident for 1 out of five residents (Resident #2) reviewed for unnecessary medications. The findings include: A family interview was conducted on 12/10/18 at 10:10 AM with Resident #2's spouse. Spouse stated that he/she felt the Resident was less interactive and had slowly been declining in awareness of his/her surroundings since the Resident was first admitted . A record review conducted on 12/10/18 at 2:20 PM revealed Resident #2 had a diagnosis of depression and had been prescribed two medications for this condition prior to admission and continued on both medications after admission. Record review conducted on 12/12/18 at 1:30 PM revealed a physician order dated 7/11/18 for a third medication for depression and a physician order dated 7/31/18 for an antipsychotic medication for agitation. Record review on 12/13/18 at 10:45 AM of behavioral health progress notes from the previous 6 months revealed that patient had been referred by nursing staff for agitation. Non-pharmacological (ways to treat diagnosis other than medication) interventions were not documented as being offered to Resident prior to or after new medications were added to his/her orders. A record review on 12/17/18 at 8:30 AM of nursing notes and behavior records for Resident #2 for May, June, July, October, November and December 2018 revealed documentation that the Resident was not exhibiting any negative behaviors or agitation. The Director of Nursing was made aware of these concerns on 12/18/18 at 9:50 AM. He/she stated that they would contact behavioral health immediately to have Resident #2 evaluated for a possible dose reduction or medication change.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on interviews with a resident and facility staff, it was determined the facility failed to provide what was on the menu for a resident who was served lunch. This was found to be evident for 1 resident (Resident # 41) while observing lunch being served during the facility's annual survey. The findings include: An interview was conducted with Resident #41 on 12/11/18 at 2:00 PM and s/he complained that the food was not correct when it is brought to them by dietary. The resident went on to say that the dietary department is unable to read the dietary slips and stated that if they are reading the diet slips correctly, why was s/he served a pureed diet, when my diet slips reads regular? An observation was made of Resident #41's plate of food and there was a serving of pureed spinach on his/her plate. The resident also stated that dinner is sometimes served as late as 7:00 PM at times. Review of Resident #41's diet slip that was on his/her tray indicated a regular diet. An interview was conducted with the Nursing Home Administrator (NHA) and Dietary Manager (DM) on 12/17/18. The DM stated that s/he is new to the facility and that it was evident that there were concerns with the dietary staff that s/he identified within their department. The DM went on to say that there was a concern of dietary staff not being able to read meal tickets correctly and noticed that staff did not follow recipe ingredients when s/he observed the staff preparing a meal. The NHA stated that education and training will be done with the dietary staff to address all the concerns. (Cross Reference F 804)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A tour of the facility on 12/18/18 at 1:40 P.M. with Staff Member #23 revealed a large stack of resident mattresses stacked on top of each other. They were not wrapped or covered to protect their cleanliness. The area the mattresses were stored was indicated as a storage area but was in the resident shower room on floor 1A and was subject to humidity on a daily basis from residents showering. Used gloves (turned inside out) were observed on top of a mattresses and residents' walkers were observed to be leaning against the clean mattresses. Also observed were discarded paper towels on the floor and a bottle of lotion on the edge of one of the corners of the mattress. Interview with the administrator on 12/18/18 at 3:15 PM revealed there is no policy on how to maintain the mattresses cleanliness in regards to the infection control process. Based on observation, and staff interview it was determined that the facility staff failed to 1) follow infection control practices and guidelines while performing duties and caring for residents and 2) provide sanitary storage conditions to prevent the development and transmission of disease by not providing proper storage of resident mattress and fall mats after disinfection by central supply. This deficient practice has the potential to affect all residents in the facility. 1a. During an observation of the 1A Unit on 12/11/18 at 01:26 pm, surveyor noted Geriatric Nursing Assistant (GNA) (Staff #33) enter room [ROOM NUMBER] with a white Styrofoam cup labeled Rm #120 and placed on top of a dispenser to care for a resident in the room. The GNA exited the room, sat the cup on a nearby medication cart, poured water into cup from a pitcher and took it to room [ROOM NUMBER]. The GNA was interviewed immediately after the observation in the presence of their Unit Manager (UM) (Staff #5). The GNA acknowledged surveyor observations and admitted that he became distracted and did not realized he had carried a resident's cup into various areas on the unit. The UM instructed the GNA to retrieve and replace the cup and sanitize the areas the cup came into contact confirming surveyor's concerns. 1b. During an observation of the kitchen on 12/18/18 at 12:26 pm surveyors noted several food tray lids lying on the floor of the food service line. Serving staff walking around them, Staff #31 bent down, pick the trays off the floor, placed then on a nearby food prep counter, then proceeded to grab clean plates to continue to plate resident's meals without removing gloves, sanitizing their hands or removing the tray lids from the service area. The Administrator was alerted to surveyor's findings and redirected staff after surveyor's intervention. Further observation of the food service area revealed a clear bottle decorated with blue curvy lines had sat on top of one of the food prep tables during the lunch service. It was later revealed at the end of the service that it was a personal water bottle belonging to Staff #32. Observation of the kitchen on 12/18/18 at 12:56 pm revealed in the food preparation area, 3 dry unlabeled storage bins with their lids opened and contents exposed. Inside of one of the bins was a metal scoop encrusted with a white substance. The floor surrounding the food plating area was sticky, had various crumbs, debris, and stains. The same was noted in areas behind the cooking appliances and food preparation station. (Cross Reference F 812)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**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 staff failed to ensure the information used to complete the Annual and Quarterly Minimum Data Set (MDS) assessment for 1) Functional Status; Activities of Daily Living and 2) Bladder and Bowel were accurate. This was found to be evident for 3 out of 4 residents (Resident #119, Resident #44 and Resident #26) reviewed for activities of daily living and 1 out of 1 (Resident #26) reviewed for bladder and bowel during the investigation stage of the survey. The findings include: MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Activities of Daily Living or ADL's are basic self-care tasks. They include bed mobility, toileting, grooming, maintaining continence, putting on clothes, Bathing, walking and transferring (such as moving from bed to wheelchair). 1. Resident #119's medical records were reviewed on 12/14/18. This review revealed that the resident was admitted to the facility in January 2017 for rehabilitation. Further review of the medical records revealed medical diagnoses which included muscle weakness, neurogenic bladder and multiple pressure ulcers. (Pressure Ulcers or Bed sores are caused by sustained pressure, friction or shear on the skin which limits the blood flow). Review of the medical records revealed a quarterly MDS assessment dated [DATE] which revealed the facility assessed the resident as extensive assist for toileting (how the resident uses the toilet room, transfer on and off the commode and adjust clothes). This assessment indicated that the resident was involved in the toileting activity and staff provided weight bearing support. During an interview with Nurse (Staff #22) on 12/14/18 the surveyor asked if the resident was able to participate in toileting Staff #22 revealed that the resident was dependent on staff for toileting. During an interview with the MDS Coordinator (Staff #10) on 12/14/18, the surveyor requested any documentation indicating that the resident was extensive assist and not dependent on staff for toileting. The surveyor also asked if the resident was always incontinent, indicating that the resident does not use the commode or if bed pan use was how the resident was coded as extensive assist. As of survey exit no additional information had been provided to the surveyor. All findings discussed with the Director of Nursing and the Administrator during the survey exit. 2a. On 12/17/18 Resident #44's medical records were reviewed. This review revealed that the resident was admitted to the facility for long term care and with diagnoses which included generalized weakness, abnormalities of gait and mobility and upper and lower extremity contracture. On 10/20/18 an annual MDS was completed which revealed that the resident was assessed as extensive assist for bed mobility, toilet use and eating. This assessment indicated that the resident was able to participate in bed mobility, toilet use and eating. During an interview with the Director of Nursing (DON) on 12/17/18 the surveyor asked if she knew the resident and she replied yes. The surveyor asked if the resident was able to do bed mobility, toileting or eating, the DON replied no, she verbalized that the resident is dependent on staff for all care. The DON acknowledged that the assessment was inaccurate for the resident. 2b. Further review of Resident #44's medical records revealed that the resident had a colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen to collect stool). Review of the 10/9/18 assessment for bowel and bladder the facility assessed the resident as frequently incontinent indicating 2 or more episodes of bowel incontinence. During an interview with the MDS coordinator (Staff #10) on 12/17/18 she acknowledged it was inaccurate and that it should have been coded as not rated. 3. Resident #26's medical records were reviewed on 12/17/18. This review revealed that the resident was admitted to the facility in 2016 for long term care and with diagnoses which included heart failure, encephalopathy (a term that means brain disease, damage, or malfunction) and chronic respiratory failure. Further review of the medical records revealed that the resident was unresponsive. Review of the 9/30/18 quarterly MDS assessment revealed the facility staff assessed the resident as extensive assist for bed mobility, dressing, toilet use and personal hygiene, indicating that the resident was involved in her/his care. During an interview with Nurse Staff #22, she revealed that the resident was dependent for all ADL needs, and that the resident was not responsive and unable to assist in care. All findings discussed with the DON and the administrator during the survey exit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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2. Review of Resident #96's record on 12/10/18 at 11:00 AM revealed that the Resident had a Permacath (a piece of plastic tubing inserted under the skin used to access the patient's veins) in the right side of his/her chest. Review of the Resident #96's care plan on 12/12/18 at 3:30 PM revealed that the Resident's catheter and care of the catheter were not addressed in the care plan. Further record review on 12/13/18 at 2:00 PM revealed a physician order to monitor Permacath daily with no guidelines for how to monitor the catheter. During an interview with Director of Nursing (DON) on 12/17/18 at 12:00 PM surveyor requested a policy for care of Permacath. DON stated he/she did not have a policy specific to address monitoring and/or care of a Permacath. Director of Nursing was made aware of these concerns on 12/18/18 at 9:40 AM. Based on observation, resident interview, record review, and staff interview it was the determined that the facility staff failed to provide a resident-centered care plans to address: 1) the the resident's choice to not have facial hair shaved and 2) the care of a resident's Permacath (a catheter used for dialysis). This was found to be true with 2 of 2 residents (Resident #31 and Resident #96) reviewed for patient centered care plans during the survey. The findings include: An interview was conducted with Resident #31 and their Resident Representative (RR) on 12/11/18 at 1:41 PM. During the interview the resident alerted surveyor to an area on the right side of their cheek near the mouth. Surveyor noted several small white raised bumps clustered reaching from the corner fold of the mouth to just under the right nostril. Also observed were 5 to 6 clusters of flat white circles and numerous short strands of thick hair along the cheek, jawline, and upper neck of the resident. Several of the strands were curled toward their skin. Resident #31 rubbed the raised bumps and stated that they came from being shaved by staff and hair having grown back into them. The RR confirmed that Resident #31 had facial hair before admission and noted occasional bumps and ingrown hairs since then but was unaware that the facility had routinely shaved the resident. The RR added that if they would have known about the routine shaving they would have discussed other hair removal treatments or not to shave the resident. Resident #31 replied that he/she did not want to be shaved. Review of the resident's medical record was conducted on 12/13/18 at 3:30 PM. Review of the care plan revealed no indication that the resident had any skin issues or addressed facial skin care preferences. An interview was conducted with the Resident's Unit Manager (UM) (Staff#5) on 12/13/18 at 3:30 PM. The UM stated that although it was staff's preference that the resident was shaved and expected that the family was made aware and consented to the procedures. However, in the presence of the surveyor, resident repeated their preference not to be shaved to the UM during an interview at 3:35 PM. During the interview with the UM (Staff #5) surveyor requested documentation to confirm that the Resident Representative was informed of and consented to Resident #31 being shaved. At 5:05 PM the Director of Nursing (DON) was made aware of surveyor's findings and the documentation request to the UM. The DON returned at 6:01 PM to state that there was no evidence that indicated the RR was informed or gave permission for Resident #31 to be shaved. She added that she spoke with resident and confirmed that the resident did not want to be shaved because it causes irritation. The DON stated that they will honor the resident's wishes, notify the RR, and create a plan of care. (Cross Reference F 684)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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2. Review of Resident #131's medical record on 12/13/18 at 3:15 PM revealed a diagnosis of Anemia. Review of Resident #131's initial care plan on 12/13/18 at 3:35 PM revealed no goals or guidelines for care of and monitoring of anemia for Resident #131. Record review of nursing notes on 12/14/18 at 11:00 AM revealed that Resident #131 was sent out to the hospital twice in September 2018 due to blood test results that showed patient had a low hemoglobin (proteins in the blood that carry oxygen) level due to his/her anemia. Review of the hospital records revealed the resident required a blood transfusion prior to re-admission to the facility. The care plan was not updated upon Resident #131's return to facility for anemia. Director of Nursing was informed on 12/18/2018 at 9:50 AM of concerns and stated he/she will review Resident #131's chart and update the care plan. Based on observations, medical record review and interviews with facility staff it was determined the facility failed to update care plans to 1) meet the specific needs for a resident with a history of falls and 2) a resident diagnosed with anemia (a condition where the patient does not have enough red blood cells to carry oxygen to parts of the body). This was found to be evident for 2 of 30 residents (Resident's #109 and #131) that were investigated during the facility's annual survey. The findings include: 1. A medical record review was conducted on Resident #109 on 12/18/18 at 2:30 PM and it revealed the resident had an unwitnessed fall on 12/8/18 and 12/9/18 resulting in a cervical fracture and laceration to head. Review of Resident #109's medical record revealed a history of resisting care and agitation at times and impulsivity. Review of the Incident/Accident report indicated that on 12/8/18 Resident #109 was observed sitting on the floor close to his/her bed and wheel chair, in his/her room bleeding from forehead. Additionally, on 12/9/18 Resident #109 was noted on the floor next to door lying on his/her left side, laceration noted with blood coming from left frontal side of scalp. Resident #109 had a fall the previous day (12/8/18), and had just returned with a fracture of the clavicle, arm in sling, but resident had taken off the sling. The report indicated the resident was alert but confused, is blind and non-compliant with POC (Plan of Care), getting up and walking without assistance. Review of therapy notes on 9/7/18 revealed tactile cueing for sit to stand, transfer onto bedside commode by bed, reminders/tactile cueing and finger spelling for locking w/c brakes prior to coming to stand. An interview was conducted with the Director of Nursing (DON) on 12/18/18 at 1:25 PM and s/he stated that the resident was ambulatory and had a bedside commode next to the bed. The DON went on to say that Resident #109 can use the bedside commode on his/her own, however, staff does assist when the resident allows but the resident is non-compliant. An interview was conducted with a Geriatric Nursing Assistant (GNA), Staff #19, on 12/18/18 at 3:40 PM and s/he stated that Resident #109 will say to staff, I am independent and will fight staff if you try to assist him/her. The GNA went on to say that the resident will tell you that s/he is not a baby, if you try to help him/her onto the bedside commode. The GNA also stated that Resident #109 must be redirected often. An interview was conducted with Staff #18, a nurse on the unit, on 12/18/18 at 3:50 PM and s/he stated that Resident # 109 is blind and hard of hearing. The nurse went on to say that the resident can ambulate but is non-compliant when assistance is offered by staff and will tell staff that s/he is independent and becomes combative. The nurse stated that staff communicates with the resident by using an object to spell words onto the palm of the resident hand and s/he will respond appropriately. The nurse also stated that the resident will also let you know if the spelling is not clear and to spell the word again for clarification. An observation was made on 12/18/18 at 3:45 PM of Staff #19 using a pencil (eraser) to spell the word hi in the palm of Resident #109 hand, and s/he responded by saying,Hi. In another interview with the DON on 12/18/18 at 4:00 PM, s/he stated that Resident #109 requires increased supervision as the resident becomes confused at times and that the staff will do frequent checks and monitoring. Review of Resident #109's care plan on 12/18/18 failed to reveal documentation that the resident required increased supervision due to confusion and that the resident is non-compliant when assistance is offered. The Nursing Home Administrator and DON were made aware of all concerns at the time of exit.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected multiple residents

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Based on observation, record review, resident and staff interview it was determined that the facility staff failed to put a system in place to ensure that food and beverages are healthy and satisfying to residents. This deficient practice has the potential to affect all residents in the facility. The findings include: During a meeting with the facility's Resident Council on 12/13/18 at 9:21 AM, members stated that they have expressed concerns in several council meetings regarding the temperature, appearance, and taste and timeliness of meals. Residents stated that for the past several months, the meal trays and service carts arrived late to the units and dining rooms resulting in cold food. They added that the dinner meal services have arrived at least 1 to 2 hours late and that the previous evening (12/12/18) the first of the delivery carts for the 2nd floor unit did not come until 6:30 PM. Because of the delays, the servers in the dining room are rushed which resulted in food served cold, and/or burnt, and messily plated. During an interview with the Food Service Director and the Administrator on 12/13/18 at 11:00 AM, the FSD admitted that originally, he believed the concerns about the food were because of the nursing staff, but soon determined that most of the occurrences were due to the performance of the kitchen staff. He added that kitchen staff had demonstrated difficulty in reading residents' meal preference cards and recipes in addition to incidents of staffing limitations. Review of the facility's scheduled meal times revealed that facility's dinner service is at 5:15 PM. However, a facility observation conducted on 12/14/18 at 6:41 PM revealed that there were no meal delivery or service carts on the units or in the dining rooms. An observation of the kitchen at 6:48 PM by surveyor found 2 food service staff present. The Dietician (Staff #30) was found at the doorway donning a hair net. Surveyor asked Dietician if she knew the expected time the dinner service would start for the residents. The FSD entered the area, acknowledged limited number of kitchen staff present, the delay in food preparation, and that he and the Dietician would help get the meals to the units and dining areas. (Cross Reference F 565 and F 809) During the council meeting, residents added that snacks are not provided consistently and that they must request several times during the evening to receive them. Residents stated that on 12/12/18 evening snacks for Diabetic residents were not delivered at all. Residents also stated that several meals arrived with just a side dish; with no proteins, or vegetables on tray and during the Sunday 12/09/18 dinner service several residents received a plate with only noodles and gravy. During an interview on 12/14/18 at 4:42 PM with the Resident Dietician (RD) (Staff #30) and the Director of Nursing (DON) the RD stated that all residents' meal preferences and menus are coordinated through a computer system, however she could not explain why residents received the incomplete meal on Sunday. The DON was also made aware of the food concerns shared by the Resident Council members. (Cross Reference F 565 and F 809) An observation of the kitchen was conducted on 12/18/18 at 12:26 PM. Surveyors noted that during the lunch service, several staff members failed to follow food safety requirements or utilized hygienic practices while handling food. (Cross Reference F 812 and F 880) Observation of the food tray service line at 12:50 PM revealed that the beverage bin that held the milk containers for the tray service did not have any ice in it. Review of the temperature logs revealed that the milk temperature check for the lunch service was not recorded. Surveyor made the dietician (Staff #30) aware of the findings. At 12:48 the dietician checked the temperature of one of the remaining milk cartons and reported that the milk temperature read 48 degrees. The dietician brought out milk from the main refrigerator and replaced them with the cartons in the service bin at 12:51 pm. Although the contents of the bin were switched out, no other carton beverages were served. (Cross Reference F 812) The Administrator and the Corporate Representative (Staff #15) were made aware of surveyor's concerns.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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4. During a meeting with the facility's Resident Council on 12/13/18 at 9:21 AM, members stated that they have expressed concerns in several council meetings regarding the temperature, appearance, and taste and timeliness of meals. Residents stated that for the past several months, the meal trays and service carts arrived late to the units and dining rooms resulting in cold food. They added that the dinner meal services have arrived at least 1 to 2 hours late and that the previous evening (12/12/18) the first of the delivery carts for the 2nd floor unit did not come until 6:30 PM. Because of the delays, the servers in the dining room are rushed which resulted in food served cold, and/or burnt, and messily plated. During an interview with the Food Service Director (FSD) and the Administrator on 12/13/18 at 11:00 AM, the FSD admitted that originally, he believed the concerns about the food were because of the nursing staff, but soon determined that most of the occurrences were due to the performance of the kitchen staff. He added that kitchen staff had demonstrated difficulty in reading residents' meal preference cards and recipes in addition to incidents of staffing limitations. Although the Administrator added that he knew of the FSD's findings, neither he or the FSD had relayed this information to the Resident Council. (Cross Reference F 565) A review of the facility's scheduled meal times revealed that residents' dinner service is at 5:15 PM. However, on 12/14/18 at 6:41 PM surveyors discovered that there were no meal deliveries on the units or service carts in the dining rooms. Further observation in the kitchen at 6:48 PM surveyor found 2 food service staff present. The FSD entered the kitchen, acknowledged the delay of dinner service and the lack of staff. (Cross Reference F 565, F 800, F 804, F 809, and F 812) Observation of the food tray service line on 12/18/18 at 12:50 pm revealed that a bin holding milk containers was left on the tray service line did not have any ice in it and later revealed that the internal temperature of the milk was 48 degrees. Review of the temperature logs revealed that the milk temperature was not checked prior to the lunch service. (Cross Reference F 812) Review of the facility's Nutrition Services Manual under Food Temperature Control Policy indicated that items such as milk should be kept refrigerated or on drained ice during service to keep it at the proper temperature. A food tray from the observed lunch service was requested by surveyors for testing. The internal temperature of the meat was 120 degrees. Further review of the Food Temperature Control Policy revealed that the recommended temperature for meat/protein as 155 to 166 degrees. Further review of the policy revealed that the temperature of the food is to be taken and recorded on the Food Temperature Control Form daily to monitor for unsatisfactory temperatures and correct problem areas. Review of the Food Temperature Control Forms from November 1, 2018 through December 17, 2018 revealed missing hold temperature entries for the breakfast, lunch, dinner food and beverage items served. The records were reviewed with the Administrator during an interview on 12/18/18 at 3:50 PM. The administrator stated that he was unfamiliar with the temperature logs in use and added that the hold temperatures were mistakenly entered in the cooking temperature column. The Administrator acknowledge that both temperature recordings were expected to be documented. During a follow-up tour of the kitchen surveyor noted 3 unlabeled, undated storage bins were uncovered. Inside of one of the bins was a metal scoop handle side down, with areas of the contents later identified as sugar, stuck on it. Sitting on top of the shelving above the bins was a decorative bottle, top opened filled with a clear liquid, that was later identified as personal water bottle belonging to kitchen Staff #32. Further observation revealed on the lower shelf at a nearby table were various seasonings and condiment containers noted with their lids opened and had various stains and crumbs on them. The floor surrounding the food plating area was sticky, had various crumbs, debris, dry and wet stains on them. The same was noted on the floor in areas behind the cooking appliances and the food preparation station. These concerns were bought to the attention of the facility's corporate representative (Staff # 15) on 12/18/18 at 2:10 pm. Based on observation, record review, resident and staff interviews it was determined the facility failed to: 1) follow resident's meal tickets and 2) provide foods that are consistent with the resident diet plan and 3) provide meals on time 4) put a system in place to provide food and drink that was attractive, appetizing, at acceptable temperatures, and assure that food is stored in a way to maintain its nutritional value for residents. This was found to be evident for 3 out of 3 residents (Resident #41, Resident #95 and Resident #110) investigated for food concerns and has the potential to affect all residents in the facility. The findings include: 1. An interview was conducted with Resident #41 on 12/11/18 at 2:00 PM and s/he complained that the food is not correct when it is brought to them by dietary. The resident went on to say that the dietary department is unable to read the dietary slips and stated that if they are reading the diet slips correctly, why was s/he served a pureed diet, when my diet slips reads regular? An observation was made of Resident #41's plate of food and there was a serving of pureed spinach on his/her plate. The resident also stated that dinner is sometimes served as late as 7:00 PM at times. Review of Resident #41's diet slip that was on his/her tray indicated a regular diet. 2. An interview was conducted with Resident #95 on 12/11/18 and s/he stated that dietary staff brings dinner trays late and at times as late as 7:00 PM. The resident went on to say that staff are not running the kitchen correct. The resident further stated that s/he has asked for a bagel and cream cheese and the facility stated that it would be available on Monday. The resident stated that it would be greater than a week before his/her request would be available. Resident #95 also stated that other concerns that s/he has are that the vegetables are over cooked, the kitchen runs out of tea bags and that if s/he would want additional food, it is not available. 3. An interview was conducted with Resident #110 on 12/11/18 at 1:38 PM and s/he stated that on his/her meal ticket it indicates tropical fruit and sliced apples are the fruit that is served. The resident went on to say that the pork that was served with lunch today was very tough and hard to chew. The resident further stated that s/he is on a pureed diet and receives regular food. An interview was conducted with the Nursing Home Administrator (NHA) and Dietary Manager (DM) on 12/17/18 at 11:05 AM and they were made aware of the concerns regarding food. The DM reported that s/he started at the facility in October 2018 and that there were dietary concerns when s/he started. The DM was asked if the facility has ever run out of food and s/he responded, yes. The DM further stated that when this happens the dietary staff will make additional food. The DM was asked if the dietary staff have problems with reading meal tickets and the DM stated that there are concerns in this area. The DM went on to say that in his/her observations it has been noted that the staff was not able to follow the recipe accordingly and that s/he has to offer instruction. The NHA stated that none of the staff have been tested for literacy to confirm that there is a problem. The NHA stated that education and training will be provided to the staff.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

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Based on observation, record review, resident and staff interview it was determined that the facility staff failed to put a system in place to ensure that residents meals and snacks were offered at scheduled times. This deficient practice has the potential to affect all residents in the facility. Findings include: During a meeting with resident representatives on 12/13/18 at 9:21 AM it was revealed that they have expressed concerns in the past several months regarding the lack of timeliness of the delivery of meals and snacks in the facility. The dinner meal services have arrived at least 1 to 2 hours late and that the previous evening (12/12/18) the first of the delivery carts for the 2nd floor unit did not come until 6:30 PM. The residents added that snacks are not provided consistently and that they must request several times during the evening to receive them. Residents stated that on 12/12/18 evening snacks for Diabetic residents were not delivered at all. During an interview with the Food Service Director and the Administrator on 12/13/18 at 11:00 AM, the FSD admitted that originally, he determined that most of the occurrences were due to the performance of the kitchen staff and staffing limitations in the department. A review of the facility's scheduled meal times revealed that residents' dinner service is at 5:15 PM. However, on 12/14/18 at 6:41 PM surveyors discovered that there were no meal deliveries on the units or service carts in the dining rooms. Further observation in the kitchen at 6:48 PM surveyor found 2 food service staff present. The FSD entered the kitchen, acknowledged the delay of dinner service and the lack of staff. (Cross Reference F 565)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and staff interview it was determined that the facility staff failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. This deficient practice has the potential to affect all residents in the facility. Findings include: An observation of the kitchen on 12/18/18 at 12:46 pm was conducted. Surveyors noted several food tray lids were on the floor. Additional observation revealed that Staff #31 bent down, pick the trays off the floor, placed then on a nearby food prep counter, then proceeded to grab clean plates and continued to serve meals without removing gloves, sanitizing their hands or removing the tray lids from the service area. The Administrator was alerted to surveyor's findings and redirected staff after surveyor's intervention. (Cross Reference F 880) Further observation at 12:51 pm revealed that the bin containing individual milk cartons for lunch distribution failed to have ice in it. Additional observation revealed that the temperature of the milk in one of the cartons was 48 degrees. A record review and interview with the Dietician (Staff #30) revealed that the milk was not tested for proper temperature prior to serving them to residents. As a result, all but 5 cartons of milk were not tested for proper temperature prior to placement on residents' lunch trays. Review of the facility's Nutrition Services Manual under Food Temperature Control Policy on 12/18/18 at 2:30 pm indicated that items such as milk should be kept refrigerated or on drained ice during service to keep it at the proper temperature. (Cross Reference F 800 and F 804) A food tray from the observed lunch service was requested by surveyors for testing. The internal temperature of the meat was 120 degrees. Further review of the Food Temperature Control Policy revealed that the recommended temperature for meat/protein as 155 to 166 degrees. Further review of the policy revealed that the temperature of the food is to be taken and recorded on the Food Temperature Control Form daily to monitor for unsatisfactory temperatures and correct problem areas. Review of the Food Temperature Control Forms from November 1, 2018 through December 17, 2018 revealed missing hold temperature entries for the breakfast, lunch, dinner food and beverage items served. The records were reviewed with the Administrator during an interview on 12/18/18 at 3:50 PM. The administrator stated that he was unfamiliar with the temperature logs in use and added that the hold temperatures were mistakenly entered in the cooking temperature column. The Administrator acknowledge that both temperature recordings were expected to be documented. (Cross Reference F 804) Observation of the food preparation area revealed 3 dry unlabeled storage bins with their lids opened and contents exposed. Inside of one of the bins was a metal scoop encrusted with a white substance. The floor surrounding the food plating area was sticky, had various crumbs, debris, and stains. The same was noted in areas behind the cooking appliances and food preparation station. Further observation of the food service area revealed a clear bottle decorated with blue curvy lines had sat on top of one of the food prep tables during the lunch service. It was later revealed at the end of the service that it was a personal water bottle belonging to Staff #32. (Cross Reference F 804) The Administrator and Director of Nursing were made aware of surveyor's concerns on 12/18/18 during the exit meeting.

Aug 2017 7 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0157 (Tag F0157)

Could have caused harm · This affected 1 resident

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2. A review of resident #56's medical record reveals an Incident Report dated 8/12/2017 that documents that the resident sustained an unwitnessed fall at 2:00 AM and that on assessment resident noted with hematoma to the left lower eye. No swelling noted at this time. Further review of resident #56's medical record reveals that an electronic message to the on-call physician was initiated on 8/12/2017 at 2:09 AM. The message reads: Urgency: FYI. Situation: Resident fell from the bed whereby sustained a hematoma on his/her left lower eye. No swelling noted at this time. Denies any pain at this time. Facility documentation reveals that delivery of the electronic message was postponed until 7:00 AM. The facility received a response from the on-call physician at 7:09 AM. In interview on 8/18/2017 at 10:20 AM, the Director of Nursing (DON) was asked to explain the delay in time that occurred between initiation and delivery of the electronic message. The DON stated that messages sent overnight with an urgency of FYI were automatically delayed for delivery until 7:00 AM. The DON confirmed that the on-call physician did not receive immediate notification of the resident's fall with injury. Based on medical record review, staff and Responsible Party (RP) interview, it was determined the facility staff failed to notify Resident #120's responsible party of falls that occurred or document the rational for the failure to notify the emergency contact. In addition, the facility staff failed to immediately notify a resident's physician after Resident #56 sustained a fall with injury. This was evident for 1 of 34 residents who were the subject of review during the Stage2 and 1 of 3 residents who were the subject of complaints during this annual survey. The findings include: 1. Surveyor review of complaint MD00115407 on 8/17/17 revealed an allegation that the facility staff failed to notify Resident #120's emergency contact representative when he/she experienced falls on 6/14/17, 7/12/17, 8/1/17 and 8/3/17. Resident #120 was admitted to the facility, with a history of Anemia; End Stage Renal Disease, Diabetes, Hypertension, Peripheral Vascular Disease, Seizure and a Left above the Knee Amputation. Medical record review revealed the following: A Concurrent Review dated 6/14/17 noted Resident #120 was found on the floor. It was noted that several attempts were made to notify the decision maker, who was not named. The times that facility staff attempted to notify the representative were not noted. A Concurrent Review dated 7/12/17 reported the Resident was found on the floor and noted the Resident rolled out of bed. It was noted the Resident was notified. Concurrent Reviews dated 8/1/17 and 8/3/17 reported the resident fell. Facility staff documented that the decision maker was notified on 8/1/17 and on 8/3/17 indicated the resident was notified. In interview with the surveyor on 8/17/7 at 1:50 PM RN #1 was asked about notification to the resident's representative regarding falls. RN #1 stated if the resident is alert and oriented and there are no injuries, the resident representative would not be notified. Review of facility documentation revealed notification to the resident's representative was not consistent. There is no documentation that indicated the resident did not wish to have the representative notified of the falls. Medical record review and staff interview failed to reveal the reason for the inconsistent notification. The findings were discussed with the Administrator during the exit conference on 8/18/17 at 2:55 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0225 (Tag F0225)

Could have caused harm · This affected 1 resident

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Based upon a review of facility documentation and staff interview it was determined that the facility failed to report an allegation of abuse to the State Agency in accordance with regulatory guidelines. This was evident for 1 of 34 residents (Resident #27) reviewed during Stage 2 of the Quality Indicator Survey. The findings include: A review of facility investigative documentation reveals that on 8/12/2017 Resident # 27 reported to the nurse that he/she was experiencing rectal pain and felt like he/she had been raped. Facility documentation reveals that an investigation into the resident's complaint was initiated, the resident's family and physician were notified and one staff member was suspended pending the outcome of the investigation. The investigation was completed on 8/12/2017 and allegations of abuse were found to be unsubstantiated. On August 18, 2017 at 12:40 PM, the Administrator stated that the incident was not reported to the Office of Healthcare Quality as the investigation began to reveal that the resident's complaint was related to constipation. On August 18, 2017 at 1:36 PM, the Director of Nursing stated that the Administrator had prepared a report to be sent to the Office of Healthcare Quality but decided not to send it in as the investigation was complete and abuse was unsubstantiated.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0272 (Tag F0272)

Could have caused harm · This affected 1 resident

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Based on review of medical record documentation and staff interview, it was determined that the facility failed to ensure that Comprehensive Minimum Data Set (MDS) assessment was accurately coded. This concern with inaccuracy was evident for 1 (Resident #19) of 26 residents reviewed during Stage 2 of the Quality Indicator Survey. The findings include: Resident #19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of March 10, 2017 and annual MDS with ARD of June 9, 2017 was reviewed on August 17, 2017. In section I for Active Diagnosis, I2900 Diabetes Mellitus (DM), was documented Yes when it should have been coded No, as there was no supportive documentation in the resident's medical record which indicated diagnosis of DM. The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. At the end of the MDS assessment, the interdisciplinary team develops a plan for the resident to obtain optimal care On August 18, 2017 at 10:00 AM, MDS inaccuracy was discussed with MDS coordinator #1.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0279 (Tag F0279)

Could have caused harm · This affected 1 resident

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Based on review of medical record documentation and staff interview, it was determined that the facility staff failed to develop an accurate comprehensive care plan. This was evident for 2 (Resident #78) and (Resident #24) of 34 residents reviewed during stage 2 of the Quality Indicator Survey. The findings include: 1. A comprehensive care plan is an outline of nursing care showing all the resident's needs and ways of meeting those needs. It is a dynamic document initiated on admission and subject to continuous assessment and revision by the nursing staff caring for the patient. The care plan typically includes nursing and medical diagnoses, nursing interventions and outcomes to ensure consistency of care. Resident #78's care plan was reviewed on August 17, 2017. Care plan with goals and interventions related to the diagnosis of dementia was developed by the facility staff on March 29, 2017 and revised on June 28, 2017. The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. At the end of the MDS assessment, the interdisciplinary team develops a plan for the resident to obtain optimal care. Resident #78's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of March 21, 2017 and another quarterly MDS with ARD of June 21, 2017 was reviewed on August 17, 2017. In section I for Active Diagnosis, a diagnosis of dementia was not coded. Further review of the resident's medical record indicated no diagnosis of dementia. Interview of physician on August 17, 2017 at 10:55 AM and interview of Unit Manager #1 on August 17, 2017 at 11:30 AM confirmed that Resident #78 does not have a diagnosis of dementia. 2. A review of Resident #24's medical record was conducted on 8/17/2017 at 9:50 AM. The resident was found to have a stage 3 ulcer to his/her sacrum (above the buttocks at the end of the tailbone) and two deep tissue injuries to his/her left foot. A review of the care plan last updated on 7/26/17 shows two care areas associated with pressure ulcers. Both were initiated on 2/14/2017. The first states, At risk for skin breakdown secondary to incontinence, has no goal, and has no interventions associated with it. The second care area states, Actual skin breakdown related to Open areas, has the goal Stablize [sic] wounds as much as possible, and also has no interventions associated with it. During an interview that took place on 8/18/2017 at 9:13 AM, Regional Nurse #1 stated that there were no other care plans associated with Resident #24's pressure ulcers, and confirmed that the two care plan problems that were given to the survey team hadn't been updated since 2/14/17, even though they had been evaluated at least quarterly.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0309 (Tag F0309)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record documentation and staff interviews, it was determined that the facility staff failed to provide services to maintain the highest practicable physical well-being related to the use of a leg brace that caused a lesion to a resident's knee. This was evident for 1 (Resident #8) of 26 residents reviewed during stage 2 of the Quality Indicator Survey. The findings include: During facility tour on August 15, 2017, Resident #8 was observed with a right knee skin lesion. An interview was conducted with the resident on the same day at 1:45 PM. When asked by the surveyor about the right knee lesion, Resident #8 stated that s/he had a brace applied to the right leg which caused this lesion, and further indicated that brace had not been used since the lesion was identified. Review of the medical record revealed a concurrent review dated July 23, 2107 which indicated that Resident #8 was observed with an unopened blister to the right knee during evening care. The area measured 0.5 cm x 0.5 cm and was intact. A new order was obtained for sure prep to be applied every shift until the blister resolved, and this treatment was done as ordered. Further review of the physician's note dated July 24, 2017 revealed that the physician documented a stage 2 blister to the right knee. Weekly skin evaluation forms were reviewed that documented a blood-filled blister on the right knee with slight discomfort to touch on July 24, 2017. On August 1, 2017, August 7, 2017, and on August 14, 2107, eschar formation was present on the right knee with no drainage noted. Review of the care plan dated July 24, 2017 revealed that Resident #8 wears a leg brace on a daily basis, and that the rehabilitation department was made aware of the blister. Resident #8's physician orders were reviewed on August 16, 2017, and no order for the right leg brace was found in the medical record. A review of Physical Therapy weekly progress notes was conducted on August 17, 2017 and revealed the following information: On June 2, 2017, it was documented that the patient would benefit from bilateral knee orthosis to increase/maintain range of motion (ROM) on bilateral knees for positioning and contracture management. On June 9, 2017, it was documented that a right knee orthosis should be used to increase passive range of motion (PROM). On June 16, 2017, it was documented that the patient demonstrated increased tolerance for orthosis donned for 3 to 5 hours without complaint of pain. No redness or skin breakdown was found post application of orthosis upon inspection. On June 30, 2017, it was documented that the patient received new knee extension braces this week and is tolerating them up to 7 hours with no skin redness, etc. On July 7, 2017, it was documented that orthotic management and training was given to caregivers through demonstration with verbal cues to reinforce technique and sequencing. Caregivers demonstrated fair to fair + carry over through return demonstration. It was also stated that further training was required until the patient was discharged from skilled physical therapy. It was documented that the plan was to continue orthotic management and training to caregivers and establish a splinting schedule at bedtime. Findings were discussed with the Administrator on August 17 and August 18, 2017, who confirmed that there was no physician's order for the brace to the right leg. Further, the Administrator indicated that when physical therapy educated nursing staff on the brace's application, they should use an education sheet but that no education sheets were found for the resident. The Administrator indicated that some GNA's confirmed that they received training. Specifically, the Administrator reports that GNA #1 received training on proper splint application from physical therapy and had used a splint on several occasions, GNA #2 stated that s/he was trained on the splint application but had never put the splint on the resident, and GNA #3 only indicated that s/he was trained on how to put a brace on. The Administrator stated that staff will be trained on splint procedures and that this will be documented on facility in-service sheets, that orders will be written once a splint is issued to the patient, and that an instruction sheet including photos will be placed in the splint book in the rehabilitation department and in the GNA [NAME]. Review of the medical record failed to reveal a physician's order for a leg brace. The resident's plan of care failed to reveal a plan to use a leg brace.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0431 (Tag F0431)

Could have caused harm · This affected 1 resident

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Based upon surveyor observation, it was determined that facility staff failed to properly store medication due to a failure to properly label opened medications. This was evident in 2 of 4 medication rooms observed during Stage 2 of the Quality Indicator Survey. The findings include: The Unit 2B Medication Room was reviewed on 8/18/2017 at 8:15 AM. The surveyor observed an opened bottle of Senna Plus that lacked an open date label. The Unit 2A Medication Room was reviewed on 8/18/2017 at 8:25 AM. The surveyor observed an opened bottle of Senexon-S that lacked an open date label. The findings were shared and confirmed with the Director of Nursing on 8/18/2017 at 10:30 AM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0514 (Tag F0514)

Could have caused harm · This affected 1 resident

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Based on medical record review documentation and staff interview, it was determined the facility staff failed to have complete and accurate documentation in the medical record. This was evident for 1 (Resident #8) of 26 residents reviewed during Stage 2 of the Quality Indicator Survey. The findings include: Resident #8's monthly physician's orders for July, 2017 were reviewed on August 17, 2017, and two physician's orders pertaining to the resident's dietary consistency were revealed. The first order dated May 29, 2017 was for a pureed diet, and the second order dated July 19, 2017 was for a Dysphagia 3 diet. A Dysphagia 3 diet includes moist foods in bite-size pieces that are easier to chew and swallow. Foods that are hard, sticky, crunchy, or very dry should be avoided. Findings were discussed with Administrator on August 17, 2017 and Administrator agreed that pureed diet should not have been documented on July, 2017's monthly physician's orders, and the nurse that did monthly order's turnover should have noticed it.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most Maryland facilities.

Concerns

• 72 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade D (40/100). Below average facility with significant concerns.

Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Courtland, Llc's CMS Rating?

CMS assigns COURTLAND, LLC an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Courtland, Llc Staffed?

CMS rates COURTLAND, LLC's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 47%, compared to the Maryland average of 46%.

What Have Inspectors Found at Courtland, Llc?

State health inspectors documented 72 deficiencies at COURTLAND, LLC during 2017 to 2025. These included: 71 with potential for harm and 1 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates Courtland, Llc?

COURTLAND, LLC 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 FUTURE CARE/LIFEBRIDGE HEALTH, a chain that manages multiple nursing homes. With 151 certified beds and approximately 143 residents (about 95% occupancy), it is a mid-sized facility located in BALTIMORE, Maryland.

How Does Courtland, Llc Compare to Other Maryland Nursing Homes?

Compared to the 100 nursing homes in Maryland, COURTLAND, LLC's overall rating (1 stars) is below the state average of 3.0, staff turnover (47%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Courtland, Llc?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Courtland, Llc Safe?

Based on CMS inspection data, COURTLAND, LLC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Courtland, Llc Stick Around?

COURTLAND, LLC has a staff turnover rate of 47%, which is about average for Maryland nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Courtland, Llc Ever Fined?

COURTLAND, LLC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Courtland, Llc on Any Federal Watch List?

COURTLAND, LLC 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.

Facility Details

Beds: 151
Avg. Residents: 143
Occupancy: 95.0%
Ownership: For profit - Limited Liability company
Chain: FUTURE CARE/LIFEBRIDGE HEALTH
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
72 Deficiencies: -10
Final Score: 40/100

Nearby Alternatives

TOWSON REHABILITATION AND HEA... 5-star COMPLETE CARE AT MULTI MEDICAL... 5-star FUTURE CARE OLD COURT 5-star

View all in BALTIMORE →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 215128