How many inspection deficiencies does FUTURE CARE IRVINGTON have?

FUTURE CARE IRVINGTON has 48 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at FUTURE CARE IRVINGTON?

FUTURE CARE IRVINGTON has a two-star staffing rating from CMS with 1.26 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 FUTURE CARE IRVINGTON located?

FUTURE CARE IRVINGTON is located in BALTIMORE, MD. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does FUTURE CARE IRVINGTON have?

FUTURE CARE IRVINGTON has 200 certified beds.

Who owns FUTURE CARE IRVINGTON?

FUTURE CARE IRVINGTON 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 FUTURE CARE IRVINGTON?

Families visiting FUTURE CARE IRVINGTON 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 FUTURE CARE IRVINGTON compare to other nursing homes?

FUTURE CARE IRVINGTON has a 4-star overall rating, placing it above average compared to other nursing homes in MD. Higher-rated facilities typically have better inspection results and staffing levels.

FUTURE CARE IRVINGTON

Name: FUTURE CARE IRVINGTON
Address: 22 SOUTH ATHOL AVENUE, BALTIMORE, MD, 21229, US
Telephone: (410) 947-3052
Rating: 4.0

22 SOUTH ATHOL AVENUE, BALTIMORE, MD 21229 · (410) 947-3052

For profit - Limited Liability company 200 Beds FUTURE CARE/LIFEBRIDGE HEALTH Data: November 2025

Trust Grade

55/100

#64 of 219 in MD

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Last Inspection: June 2023

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

Overview

Future Care Irvington in Baltimore has a Trust Grade of C, which means it is average and sits in the middle of the pack among nursing homes. It ranks #64 out of 219 in Maryland, placing it in the top half, and #6 out of 26 in Baltimore City County, indicating only a few local facilities are better. The facility is showing improvement, as the number of issues reported decreased significantly from 17 in 2023 to just 1 in 2025. However, staffing is a concern with a low rating of 2 out of 5 stars and a high turnover rate of 52%, significantly above the state average. The facility has faced some serious incidents, including a resident who suffered a head injury due to inadequate supervision and another who went untreated for a painful toothache, which ultimately required a hospital visit. Despite these weaknesses, the nursing home does have good RN coverage, surpassing 89% of Maryland facilities, indicating that registered nurses are more involved in resident care.

Trust Score: C
In Maryland: #64/219
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $28,915 in fines. Higher than 56% of Maryland facilities. Some compliance issues.
Skilled Nurses: Each resident gets 75 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: 48 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★★

5.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2023: 17 issues

2025: 1 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

Staff Turnover: 52%

Near Maryland avg (46%)

Higher turnover may affect care consistency

Federal Fines: $28,915

Below median ($33,413)

Moderate penalties - review what triggered them

Chain: FUTURE CARE/LIFEBRIDGE HEALTH

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 48 deficiencies on record

2 actual harm

Jul 2025 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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Based on medical record review and staff interview, facility staff failed to follow a resident's plan of care to prevent injury to resident while providing care. This resulted in harm to Resident #6. This was evident for 1 of 3 residents reviewed for falls during a complaint survey.After the incident, the facility developed, initiated and completed a plan of correction to prevent further injuries to residents while providing care. Therefore, this deficiency will be cited as past non-compliance. The date of correction was 8/18/23. The findings include:Review of complaint intake MD00195745 (Iqies: 297381) on 7/17/25 at 10:52 AM revealed that Resident #6's family alleged that the resident fell from his/her bed and sustained a laceration to the head due to facility staff failing to provide adequate supervision to the resident. Review of Resident #6's medical record on 7/17/25 revealed a care plan which stated that the resident required 2 person assistance for toileting and bed mobility as of 2/21/21. Review of Resident #6's medical record on 7/17/25 revealed a progress note which stated that the resident had a fall incident on 8/12/23. The resident was observed with a laceration to the right side of his/her forehead as a result of the fall. The resident's forehead laceration was wrapped with gauze and the resident was transferred to the local hospital for evaluation and treatment. Continued progress note review on 7/17/25 at 12:00pm revealed that the resident returned from the local hospital after treatment on 8/13/23. The resident returned with forehead stitches that were used to close the forehead laceration. Interview with the Director of Nursing (DON) on 7/17/25 at 12:30pm confirmed that the Resident #6 had a fall incident on 8/12/23. The resident sustained a forehead laceration from the fall which required the resident to be transferred to the local hospital for treatment. The DON confirmed that a fall investigation was conducted, and the fall investigation revealed that the assigned nursing staff, Geriatric Nursing Assistant (GNA) #9, failed to follow the resident's care plan when he/she provided toileting care for the resident on 8/12/23. The facility developed a place of correction which included re-education of all nursing staff on reviewing the resident's plan of care prior to providing care to the resident and bed mobility techniques. Review of the facility's fall investigation on 7/18/25 at 9:47 AM revealed that the fall incident occurred on 8/12/23 at approximately 12:15 PM. The facility investigation contained a witness statement from GNA #9 dated 8/14/23 which stated that GNA #9 failed to follow the resident's care plan for 2 person assistance when providing toileting care. GNA #9's statement revealed that the resident fell from his/her bed and hit his/her head on the floor when GNA #9 provided toileting care to the resident alone. The statement was taken by former Administrator #18 and the DON was the witness. The DON provided the surveyor with the GNA Kardex for Resident #6 on 7/18/25 at 10:30 AM. Review of the GNA Kardex revealed that the resident required 2 person assistance for toileting care and bed mobility. Interview with former Administrator#18 on 7/22/25 at 9:30 AM confirmed that he/she conducted the interview with GNA #9 after the fall incident with the DON as a witness. Former Administrator #18 also confirmed that GNA #9 admitted to providing toileting care to resident #6 alone when the resident's care plan required 2 person assistance for toileting care and bed mobility. The facility's Plan of Correction included the following immediate action taken related to the facility's staff failure to follow Resident #6's plan of care which was verified by the survey team: The DON completed re-education of GNA#6 and all other nursing staff on reviewing bed mobility requirements prior to resident care and bed mobility techniques. Unit Managers/DON/ADON reviewed current residents' GNA Kardexes and care plans to ensure the appropriate bed mobility/fall prevention needs were documented. Reviewed the last 30 days of falls (ending in 8/14/23) involving current residents to ensure that no other residents were impacted by nursing staff failing to follow bed mobility plans of care. Conduct observations of residents requiring 1-2 person assistance with bed mobility daily for 2 weeks. Conduct random observances of 10% of residents requiring 1-2 person assistance for bed mobility for 2 weeks. Review incident reports daily in clinical meetings to ensure nursing staff were following the resident's plan of care. Charge nurses/supervisors continue random audits of 10% of residents requiring 1-2 person assistance with bed mobility weekly for 10 weeks after initial 2 week evaluation. Report results of the bed mobility observations and audits to the QAPI committee.

Jun 2023 17 deficiencies

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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Based on interview and review of medical records it was determined that the facility failed to obtain a resident's advanced directives. This was found evident for 1 of 3 residents (Resident #367) reviewed for advanced directives during an annual and complaint survey. Advanced Directive: A written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. The findings include: On 6/9/23 at 9:03 AM, the surveyor reviewed Resident #367's medical record. The review revealed that Resident #367 was admitted to the facility in late May 2023. The Brief Interview for Mental Status (BIMS) evaluation was done on 5/25/23, and indicated Resident #367 was cognitively intact, with a score of 15. Further review of Resident #367's medical record revealed a progress note written by Social Worker Staff #19. The note stated that Resident #367 had an appropriate Medical Order for Life-Sustaining Treatment (MOLST) in the record. The note further stated that the Social Worker would follow up with the resident's daughter regarding obtaining a copy of Resident #367's advanced directives. On 6/9/23 at approximately 9:20 AM, the surveyor further reviewed Resident #367's medical records. A MOLST order, dated 3/17/23, was reviewed. In the section labeled The basis of these orders a box was checked on health care agent as named in the patient's advanced directives, indicating the life-sustaining treatment order was discussed and consented from Resident #367's health care agent. Further review of the medical record revealed no advanced directive was found for Resident #367. On 6/9/23 at 9:55 AM, the surveyor conducted a phone interview with Staff #19. During the interview, Staff #19 stated she remembered that Resident #367 had advanced directives indicated in his/her MOLST order. She stated she had not reached out the hospital to obtain a copy and that she was planning on reaching out to Resident #367's daughter first. When asked if she had reached out to Resident # 367's daughter, Staff #19 could not remember. The surveyor could not find any documentation that Resident #367's daughter was contacted or the status of obtaining the advanced directives. On 6/9/23 at 10:28 AM, the surveyor interviewed the Corporate Clinical Nurse Consultant. During the interview the surveyor discussed the concerns that a cognitively intact resident, with a BIMS score of 15, had an order based off of his/her advanced directives; however the advanced directives were not in the medical record.

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 record review, staff, and resident interviews it was determined that the facility failed to ensure that a resident was free from verbal abuse. This was found to be evident for 1 (Resident # 115) out of 2 residents reviewed for verbal abuse. The findings include: On 6/1/23 at 10:30 AM, the surveyors reviewed the Facility Reported Incident dated 11/7/22, the facility investigation alleged that Geriatric Nursing Assistant (GNA) # 3 had verbally abused Resident # 115. The surveyors reviewed the facility's Abuse and Neglect of Residents Policy on 6/1/23 at 10:44 AM. The definition of verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents, or within hearing distance, regardless of their age, ability to comprehend, or disability. On 6/2/23 at 9 AM, the surveyors conducted an interview with the Administrator, Regional Clinical Services Manager (RCSM) and the Director of Nursing (DON) about the verbal abuse investigation. During the interview the RCSM confirmed that GNA # 3 spoke inappropriately about Resident # 115 while providing care, therefore, the GNA was educated for customer service and the allegation for verbal abuse was unsubstantiated (compliant). During an interview conducted on 06/06/23 at 08:37 AM, the surveyors asked Resident # 115 if s/he remembered the incident that occurred with the GNA in the bathroom. Resident # 115 stated yes, GNA # 3 verbally abused me while providing my care. She stepped out of the room first, but I heard it. The resident further stated, I felt like I'd been talked about for no reason, it didn't feel good, and she doesn't work with me anymore. On 6/6/23 at 10:14 AM, the surveyors reviewed the consult with psychology from 11/14/22, that stated Resident # 115 reported that GNA # 3 had been verbally abusive and had not listened to or met the resident's needs. The resident also reported that since GNA # 3's assignment was changed, s/he now felt safe from verbal abuse.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interviews and reviews of the Facility Reported Incident (FRI) investigation documentation it was determined the facility failed to thoroughly investigate allegations of abuse. This was evident for 2 (Resident # 115 and # 21) out of 4 residents reviewed for abuse. The findings include: On 6/1/23 at 10:44 AM, the surveyors reviewed Facility Reported Incident (FRI) Facility Reported Incident dated 11/7/2022. The report revealed an allegation of verbal abuse. Geriatric Nursing Assistant (GNA) # 3 allegedly verbally abused Resident # 115 when she referred to the resident as a baby when he took off his/her shirt during care. During the interview conducted on 6/2/23 at 9:00 AM, with the Administrator, Regional Clinical Services Manager (RCSM) and the Director of Nursing (DON) about the allegation of Resident/Patient/Client Verbal Abuse for Resident # 115, the surveyors asked why the resident interview question asked, Has any staff member said to you that you act like a baby. The RCSM responded that she was unsure and would defer to Night Supervisor # 5, who had conducted that investigation. When further questioned about the verbiage of the investigation, the RCSM and DON stated that it might have been more appropriate to question about all types of verbal abuse during the investigation interviews. On 6/1/23 at 11:30 AM, the surveyors reviewed Facility Reported Incident (FRI) Facility Reported Incident dated 11/7/2022. The report revealed an allegation of physical abuse was investigated about a bug or person that bit Resident # 21 on the side or bottom. During the interview conducted on 6/2/23 at 9:00 AM, with the Administrator, the RCSM and the DON about the allegation of Resident/Patient/Client Physical Abuse for Resident # 21. The surveyors asked why the resident interview question asked, Have you ever been bitten for a physical abuse allegation. The DON responded that the actual interview included a conversation about being bitten by a bug or a person. The RCSM and DON stated that the question may have been too specific for an investigation of physical abuse.

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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Based on record reviews and interviews it was determined that the facility failed to provide notification in writing of a resident's transfer to the hospital. This was evident for 2 (# 113 and # 51) out of 2 residents reviewed for transfer notifications. The findings include: On 06/06/23 at 07:49 AM, the progress notes revealed hospitalizations for Resident # 113 on 2/8/23 and 3/21/23. The review of the medical records for Resident # 113 did not reveal written notification to the residents Power of Attorney (POA) in writing of the hospital transfers. During an interview on 06/06/23 at 08:43 AM, the Licensed Practical Nurse (LPN) # 6 stated the facility notified the responsible party and completed the bed hold paperwork when a resident is transferred to the hospital. During an interview with the Regional Care Services Manager (RCSM) on 06/06/23 at 11:46 AM, the RCSM confirmed that the facility did not notify Resident # 113's Power of Attorney, in writing of the hospital transfers. On 06/06/23 at 12:10 PM, a review of the progress notes revealed hospitalizations for Resident # 51 on 1/3/23 and 4/3/23. Further review of the resident's medical records did not reveal written notification to the residents Power of Attorney in writing of the hospital transfers. During an interview with the Regional Care Services Manager (RCSM) on 06/07/23 at 10:20 AM, the RCSM confirmed that the facility did not notify Resident # 51's Power of Attorney, in writing of the hospital transfers.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observations, interviews, and record reviews, it was determined that the facility failed to: 1) develop comprehensive care plans for, 1) oxygen therapy and 2) behaviors related to psychiatric diagnoses. This was found to be evident for 2 (# 125 and # 157) out of 9 residents reviewed for comprehensive care plans. The findings include: 1) 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. During an observation conducted on 05/30/23 at 10:27 AM, the surveyors observed Resident # 125 administered through a nasal cannula. On 06/12/23 at 12:25 PM, a review of Resident # 125's care plan did not reveal a care plan for oxygen therapy. During an interview conducted on 06/13/23 at 01:43 PM, the Regional Clinical Services Manager (RCSM) confirmed Resident # 125 did not have a care plan that addressed the continuous Oxygen therapy. The RCSM provided the surveyors with a care plan that included oxygen therapy. 2) On 6/5/23 at 11:01 AM, a medical record review was conducted. Resident # 157 has a diagnosis of Bipolar, dementia, history of alcohol abuse and smoking among other diagnosis. His/ Her behaviors include yelling and screaming, false beliefs, removing gown and diaper, jittery and nervousness, suspicious of others. Resident # 157 is currently on Quetiapine 50 mg 1 tab at bedtime and Remeron to boost appetite. He/She is to be followed by psychiatric services. An order was written on 4/17/23 and Resident #157 was not seen as of yet. On 6/5/23 Resident #157 contacted 911 to report that People were being mean to her. Two Police officers arrived to hear the resident's concerns. Report taken and the Officers exited the building. There is a mood care plan, however it is not comprehensive and does not address his/her behaviors or possible side effects of medication. No behavior monitoring for jittery/nervousness behavior for May or June 2023. The comprehensive care plan did not reveal that Resident # 157 had a mental illness when she came to the facility. That was confirmed on 6/5/234 at 11:40 AM with the Regional Clinical Nurse Manager, who agreed and stated the care plan will be updated and changed. The RCSM was to put this in the plan of correction.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, the facility failed to provide bladder care to a dependent resident, # 148, on a daily basis. This was evident for 1 (Resident # 148) out of 3 dependent residents reviewed for bowel and bladder care. The findings include: On 6/12/23 at 12:29 PM a review of residents GNA [NAME] was reviewed. (Geriatric Nursing Assistant, [NAME] is documentation of what was done for resident on a day to day basis). Family of resident reported a complaint, #MD00189280, to the Office of Health Care Quality (OHCQ) stating the resident was being neglected at the facility and staff are not monitoring the pt (patient) and that the resident is often left soiled for extended periods of time to the point that rehab services will not see the resident. Documentation revealed that Resident #148 had been changed every day with the exception of on 4/8/23 evening shift, and on 4/7/23 night shift. In addition, the record review revealed that in February 2023 on the 2/15-day shift, 2/11, 2/12 night shift, and in March 2023, 3/7, 3/9, 3/14, 3/16-day shift and on 3/7 night shift. Tthere was no documentation that Resident #148 was changed. An interview was held with the Director of Rehabilitation Services, Staff # 25, on 6/12/23 at 11:58 AM. Staff # 25 stated the resident has never been too soiled that rehabilitation cannot do their job and if the resident was soiled occupational rehabilitation staff will change his/ her diaper.

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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Based on interviews with staff and medical record review it was determined that the facility failed to follow-up on a physician's order. This was found evident of 1 of 6 Residents (Resident #97) reviewed for positioning during an annual and complaint survey. The findings include: On 6/9/23 at 5:39 AM, the surveyor reviewed Resident #97's medical records. The review revealed that Resident #97 was admitted to the facility in late 2022 and had a medical history that included, muscle weakness, difficulty in walking, and complications from surgical and medical care. On 6/9/23 at 11:06 AM, the surveyor interviewed Resident #97. During the interview Resident #97 stated the staff had just brought a wheelchair to his/her room. Resident #97 further explained he/she hadn't had one for a month and he/she recently went to his/her podiatry (study, diagnosis, and treatment of disorders of the foot, and ankle) appointment in a stretcher. On 6/9/23 at 11:50 AM, the surveyor reviewed Resident #97's orders. On 5/3/23 an order was placed requesting a clarification of weight bearing status from the consulting podiatry evaluation completed on 5/1/23. The surveyor further reviewed the orders and found no follow-up clarification order for weight bearing status for Resident #97. On 6/12/23 at 10:03 AM, the surveyor interviewed Unit Manager Staff #26. During the interview Staff #26 stated after a resident returns from a consult appointment the nurse assigned to that resident reviews the recommendations and would communicate the recommendation by entering them into the computer. The secretary would then make the appointments. Staff #26 further stated she had called Resident #97's podiatry office multiple times to clarify weight bearing status and left messages at the podiatry office. Staff #26 reported she does not always document after reaching out to consulting services. She reported she had left a message on 6/9/23 and would check to see if they called back. On 6/12/23 at 10:12 AM, the surveyor conducted a follow-up interview with Staff #26. She stated that the podiatry office returned her call and clarified that Resident #97 should be at full weight bearing status and could now work with Physical Therapy (PT). This clarification was provided after the surveyor had inquired, with no documentation on any follow-up attempts, and over a month from when the order was written. On 6/12/23 at 10:52 AM, the surveyor interviewed Rehabilitation Director Staff #25. Staff #25 reported that both physical therapy and occupational therapy worked with Resident #97 when he/she was first admitted and was discharged with the recommendations to start therapy when Resident#97 was allowed to weight bear on his/her feet. On 6/13/23 at 10:06 AM, the surveyor conducted a follow-up interview with Staff #25. During this interview Staff #26 reported Resident #97 received an order and was now able to work with therapy again due to the new weight bearing status clarification. She reported that Resident #97 was eager and motivated to start therapy.

CONCERN (D)

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 medical record review and interview it was determined that the facility failed to ensure interventions were implemented to prevent significant weight loss for a resident who was receiving enteral nutrition (receiving feeding through an artificial tube, not by mouth.). This was evident for 1 out of 5 residents reviewed for nutrition. The findings include: Review of the medical record on 6/5/23 at 10:47 AM for Resident #142 revealed they had been admitted to the facility beginning on 12/22/22. The resident's weight was documented as obtained upon admission (198 lbs.), and upon re-weight on 12/23/22 (199.7 lbs.). Additional weights were obtained on 1/4/23 (12 days later, 201 lbs.) and 2/8/23 (35 days later, 173.8 lbs.), at which point Resident #142 had sustained a significant weight loss of 27.2 lbs. On 6/5/23 at 2:02 PM the surveyor reviewed the facility's policy for obtaining resident weights. According to the facility policy, residents are weighed upon admission, then re-weighed within 1-3 days to ensure the accuracy of the admission weight and are to be placed on weekly weights for at least 4 weeks or until weight is stable as determined by the Risk Committee. Further review of the medical record on 6/6/23 at 9:16 AM revealed a dietary note written by Staff #36, Registered Dietician, dated 1/29/23 at 12:09 PM documenting the last weight as having been obtained on 1/4/23 and their subsequent estimation of the resident's nutritional needs via tube feeding. Another dietary note written on 2/10/23 at 9:20 PM detailed follow up of the resident addressing the weight obtained on 2/8/23 and noted the significant loss, with a recommendation from Staff #36 to start weekly weights for the resident for close monitoring. A change in condition form was completed by nursing staff dated 2/11/23 which documented the weight loss and notification to the primary care clinician. Documentation of weights showed the next weight was obtained on 2/16/23 and then not again until 3/3/23 (15 days later). On 2/28/23 Staff #36 documented that they were monitoring weekly weights. On 3/3/23 when the resident was weighed, they had sustained further weight loss of 3.6 lbs. On 6/6/23 at 10:15 AM an interview was conducted with Staff #36, who confirmed that weights are to be done weekly for residents upon admission for the first 4 weeks, and that weights for this resident had been missed. On 6/6/23 at 12:20 PM, the surveyor was provided with a concerns chart for unintended weight loss/gain dated 2/16/23 that stated the following interventions: Increased En (tube) feeding and started weekly wt (weights). A weekly risk meeting staff sign in sheet was also provided to the surveyor that was dated 2/21/23. However, upon surveyor's review of the medical record, no weights had been obtained after 2/16/23 until 3/3/23. On 6/7/23 at 2:00 PM, medical provider evaluations (form the physician uses to document resident assessment/visits) from February 2023 were reviewed and no documentation could be found that specifically addressed the resident's significant weight loss.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with Resident and staff, review of facility's policy, and of medical records it was determined that the facility failed to follow professional standards for a resident receiving oxygen by: a) administrating oxygen without an order, and b) administrating oxygen at an inaccurate rate. This was found evident of 1 of 7 Residents (Resident #131) reviewed for respiratory care during an annual and complaint survey. The findings include: 1a) On 6/7/23 at 9:49 AM, the surveyor reviewed Resident #131's medical record. The review revealed that Resident #131 was admitted to the facility on [DATE]th 2023 and had a past medical history of chronic respiratory disease, chronic obstructive pulmonary diseases, and heart failure. Further review of the record revealed a nursing admission note dated 4/7/23 stating, Resident #131 was oriented to room and was on 4 Liters of oxygen via Nasal Cannula (a tube that lays outside of nares that delivers oxygen). On 6/7/23 at 10:20 AM, the surveyor reviewed the orders for Resident #131. There was no order for Resident #131 to receive oxygen via nasal cannula from his/her admission date on 4/7/23 through 4/10/23. On 6/8/23 at 10:30 AM, the surveyor reviewed the pulse oximetry readings (a measurement of oxygen saturation in the blood) for Resident #131. The readings from 4/7/23-4/9/23 indicated that Resident #131 was on oxygen via nasal cannula when the measurements was taken on 9 out of the 10 measurements. The surveyor reviewed the facility policy titled: Oxygen Administration per Nasal Cannula. In the section labeled, policy it states, A physician's order is required for administrating oxygen. 1b) On 6/7/23 at 12:03 PM, the surveyor observed Resident #131's oxygen flow meter (a device used to measure the rate at which gas/oxygen flows) measuring the oxygen flow at 3 Liters (L). Resident #131 was receiving the oxygen via nasal cannula. On 6/7/23 at 12:05 PM, the surveyor conducted an interview with the Licensed Practical Nurse (LPN), Staff #35. Staff #35 stated he was Resident #131's nurse. Staff #35 walked to Resident #131's room and observed Resident # 131 was receiving 3L of oxygen. Staff #35 assessed Resident #131 and stated it was an error. Staff # 35 then adjusted the flow rate of Resident #131's oxygen to 2L. On 6/9/23 at 6:20 AM, the surveyor interviewed the Corporate Clinical Nurse Consultant and discussed the concerns of oxygen being delivered without an order and at an inaccurate rate.

CONCERN (D)

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

Deficiency F0711 (Tag F0711)

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 reviews, observations, and interviews it was determined the facility failed to ensure a resident's orders for life sustaining treatment were valid and reviewed by the physician during the facility's admission process. This was evident for 1 out of 3 residents reviewed for advanced directives. The findings include: On 6/1/23 at 1:20 PM the surveyor reviewed the paper chart for Resident #151 and was unable to locate a Maryland Orders for Life Sustaining Treatment (MOLST) form. A Pennsylvania Orders for Life Sustaining Treatment (POLST) form was observed located in the paper chart last dated 3/3/23. Resident #151 was admitted to the facility on [DATE]. The Pennsylvania Life Sustaining Treatment Orders had not been signed by a physician. On 6/1/23 at 1:26 PM the surveyor requested a copy of the POLST form from Staff #43, Unit Manager, Regional Mobile Resource RN, and inquired as to where the MOLST form was located. Surveyor observed the electronic medical admission record which stated See MOLST. On 6/1/23 at 1:41 PM, the Director of Nursing responded to the surveyor that only the POLST form could be found in the resident's medical records. Subsequently, the Corporate Clinical Nurse Consultant inquired to the surveyor as to whether there was a concern with advanced directives and further reported to the surveyor that the facility doesn't have to do anything with a Pennsylvania MOLST, and if there is a problem, they would have to perform a whole facility audit of charts. On 6/6/23 at approximately 12:50 PM, the surveyor again reviewed the resident's chart and observed the POLST form was present, and no MOLST was present. On 6/8/23 at 8:24 AM, the surveyor observed the electronic medical admission record which stated See POLST dated 3/3/23, however, a physician order had been placed on 6/8/23 stating: See MOLST Dated 6/7/23. Further review of the medical record revealed a MOLST had been completed which was dated 6/7/23. Upon review of the medical provider evaluation (form the facility uses to document assessment performed by the physician) which was dated 3/16/23, no review of advanced directives or orders for life sustaining treatment was documented. During an interview on 6/8/23 at 12:31 PM, the Corporate Clinical Nurse Consultant stated to surveyors that the facility's policy is that the facility honors other state's advanced directives. The surveyor then inquired as to why the Social Worker had replaced the POLST with a MOLST the day prior, to which they replied the surveyor would need to ask her (the social worker) why they did that. On 6/8/23 at 12:42 PM the facility's policy regarding advanced directives was reviewed by the surveyor. On 6/9/23 at 11:49 AM, Staff #44, Social Work Director, was interviewed as to the process followed when a resident is admitted to the facility with an out of state POLST. Staff #44 responded to surveyors with the following information: We try to honor those, I try to update them to a Maryland form, but they do honor out of state MOLSTS. When asked by the surveyor why they had obtained a MOLST to replace the POLST for Resident #151, they replied it was because you had questioned it. On 6/9/23 at 12:42 PM the Medical Director was interviewed who reported their understanding of the expectations for physicians obtaining a MOLST occurs at the time of admission, typically 24-72 hours and it is expected that they review the MOLST and it should be in the chart, if a resident is transferred, they accept the MOLST from the hospital if it is filled out correctly, they do not have to do another. With regard to out of state orders for life sustaining treatment, they reported a review should occur on admission, and if they are filled out appropriately, it should be respected while trying to make state specific changes.

CONCERN (D)

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

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

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Based on interviews with staff and record review it was determined that the facility failed to: 1) comprehensively review behavioral health medications, and 2) contact psychiatric services for a resident who had an order to see a Psychiatrist. This was evident for 2 (Resident # 124 and #157) out of 8 residents reviewed for behavioral health during the annual and complaint survey. The findings include: Gradual Dose Reduction: Is a process of tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or the medication can be discontinued. 1) On 6/8/23 at 10:21 AM, the surveyor reviewed Resident # 124's medical record. The review revealed that Resident #124 had a past medical history of delusional disorders, unspecified dementia, psychotic disturbance, mood disturbance and anxiety. Further review of the medical record revealed Resident #124 had been seen by Certified Registered Nurse Practitioner - Psychiatric Mental Health CRNP-PMH (Staff #41) for a follow-up evaluation on 11/21/22. Staff #41 recommended that Resident #124 start Olanzapine, a psychotropic medication used to treat mental and mood conditions. On 6/8/23 at 10:45 AM, the surveyor reviewed Resident # 124's orders. On 11/21/22 Olanzapine was ordered for Resident #124. Further review revealed that Resident #124 received Olanzapine starting on November 22, as ordered, every day, November 22, 2022 through the end of January 2023. On 6/8/23 at 10:50 AM, the surveyor reviewed additional follow-up visits by Staff #41. On 12/30/22 Staff #41 evaluated Resident #124 as a follow-up visit. Staff #41 documented that psychiatric medications were reviewed in the note, however wrote, No to a Gradual Dose Reduction (GDR) followed by; GDR is NOT relevant at this time as pt [patient] not on psychotropics at this time. No documentation was found in the note to indicate the effectiveness of the new medication recommended by staff #41, that was started on 11/22/22. Staff #41 conducted a follow-up evaluation on 1/23/23. Again, Staff #41 documented that Resident #124's psychiatric medication was reviewed and recommended, the staff responded, no, to the GDR due to Resident #124 not being on any psychotropic medications at this time. On 2/27/23 Staff #41 documented a follow-up evaluation. In this note Staff #41 documented that Resident #124's psychiatric medications were reviewed and indicates that no GDR is indicated because Resident 124 was benefiting from and tolerating psychotropics as prescribed. On 6/13/23 at 2:30 PM, the surveyor conducted a phone interview with the Certified Registered Nurse Practitioner - Psychiatric Mental Health CRNP-PMH (Staff #42). Staff #42 stated that Staff #41 no longer worked for Counterpoint Health Services, the providers of psychiatric services for the facility. Staff #42 stated he would expect documentation and evaluation of a new medications if one was just started. He, also, stated a GDR would not be indicated after a short course of a medication, however the multiple documentations of no psychotropic medications for Resident #124 may have been an oversite. 2) On 6/5/23 at 11:01 AM a medical record was reviewed. Resident # 157 has a History of Bipolar, Dementia, alcohol abuse, smoking, and dementia among other diagnoses. His/Her behaviors include: yelling, screaming, false beliefs, removing gown and diaper, jittery and nervousness and suspicious of others. His/Her affect is flat, and he/she was reluctant to answer questions. An order was written for the resident to see Psychiatric Services on 4/17/23. Resident #157 has not been seen to date. The resident had an incident on 6/6/23 in which she called the police to say people were mean to her and transferred her roughly. This incident was reviewed and not substantiated. The Regional Clinical Service Manager was notified and stated that Psychiatric Services were out sick for 1 week during the month of May 2023. She stated on 6/5/23 at 11:01 AM, that she will arrange Psychiatric Services to see the resident.

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** Based on observations, interviews, and review of policies and procedures, the facility failed to: 1) ensure that staff performed hand hygiene, and 2) to sanitize equipment between residents. This was evident for 3 (# 28, # 29, and # 38) out of 8 staff observed during the annual and complaint survey. The findings include: Hand Hygiene observations were conducted on 06/13/23 at 08:08 AM during the breakfast service. The surveyors observed Certified Nursing Assistant (CNA) # 28 enter and exit resident room numbers 248, 250, and 242 without performing hand hygiene. 1) During the continued observations, the surveyors interviewed CNA # 28. The CNA confirmed she had not performed hand hygiene. When asked what her understanding of the handwashing policy was, she stated, It is expected that I perform hand hygiene on entry and exit of resident's room. I usually do but I was nervous because you were watching. Hand Hygiene observations were conducted on 06/13/23 at 08:15 AM during the breakfast service. The surveyors observed CNA # 29 enter and exit resident room numbers 252, 256 and 262 without performing hand hygiene. During the continued observations, the surveyors interviewed CNA # 29. The CNA confirmed she had not performed hand hygiene. When asked what her understanding of the handwashing policy was, she stated, I usually do it after I'm done. The policy is to do it, but my hands get sticky. During an interview conducted on 06/13/23 at 09:06 AM, the Regional Clinical Services Manager (RCSM) was informed of the hand hygiene observations. The RCSM stated that the staff involved already told the Director of Nursing (DON) that they were observed not performing hand hygiene and they were pulled off the floor for additional training. On 06/13/23 09:37 AM, the facility Handwashing/Hand Hygiene, Employee policy statement was found to state that personnel should perform hand hygiene before and after direct contact with residents. 2) On 6/15/23 at 8:45 AM, the surveyor observed Licensed Practical Nurse (Staff #38) walk out of room [ROOM NUMBER] with a blood pressure machine and leave the machine next to the medication cart. Staff #38 reported she just took a resident's blood pressure, and she was going to give the resident their medications. The surveyor observed Staff #38 give the medications to the resident in room [ROOM NUMBER] and return to the medication cart. On 6/15/23 at 8:53 AM, the surveyor observed staff #38 grab the blood pressure machine, hand sanitize and take the machine into room [ROOM NUMBER], however the blood pressure machine was not sanitized. The surveyor observed Staff #38 take Resident #87's blood pressure with the machine and bring the machine back out to the medication cart. The surveyor then observed Staff #38 administer the medications to Resident #87. On 6/15/23 at 9:03 AM, the surveyor conducted a follow-up interview with Staff #38. During the interview Staff #38 stated, I realized I forgot to wipe down the machine between residents.

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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Based on interviews and review of medical records, and resident interviews, it was determined that the facility failed to: 1) update a care plan to reflect the current needs of the resident, and 2) involve the resident in the care planning process. This was evident of 4 (Residents #80, #97, #142 and #148) of 7 residents reviewed for care planning during an annual and complaint survey. The findings include: 1a) On 6/7/23 at 7:51 AM, the surveyor reviewed Resident #80's medical record. The review revealed that Resident #80 had a past medical history of, muscle weakness, unspecified fall, and anemia (low amount of red blood cells). On 6/13/23 at 7:19 AM, the surveyor reviewed the change in condition notes for Resident #80. The review revealed that Resident #80 had documented change of condition related to falls on 5/27/23, 5/30/23 and 6/5/23. Further review of the change of condition note written on 5/27/23 recommended re-educating the Resident regarding unassisted ambulation. On 6/13/23 at 8:16 AM, the surveyor reviewed Resident #80's care plan. An actual fall care plan was initiated on 5/30/23, however the first initial fall happened on 5/27/23. No new intervention was placed after the 5/27/23 fall. On 6/13/23 at 10:29 AM the surveyor interviewed the Director of Nursing (DON). During this interview the DON acknowledged initiating the actual fall care plan was missed on 5/27/23. 1b) Review of Resident #142's medical record on 6/6/23 at 8:23 AM revealed the resident had a foley catheter (tube that drains urine from the bladder) inserted on 5/25/23, with no corresponding revision or addition to the resident's comprehensive care plan to address the foley catheter. During an interview on 6/8/23 at 10:30 AM no documentation of the foley catheter having been care-planned could be provided to the surveyor at which time the Corporate Clinical Nurse Consultant confirmed verbally that Resident # 142's foley catheter had not been care-planned. Cross Reference F842. 2a) On 6/1/23 at 10:29 AM, the surveyor interviewed Resident #97. During the interview Resident #97 stated he/she never participated in care plan meetings. On 6/9/23 at 5:39 AM, the surveyor reviewed Resident #97's medical record. The review revealed that Resident #97 was admitted to the facility in late 2022 and was his/her own Responsibly Party (RP). On 6/9/23 at 5:42 AM, the surveyor reviewed a progress note dated 5/4/23, written by Licensed Practical Nurse (LPN) Staff #37. The progress note stated that the Nurse Practitioner reviewed laboratory results for Resident #97 and no new orders were given. It also stated that Resident #97 was aware of the laboratory results and is his/her own RP. Further review of the progress notes written on 5/4/23 revealed a note written by Unit Manager Staff # 26. The note stated, a care plan meeting was conducted with Resident #97's son via the telephone. It further stated that medications were reviewed with the family and no concerns were expressed. There was no documentation that Resident#80 was present or invited to participate in the care plan. On 6/9/23 6:20 AM, the surveyor reviewed Resident #97's care plan attendance log with the Corporate Clinical Nurse Consultant. Resident #97 was documented in attendance, along with his/her son, on the care plan meeting that was conducted in December of 2022; however the care plan meeting that was conducted in March only had Resident #97's son. No attendance documentation was found for the 5/4/23 care plan meeting on the attendance log. The Corporate Clinical Nurse Consultant stated she would look into the concern. No new documentation was provided at the time of the survey exit on 6/16/23. 2b) On 6/14/23 at 1:23 PM a resident interview was held. Resident # 148 stated she/he had never been invited to a care plan meeting, although his/ her family has attended. Record review on 6/12/2023 at 12:21 PM revealed the resident is alert and oriented x 3. Further review of the record and Social Worker interview on 6/14/2023 at 1:23 PM indicated that on 5/10/23 Social Worker # 37 called the responsible party to advise of the care plan meeting to be held on 5/15/23 at the preferred time. Social Worker # 37 stated that a message was left by phone. The family attended along with the Interdisciplinary team and all the names of those who attended the meeting were on the care plan assignment sheet. Social Worker # 37 stated that he/she believed the resident refused, but there was no documentation of that in the record. The Social Worker and Regional Clinical Services Nurse (RCS) were informed by the surveyor on 6/14/23 at 2:30 PM, that this would be a deficiency.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews of facility staff it was determined the facility failed to ensure that tube feedings were managed appropriately according to professional standards. This was evident for 4 residents (#142, #156, #12 and #123) out of 4 residents who were observed to have tube feedings in place. The findings include: On [DATE] at 12:36 PM the surveyor observed Resident # 142's tube feed and line to be disconnected from the resident. Upon further observation, the tube feed container hanging in the room next to the resident was found to have a label which included a date of [DATE], and a time of 7:30 PM. The tubing line that was connected to the feed container was observed to have a label dated [DATE] and failed to include an expiration time for the line. During an interview with Staff #37, Charge Nurse, Licensed Practical Nurse, on [DATE] at 12:50 PM, they reported that staff is not expected to fill out everything on the tube feed labels and the facility's policy is that tube feed lines expire after 24 hours. The surveyor brought the concern regarding Resident #142's tube feed to the attention of Staff #37 and accompanied them to Resident #142's room to observe the concern. Regarding the tube feed line, Staff #37 confirmed the surveyor's observation and stated: It should be changed after 24 hours. On [DATE] at approximately 1:24 PM the surveyor observed an open system tube feed (feed bag that has tube feed poured into it) hanging in the room next to Resident #123. The cream colored solution contained in the open system tube feed was observed to have a curdled appearance. The surveyor further observed worn off writing in marker on the back of the feed bag which appeared to have a date of [DATE]. The tubing line was observed to be labeled clearly with a date of [DATE] and failed to include a time of expiration. On [DATE] at approximately 1:24 PM the surveyor observed Resident #156's tube feeding infusing with a tube feeding line that was labeled with a date and time of [DATE] at 6:00 AM. On [DATE] at approximately 1:25 PM the surveyor observed Resident #142's tube feeding to now be connected to the resident and infusing with the same tube feeding line dated [DATE] with no expiration time which was brought to the attention of Staff # 37 at 12:50 PM. On [DATE] at approximately 1:25 PM, Resident #12's tube feeding was observed and found to be connected to the resident infusing with the tube feeding line that had no label present to indicate the date and time the line should expire. On [DATE] at 1:38 PM the surveyor rounded with Staff #37 in the rooms of Resident #142, #12, #123, and #156. Staff #37 acknowledged surveyor's concerns and additionally confirmed that the tube feed lines were expired. Regarding Resident #123, Staff #37 reported the following: the bag looks gross and should have been thrown away. On [DATE] at 1:58 PM the surveyor's concerns were brought to the attention of the facility's Executive Director, Director of Nursing, and Corporate Clinical Nurse Consultant. On [DATE] at 9:26 AM, the surveyor requested and reviewed the facility's tube feed policy which included solution expiration times, however, did not address the feeding tube line expiration times or the facility's policy for labeling of feed solutions and lines. At this time, the surveyor inquired to the Corporate Clinical Nurse Consultant as to the protocol employees are taught during the orientation process, at which time they stated the following information: employees are expected to refer to the manufacturer's guidelines for the tubing itself and I read it and it is 24 hours expiration. On [DATE] at 10:00 AM, the general guidelines being taught by the facility for tube feedings were reviewed and no information could be found relating to labeling and expiration of tube feed lines. On [DATE] at 10:00 AM the Corporate Clinical Nurse Consultant reported to surveyors that they would be calling the tubing manufacturer to clarify how long the tubing can be used for. During an interview with Staff #8, Director of Education on [DATE] at 10:36 AM, they stated that during orientation for employees they are taught to date, label, and initial anything they open, including the spike set (tubing line for tube feed administration). Regarding surveyor's observation of Resident #123's open system, Staff #8 stated that bag should have been thrown away. On [DATE] at 11:28 AM, the surveyor made another observation of Resident #123's tube feeding. The open system tube feeding was observed to be hanging in the room with a date of [DATE] written on the bag and no time indicating when the solution would expire, and no date or time found on the tubing line. On [DATE] at 11:30 AM Staff #43, Unit Manager, Regional Mobile Resource RN, accompanied the surveyor to observe the concern for Resident #123's tube feeding at which time they verbally confirmed the feed should have been discarded and proceeded to appropriately discard the feed system. On [DATE] at 11:29 AM the surveyor provided an opportunity for the facility to submit any and all further documentation of the complete tube feeding policy and expectations for nurses when they go to hang tube feedings.

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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Based on observation, medical record review and interview it was determined that the facility failed to ensure the accuracy of medical orders/records and bathing documentation. This was evident for 1 (Resident #142) out of 2 residents that were reviewed for bowel and bladder, 1 (Resident #24) out of 9 residents reviewed for pressure ulcer/injury, and 1 (Resident #41) out of 1 resident that was reviewed for neglect. The findings include: 1) Upon review of Resident #142's medical orders on 6/5/23 at 9:17 AM, no order was present directing the insertion/placement of a foley catheter (tube that drains urine from the bladder). On 6/5/23 at 9:17 AM a nursing note dated 5/25/23 at 4:12 PM was reviewed which stated the following information: MD (medical doctor) ordered to place foley catheter for wound healing however, the medical order stated the following information: Patient has Foley catheter ,size French 16, for wound healing. Provide catheter care every shift. On 6/5/23 at 11:11 AM the surveyor requested documentation of the order for insertion/placement of Resident #142's foley catheter from the Corporate Clinical Nurse Consultant. During an interview on 6/5/23 at 1:30 PM, the facility's Corporate Clinical Nurse Consultant could not provide documentation of a medical order that directed insertion or placement of Resident #142's foley catheter and reported the following information: When the order was transcribed it does not say insert the foley, it says patient has foley catheter, but the progress note says MD ordered to place foley catheter for wound healing. Is this a records issue or a practice issue? Cross Reference F657. 2) On 6/15/23 at 10:13 AM, Resident #24 was observed sleeping in bed with bilateral (both sides) pressure relieving foot boots in place. Upon surveyor review of Resident #24's medical orders on 6/15/23 at 12:33 PM, no active order could be found for application of bilateral pressure relieving foot boots. Further review of Resident #24's medical record on 6/15/23 at 12:33 PM revealed physician medical provider evaluations dated 6/1/23, 6/2/23, and 6/14/23 which included documented assessment of the resident that states: Patient has bilateral feet boot in place. On 6/15/23 at 1:11 PM, the surveyor's concern was brought to the attention of the Director of Nursing and the Corporate Clinical Nurse Consultant and an opportunity to provide any documentation regarding a medical order for the boots was provided. On 6/16/23 at 8:29 AM, Resident #24 was again observed in bed with bilateral pressure relieving boots in place. On 6/16/23 as of 11:26 AM, no documentation of a medical order for the pressure relieving boots was provided from the facility and upon record review no order had yet been obtained. 3) On 6/12/23 at 10:28AM during an interview with Staff #10, Unit Manager, reported to the surveyor that Resident #41 frequently refused showers. On 6/12/23 at 11:40 AM, medical records for Resident #41 were reviewed which revealed that documentation of the resident's bathing was inaccurate. The Geriatric Nursing Assistant (GNA) task list (place where gna's document the bathing of a resident) was completed which reported the resident had received showers on 6/1, 6/6, and 6/10/23. On the treatment administration record (TAR) (record where nurses document care of a resident) the resident was documented as having been administered a shower on 6/2, 6/4, 6/5, 6/6, 6/7, 6/8, 6/9, 6/10, 6/11, 6/13, 6/14, and 6/15/23, with the treatment order stating the following information: shower twice weekly Tuesday, Friday, 3-11 shift. Further review of the medical record revealed staff had documented the resident had received tub baths on 10/9/22, 10/27/22, and 10/31/22. On 6/12/23 at 11:45 AM the Director of Nursing and the Corporate Clinical Nurse Consultant confirmed that there were no bathtubs within the facility. On 6/16/23 at 9:55 AM medical record review revealed several documented resident refusals of showers. During an interview on 6/16/23 at 10:59 AM, the surveyor had brought concerns to the attention of the Administrator and they confirmed that the check marks on the TAR meant a shower had been administered. They further stated the following information: Residents can have showers every day if they want. At this time the surveyor shared concerns about conflicting documentation between the TAR and the GNA task list.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation of dry goods in the kitchen on 5/30/23 at 9:15 AM, and foods stored in the freezer, the facility failed to label four food items in the freezer with the date. This was evident for 8 items in the freezer, pasta, and can goods in the dry storage areas. The findings include: On 5/30/23 at 9:15 AM a tour of the kitchen was conducted with Staff # 1 (kitchen supervisor). The freezer had a bag of cooked chicken that was not dated, opened and unopened french fries not dated, unopened hot dogs not dated and 4 large boxes of cheese cakes not dated. The items were pulled out of freezer and thrown away. In addition the dry storage area had pasta that was not dated and 1 large can of green beens that was dented and other cans of vegatables not dated. These items were pulled from the dry storage area, as well. The refrigerator had a case of strawberries that was delivered 3 days ago that had mold growing on them. The Director of Dietary Services was made aware of these concerns on 6/2/23 at 10:30 AM.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected most or all residents

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Based on observation, record review and interview it was determined that the facility failed to ensure posting of the most recent survey results. This was evident during surveyor review of a complaint during the facility's annual survey. The findings include: On 6/16/23 at 10:17 AM, the survey results book that the facility keeps for public review was requested by the surveyor and was observed located at the front desk. Upon surveyor review of the book it was found to have survey results dating up to May, 2021, but did not contain the most recent complaint survey results from 2022. On 6/16/23 at 10:59 AM, the surveyor's concern was brought to the attention of the facility's Executive Director at which time they acknowledged the surveyor's concern. On 6/16/23 at approximately 12:00 PM the Executive Director approached the surveyors stating that the facility staff knew that staff had placed the most recent survey results in the book a few months ago, but someone must have removed it.

Dec 2022 7 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · 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 that the facility failed to ensure that a resident was free of pain as evidenced by a resident that was sent out to the hospital for tooth/mouth pain. This was found to be evident for 1 out of 1 resident (Resident #44) reviewed for pain management. This deficient practice resulted in harm to the resident. The findings include: During an interview conducted with Resident #44's Responsible Party on 11/30/2022 at 8:31 AM, the Responsible Party (RP) stated that the resident had suffered from tooth pain for several days and went without treatment of the toothache pain. The Responsible Party further stated that he/she was advised the resident had an order for Oxycodone but for some reason the facility would not give the pain medication to the resident. After several days of the resident's untreated toothache pain, the Responsible Party called 911 and the resident was sent out to the hospital on the evening of 08/19/2022. According to the Centers of Medicare and Medicaid Centers (CMS) the Minimum Data Set (MDS) is a powerful tool for implementing standardized assessment and for facilitating care management in nursing homes (NHs). BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well a resident are functioning cognitively at the moment. It is a required screening tool used in nursing homes to assess cognition. The resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment. On 11/30/2022 at approximately 8:45 AM a review of Resident #44's MDS quarterly assessment dated [DATE] revealed the resident was assessed and scored a 15 on his/her Brief Interview for Mental Status. On 12/01/2022 at 8:30 AM a review of Resident #44's progress note, dated 08/14/2022, revealed a change in condition note that stated that the resident complained of a toothache, no redness or swelling noted provider (Physician #43) recommendation feedback: order a dental consult. Review of the change in condition note revealed that the provider's recommendation did not include treatment of the toothache pain. Further review of the progress notes confirmed a dental consult was requested on 08/15/2022. Review of the resident's Medication Administration Record (MAR) revealed an order for Tylenol Extra Strength Tablet 500 milligram (mg) every 8 hours as needed for pain. Review of the administration record showed that the resident had not received Tylenol on 08/14/2022 or any other time for the month of August for tooth pain. Record review conducted on 12/01/2022 at approximately 10:15 AM revealed the License Practical Nurse (LPN) #38 sent a message to Physician #43 through a message system called eMediCall on 08/18/2022 at 6:53 PM. The message stated, resident complained of tooth pain and stated that Tylenol 500 mg is not effective. She states that the last time this occurred Oxycodone was given and was effective, is that an option to be given? Physician # 43 responded OK on 08/18/2022 at 7:11 PM through eMediCall. On 08/18/2022 at 7:41 P.M., LPN #38 sent another message to Physician #43 through eMediCall that stated, would you like Oxycodone 5 mg (milligram) PRN (as needed) for pain 6-10 (pain scale) and a dental consult to treat as needed? On 08/18/2022 at 7:42 P.M. the physician responded via EmediCall yes please. Further review of the Patient Orders revealed that LPN #39 sent a message to the Certified Registered Nurse Practitioner (CRNP) #44 through eMediCall on 08/19/2022 at 2:27 PM. The message stated, Patient needs C2 form to Oxycodone 5 mg and flagged in patient chart. Thanks The CRNP #44 responded through eMediCall, OK. A pain scale is a tool that is used to help assess a person's pain. A person usually self-reports their pain using a specially designed scale. The numeric rating scale (NRS) is a pain screening tool, commonly used to assess pain severity at that moment in time using a 0-10 scale, with zero meaning no pain and 10 meaning the worst pain imaginable. On 12/01/2022 at approximately 9:15 AM a review of Resident #44's MAR revealed an order for Oxycodone HCI Tablet 5 mg. Give 1 tablet by mouth every 4 hours as needed for toothache. The order start date was 08/18/2022 at 23:45 (11:45 PM). Review of the Administration documentation revealed that Resident #44 did not receive the first dose of the pain medication Oxycodone 5 mg until 08/19/2022 at 17:42 (5:42 PM). The resident's pain score was assessed at an 8 out of 10 at the time of administration of the Oxycodone 5 mg. Further review of the MAR revealed the Pain Level Record showed Resident #44 pain level was documented as an 0 on 08/14/2022 and 08/18/2022, however the resident complained of a toothache. On 08/19/2022 at 17:42 (5:42 PM) the resident was administered Oxycodone 5 mg and assessed at a pain level of 8 out 10 however the Pain level Record documented the pain level at an 0. Review of the resident's progress note dated 08/19/2022 at 00:13 (12:13 AM) revealed a change in condition that documented the situation for the change in condition as Pain (uncontrolled). On 12/01/2022 at approximately 9:45 AM review of Resident #44's Emergency Medical Technicians (EMT) report assessment conducted on 08/19/2022 at 20:03 (8:03 PM) stated, assessment shows some minor swelling to the left cheek and left bottom molar. Redness and irritation were noticed on the left bottom molar. Pt (patient) rates pain as an 8 or 9 [out of 10]. On 12/01/2022 at approximately 9:55 AM review of Resident #44's Hospital Final Report stated during triage pt. (patient) has mild swelling to the left side and pain score (1-10): 8. Review of the history of present illness stated that Resident #44 stated he/she still able to eat, drink and swallow however does have pain. Review of the physical exam for ears, nose, mouth and throat: mildly poor dentition throughout. Left mandibular (lower jaw) second molar has some periapical (surrounding the tip of the root of a tooth) or swelling and degradation (the process of something becoming worse or weaker or being made worse or weaker) of the tooth. No visible abscess. There is no facial swelling. Treatment: resident started on a 7-day course of clindamycin (antibiotic) and advised to follow-up with Dentist within the next week. Return to the ED (emergency department) for any new or worsening symptoms. Tylenol 500 mg every 8 hours as needed for pain. During an interview conducted on 12/01/2022 at approximately 10:05 AM, the Director of Nursing (DON) stated she was made aware of Resident #44's tooth pain and pain medication was not administered at the end of the day shift (7AM -3PM) on 08/19/2022. The DON stated that she contacted the physician and obtained the C2 form that is required to obtain Oxycodone 5 mg and an order for an antibiotic based on the resident's tooth pain. On 12/01/2022 at approximately 2:00 PM the Surveyor advised the Administrator, Regional Clinical Nurse #4, and the Director of Nursing of the deficient level of practice that had been identified as a Harm.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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2) On 11/29/2022 a review of the facility's investigation of a Facility Reported Incident (FRI) revealed that the facility received an allegation of neglect made by Resident #43's family member. The investigation report included numerous interview statements from residents throughout the unit where Resident #43 resided, who all denied neglect or abuse by staff members, but did not include interview statements from other staff members which could have affected the outcome of their investigation. Further review of the investigation report revealed the facility interviewed Resident #43 with a BIMS of 15 who denied the allegation of neglect or abuse. Surveyors conducted an interview on 11/29/2022 at 9:30 AM with Geriatric Nursing Assistant (GNA) #5 who stated, I do not remember this resident. I do not recall working with the resident. I do not recall working with this resident. I do not recall writing or making a statement for this allegation. During an interview held on 11/29/2022 at 9:50 AM with Registered Nurse (RN) #4 (Corporate Nurse) it was revealed that the incident was reported by Resident #43's family member via the facility's corporate care telephone line on 9/19/2022 1:30 PM. Review of the Resident #43's medical record revealed that GNA #5 did work with Resident #43 on 9/19/2022 and documented that care was provided to Resident #43. Surveyors interviewed Staff #31 on 11/29/2022 at 10:38 AM which revealed, I was the Unit Manager on 9/19/2022 and worked with GNA #5 and Resident #43. GNA #5 worked with Resident #43 on 9/19/2022 and states he/she had a rough day at work and fell behind rendering care for residents. The errors on the facility investigation are an oversight on my part. The correct dates should read 9/16/2022 and 9/19/2022 not, 7/16/2022 and 7/19/2022. During a subsequent interview with RN #4 on 11/29/2022 at 10:43 AM it was revealed that, There are several errors/typos of dates in the investigation that list dates of 7/16/2022 and 7/19/2022 as the dates that involved staff worked and were interviewed. I wanted to be clear that the claim of neglect was received by our complaint phone line and then it was reported to me by our corporate office on 9/19/2022 as a general complaint with a specific date of incident as 9/16/2022. The investigation was initiated as a neglect claim on 9/19/2022. The concern that the facility's investigation lacked sufficient staff interviews and included incorrect documentation of dates and times the investigation occurred was discussed with the Administrator and RN #4 on 11/29/2022 at 11:50 AM and again during the survey exit conference on 12/01/2022. Based on interviews and review of the Facility Reported Incident (FRI) investigation documentation it was determined the facility failed to thoroughly investigate an allegation of: 1) misappropriation of funds and 2) neglect. This was evident for 2 out 2 residents (Resident #27 and Resident #43) reviewed during the complaint survey. The findings include: 1) On 11/18/2022 at 9:45 AM review of the Facility Reported Incident (FRI) revealed that Resident #27 reported to the facility that he/she was missing $300.00 from the bedside table. A review of the facility's investigation file revealed the facility did not conduct a thorough investigation. The facility failed to ensure that the police were to come to the facility to obtain a report for the alleged missing money. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. It is a required screening tool used in nursing homes to assess cognition. The resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment. During an interview conducted on 11/18/2022 at approximately 11:15 AM, Resident #27 with a BIMS of 15 stated he/she had three (3) $100.00 bills in the bedside table drawer. The resident stated on 11/03/2022 he/she discovered the (3) $100.00 bills were missing from the bedside drawer. The resident further stated the Administrator advised a police officer would come to see him/her, but a police officer never came. On 11/18/2022 at approximately 11:30 AM the surveyor advised the Regional Clinical Nurse #4 that the investigative file for the alleged missing money for Resident #27 only had interviews of staff and residents, therre was no record of Resident #27 interviewed, no details of the investigation and no documentation that a police officer responded and came to the facility. During an interview on 11/18/2022 at approximately 1:30 PM the Administrator provided the Surveyor with the timeline of events of the facility's investigation that was written by the Administrator on 11/18/2022. The Administrator stated that he contacted the police department on 11/18/2022 and confirmed the facility called the police on 11/03/2022. However, there was no record that a police officer responded and came to the facility to speak with Resident #27. The Administrator confirmed that the facility failed to follow up with the police department to ensure a police officer responded to the facility's call. The surveyor advised the Administrator that the facility failed to conduct a thorough investigation.

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 F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and review of medical record documentation including MDS assessments, the facility failed to ensure that comprehensive Resident Assessment Instrument (RAI) Significant Change in Status (SCSA) assessments were opened and conducted when 1/46 residents (#10) reviewed: (1) suffered a fall with no care plan in place; (2) developed Moisture Associated Skin Damage (MASD) that advanced quickly to a stage 3 sacral pressure ulcer, and additionally developed right heel a Deep Tissue Injury (DTI). This concern was evident for 1/46 residents reviewed during survey. The Findings include: Definitions The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths, and needs, plan for resident care delivery, and evaluate the residents progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. The Minimum Data Set (MDS) assessments are an integral part of the RAI and include completion of standardized assessment questions. There are comprehensive MDS assessments and periodic non-comprehensive MDS assessments which facilities conduct to maintain an accurate understanding of each resident's most current needs and strengths, and to ensure care planning remains current and effective. Upon completion of a comprehensive MDS assessment, care areas trigger. In this regard the MDS assessment is a screening tool that triggers the Care Area Assessments (CAAs) where the triggered care areas are then assessed more fully. CAAs require a comprehensive review of the care area and all related data. Under the mandated RAI process, the outcome of the comprehensive CAA process is a determination of what needs care planning and how to structure and develop the care plans that meet the individualized needs of each resident. Care plans communicate in writing to all facility staff exactly what expectations are for care delivery. A pressure Ulcer/Injury is a localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. Moisture Associated Skin Damage (MASD) is a weakened skin condition caused by moisture exposure for an extended period. Presence of MASD is a risk factor for the development of pressure ulcers. If/when the most superficial skin layer breaks down exposing/ involving the second underlying (dermis) layer, then the open wound is no longer, only MASD. A stage 3 pressure ulcer has full thickness tissue loss. Subcutaneous fat may be visible; but bone, tendon or muscle is not exposed. Slough and/or eschar may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. A stage 4 pressure ulcer has full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Deep Tissue Injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue Wound eschar tissue is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. The RAI Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. Review of the medical record on 11/18/22 starting at 11:00 AM, revealed that Resident #10 was admitted to the facility during August 2020. In the comprehensive MDS admission assessment (reference date of 8/17/20), facility staff coded that Resident #10 was admitted with no pressure ulcers evident and that Resident #10 was at increased risk for pressure ulcers. Further review of the medical record revealed that the facility developed a care plan for Resident #10 for the risk for pressure ulcer development during his/her admission month. Review of the medical record revealed a nursing assessment note signed 2/26/21 that documented new onset of Moisture Associated Skin Damage (MASD) and then on 3/2/21, the risk for impaired skin integrity care plan was updated regarding the MASD. Further review of the medical record revealed a consulting physician, wound note dated 3/5/21. The consulting physician documented that Resident #10 had a sacral wound that measured 3.3 x 3.9 x 0.1 with 5% dermis involvement, with evidence of necrotic tissue in the wound bed, and treatment with an ointment was started. With the sacral location, skin breakdown evident, dermis involvement and necrotic tissue visualized, this documented wound was by definition at least a stage 3 pressure ulcer on 3/5/21. The consulting physician nonetheless inaccurately documented that the stage 3 pressure ulcer was still MASD. In 5/5 (five out of five) wound assessment notes between 3/5/21 and 3/19/21, the facility documented that the worsening pressure ulcer was MASD. When seen on 3/19/21, the risk for pressure ulcer care plan still inaccurately communicated that the resident's MASD will have decreased surface area and drainage by next review date. On 3/23/21, Resident #10 was discharged from the nursing home and transferred to a local hospital. Per the hospital record, Resident #10 had increased swelling lasting 3 weeks related to infection. The hospital record also revealed that on 3/26/21, Resident #10 returned to the nursing home from the hospital with new orders for antibiotic treatment for 6 weeks. A wound evaluation note on this date indicated that s/he returned with a new stage 3 pressure ulcer that was acquired in the hospital. However, the 3/5/21 wound documentation noted above had shown the pressure ulcer with necrotic tissue was at stage 3 then, so according to the nursing home record, the stage 3 pressure ulcer was not newly acquired while in the hospital and the present on admission documentation was therefore not accurate. By 3/29/21 the sacral wound had worsened further measuring larger, 11.5 x 7.5 x 0.0, with undefined irregular edges; light serious drainage, with 26-50% necrotic tissue visualized. On 3/29/21, more than a month after the wound began, a new care plan was opened for the actual pressure ulcer. However, the required comprehensive MDS assessment that should have informed the care plan was not conducted. The new care plan was also ineffective in that it instructed that staff provide treatment as ordered but failed to specify what treatment or in what frequency to provide it. The software system for the plan prompted staff in all caps to fill in SPECIFY TREATMENT AND FREQUENCY but this prompt in all caps was left in the plan exactly as written. The plan also instructed to observe site for changes without identifying which site or sites staff should observe. Without the required comprehensive SCSA assessment, the incomplete care plan did not reflect the assessed, individualized needs of the resident as required under the RAI process. The facility then completed a quarterly MDS assessment with an assessment reference date of 3/31/21. This is mandated time point (when completing quarterly update assessments) when facilities are required to review if there has been a significant change in resident status looking back to the last MDS assessment. Significant change since the last MDS assessment was evident, but the facility nonetheless failed to conduct an SCSA. Another wound evaluation note dated 4/1/21, for the sacral ulcer revealed it was continuing to worsen. It measured 12.5 x 10.5 x 0.0, with an irregular edge; necrotic tissue 0-25%, no slough, light serous drainage. Evidencing further decline, the physician evaluation on this date (4/1/21) revealed a new deep tissue injury (DTI) to the resident's right heel. With the new deep tissue injury evident the facility did not conduct the required SCSA. On 4/3/21 Resident #10 was discharged to the hospital again and returned on 4/22/21. On return the facility again failed to open and conduct the required SCSA to inform care planning as is required in the RAI process. In interviews on 11/22/21, both the MDS Coordinator (Staff #15) and the wound care nurse (Staff #10) reported that they participate in the interdisciplinary team (IDT) meeting each morning. The wound nurse stated that new wounds are communicated to the team and the MDS Coordinator confirmed the same. Nonetheless, the facility failed to identify the ongoing clinical deterioration of Resident #10 and the need to initiate an SCSA to reevaluate and address his/her changing needs. The resident was then discharged to the hospital again on 5/16/21. In that discharge assessment of 5/16/21, the facility coded that the pressure ulcer had worsened to stage 4. When discharged on 5/16/21, no SCSA had ever been conducted after the 2/26/21 wound evaluation first noted MASD; after it first advanced to a pressure ulcer, after development of infection requiring hospital intervention, and after Resident #10 additionally developed the right heel DTI. Without having conducted the comprehensive SCSA assessment to inform care planning, no staff had ever identified a missing care plan for falls, and an ineffective and incomplete care plan for the resident's wounds. Cross Reference Federal Survey Tags F637, F641, F656 and CO[DATE], 2910, 2950, and 2970

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and review of medical record documentation including MDS assessments, the facility failed to ensure the accuracy of Resident Assessment Instrument (RAI) assessments when one pressure ulcer and one fall were not accurately coded for 1/46 residents (Resident #10) reviewed during survey. The findings include: Definitions The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths, and needs, plan for resident care delivery, and evaluate the residents progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. A pressure Ulcer/Injury is a localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. Moisture Associated Skin Damage (MASD) is a weakened skin condition caused by moisture exposure for an extended period. Presence of MASD is a risk factor for the development of pressure ulcers. If/when the most superficial skin layer breaks down exposing/ involving the second underlying (dermis) layer, then the open wound is no longer, only MASD. A stage 3 pressure ulcer has full thickness tissue loss. Subcutaneous fat may be visible; but bone, tendon or muscle is not exposed. Slough and/or eschar may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. Wound eschar tissue is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. 1. Review on 11/18/22 of the admission MDS assessment (reference date 8/17/21) revealed that the assessment triggered the care area for falls. Once a care area has been triggered by the MDS assessment facilities are required to conduct the Care Area Assessment (CAA) which is a more comprehensive review of the related and underlying issues that may be causal to the care area concern. Continued review of medical record documentation revealed that in the MDS admission assessment with assessment reference date of 8/17/20, facility staff signed off on 8/20/21 that the falls related CAA for Resident #10 was completed, that a falls care plan was needed, and that the falls care plan was developed and opened. However, review of all care plans in the medical record for Resident #10 revealed that no care plan for falls or falls risk was opened. The MDS documentation that the falls care plan was opened was not accurate. Although s/he had known falls risk evidenced in his/her admission assessment, with no falls care plan in place to mitigate the risk for falls and the risk for harm from falls, on 3/2/21 Resident #10 suffered an unwitnessed fall when s/he was found on the floor and had hit his/her head. Staff documented that neurological assessment checks started many hours before the documented fall and continued until the last documented neurological check at 02:25 on 3/4/22. It could not be determined if the documented time of the fall was inaccurate or if the documented times for the neuro checks was inaccurate. In the next MDS assessment with assessment reference date of 3/23/21, the facility inaccurately coded there had been no falls since the prior MDS assessment. 2. Review of the medical record on 11/18/22 starting at 11:00 AM, revealed that Resident #10 was admitted during August 2020 with no pressure ulcers evident. In the MDS admission assessment, facility staff documented that Resident #10 was at increased risk for pressure ulcers. Related to this admission assessment, the facility developed a care plan for Resident #10 for the risk for pressure ulcers. Review of the medical record revealed a nursing assessment sheet signed 2/26/21 that documented new onset of Moisture Associated Skin Damage (MASD). On 3/2/21, the risk for impaired skin integrity care plan was updated regarding the newly acquired MSAD. Further review of the medical record revealed a consulting physician, wound note dated 3/5/21. The consulting physician documented that Resident #10 had a sacral wound that measured 3.3 x 3.9 x 0.1 with 5% dermis involvement, and treatment with an ointment was started. The physician also documented evidence of necrotic tissue in the wound bed. With skin breakdown, dermis involvement and necrotic tissue seen and documented, this wound was by definition at least a stage 3 pressure ulcer on this date 3/5/21. The consulting physician nonetheless inaccurately documented that the stage 3 pressure ulcer was still MASD. In interview on 11/22/21 the facility wound nurse (Staff #10), reported that she has worked as the facility wound nurse for four years and holds a WWC certification (professional Wound Care Certification). She was able to describe the differences accurately between pressure ulcer stages, and between MASD and pressure ulcers. In her 3/5/21 wound evaluation note, Staff #10 documented that she assessed Resident #10 with sacral wound that measured 3.3cm x 3.9cm x 0.1cm, with an irregular wound edge and light serous drainage. However, she also inaccurately documented in her 3/5/21 note that the pressure ulcer was MASD. On 3/12/21 and 3/19/21 Resident #10 was seen in wound rounds again. The sacral wound deteriorated further while staff continued to inaccurately document it was MASD. On 3/23/21, Resident #10 was discharged from the nursing home and transferred to a local hospital. In the MDS assessment for the 3/23/21 discharge to the local hospital, the diagnostic error repeatedly entered in the consulting physician notes and repeatedly carried into the nursing wound evaluation notes, was then caried into the 3/23/21 MDS assessment which showed no pressure ulcers. In interview on 11/22/22 at 1:30 PM, the MDS Coordinator stated that she sometimes assesses resident wounds directly but not always. With reliance on the many inaccurate wound notes in the record, the facility coded into the MDS discharge assessment inaccurately that at the time of the discharge, Resident #10 had no pressure ulcers that were acquired in the nursing home. Cross Reference Federal Survey Tags F637, F656, F686 and CO[DATE], 2910, and 2950

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and review of medical record documentation including MDS assessments, the facility failed to ensure an effective care planning process when it relied on noncompliant assessment practices that should have informed care planning but did not. The failure to ensure that the care plans for Resident #10 reflected adequately assessed needs of the resident increased the risk for serious harm. This concern was evident for 1/46 residents reviewed during survey. The Findings include: Definitions The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate the residents progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. The Minimum Data Set (MDS) assessments are an integral part of the RAI and include completion of standardized assessment questions. There are comprehensive MDS assessments and periodic non-comprehensive MDS assessments which facilities conduct to maintain an accurate understanding of each resident's most current needs and strengths, and to ensure care planning remains current and effective. Upon completion of a comprehensive MDS assessment, care areas trigger. In this regard the MDS assessment is a screening tool that triggers the Care Area Assessments (CAAs) where the triggered care areas are then assessed more fully. Under the mandated RAI process, the outcome of the comprehensive CAA process is a determination of what needs care planning and how to structure and develop the care plans that meet the individualized needs of each resident. A pressure Ulcer/Injury is a localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. Moisture Associated Skin Damage (MASD) is a weakened skin condition caused by moisture exposure for an extended period of time. Presence of MASD is a risk factor for the development of pressure ulcers. If/when the most superficial skin layer breaks down exposing/ involving the second underlying (dermis) layer, then the open wound is no longer, only MASD. A stage 3 pressure ulcer has full thickness tissue loss. Subcutaneous fat may be visible; but bone, tendon or muscle is not exposed. Slough and/or eschar may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. A stage 4 pressure ulcer has full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Deep Tissue Injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue Wound eschar tissue is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. The RAI Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. 1. Review of the medical record on 11/18/22 starting at 11:00 AM, revealed that Resident #10 was admitted to the facility during August 2020 and that the admission MDS assessment (assessment reference date of 8/17/20) triggered the care area for falls. Continued review of medical record documentation revealed that in the MDS admission assessment, facility staff signed off on 8/20/21 that the falls related CAA for Resident #10 was completed, that a falls care plan was needed, and that the falls care plan had been opened. However, review of all care plans in the medical record for Resident #10 revealed this was not accurate and that no care plan for falls or falls risk was opened. Although Resident #10 had known falls risk evidenced in his/her admission assessment, with no falls care plan in place to mitigate the risk for falls and to mitigate the risk for harm from falls, on 3/2/21 Resident #10 suffered an unwitnessed fall when s/he was found on the floor and hit his/her head. Staff documented that neurological assessment checks started many hours before the documented fall and continued until the last documented neurological check at 02:25 on 3/4/22. It could not be determined if the documented time of the fall was inaccurate or if the documented times for the neuro checks was inaccurate. After the neurological checks for Resident #10 had ended, on 3/5/21 the facility then opened the only falls related care plan during the resident admission. The only planned intervention in the falls care plan was to conduct neurological checks which were already finished and were no longer in place by the time the plan was opened. This care plan did not reflect assessed needs of the resident. Additionally, after the actual fall the facility still did not open a falls risk care plan to address his/her known fall risk and communicate to and amongst staff what interventions or strategies would be followed to reduce the risk for additional falls and to reduce the risk for injury in the event of another fall. 2. In the comprehensive MDS admission assessment with reference date of 8/17/20, facility staff coded that Resident #10 was admitted with no pressure ulcers evident, but that Resident #10 was at increased risk for pressure ulcers. Further review of the medical record revealed that the facility developed a care plan for Resident #10 for the risk for pressure ulcer development during his/her admission month. Review of the medical record revealed a nursing assessment note signed 2/26/21 that documented new onset of Moisture Associated Skin Damage (MASD) and then on 3/2/21, the risk for impaired skin integrity care plan was updated regarding the MASD. Further review of the medical record revealed a consulting physician, wound note dated 3/5/21 that evidenced the MASD had progressed to a stage 3 pressure ulcer (See Federal Survey Tag F686). The consulting physician inaccurately documented however, that the pressure ulcer was still MASD. In 5/5 (five of five) wound assessment notes between 3/5/21 and 3/19/21, the facility documented that the worsening pressure ulcer was MASD. When seen by the wound nurse on 3/19/21, the risk for pressure ulcer care plan still communicated that the resident's MASD will have decreased surface area and drainage by next review date. On 3/23/21, Resident #10 was discharged from the nursing home and transferred to a local hospital. Review of the hospital record revealed that Resident #10 returned on 3/26/21 with a new 6-week treatment plan for infection. On his/her return, a required comprehensive SCSA that should have informed the facility care planning process was not opened or conducted, and Resident #10 continued with no care plan at all for his/her known falls risk. On 3/29/21 the facility opened a new care plan for the sacral pressure ulcer but did not conduct a comprehensive MDS assessment to inform the care plan as required in the RAI process. In addition to being uninformed by the required assessment, the plan itself was ineffective in that it instructed that staff provide treatment as ordered but failed to specify what treatment or in what frequency to provide it. The software system for the plan prompted staff in all caps to fill in SPECIFY TREATMENT AND FREQUENCY but this prompt in all caps was left in the plan exactly as written. The plan also instructed to observe site for changes without identifying which site or sites staff should observe. The facility then completed a quarterly MDS assessment with an assessment reference date of 3/31/21. This is a mandated time point (when completing quarterly update assessments) when facilities are required to review if there has been a significant change in resident status looking back to the last MDS assessment. Significant change since the last MDS assessment was evident, but the facility nonetheless did not conduct the required assessment to inform effective care planning as required. On 4/3/21 Resident #10 was discharged to the hospital again. Resident #10 had the sacral pressure ulcer dating back to early March, but on 4/5/21, staff inaccurately documented the care plan goal that Resident #10 would maintain intact skin through the review period. Resident #10 was discharged to the hospital again on 5/16/21. When discharged on 5/16/21, no SCSA had ever been conducted as the resident's condition deteriorated; no care plan for high falls risk had ever been opened, and the ineffective and incomplete care planning for wound care had not been corrected. Cross Reference Federal Survey Tags F637, F641 and F686; and CO[DATE], 2910, and 2950

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 observation, record review and interviews, the facility failed to provide care to Resident # 17 and Resident # 54 who are unable to care for themselves. This was evident for 2 of 2 residents (Resident # 17 and # 54). The findings include: 1. On 11/14 22 at 12:15 PM, this surveyor went to visit Resident #17 in their room. The resident was lying on his/her back. The Daughter was in the room at the time. The resident appeared wet and wore a brief that was visibly soiled with fecal matter. Resident #17 also has multiple wounds. The resident's daughter insisted this surveyor see the wounds. The Nurse was called into the resident's room and the resident's wounds were observed. Interview with the Nurse revealed that all dressings were changed the day before on 11/13/22. The surveyor observed that the dressings were soiled. Inside of resident's mouth there was observed by the surveyor a layer of white crusty substance. The Nurse was shown the inside of resident's mouth and roof of the mouth. The Nurse was able to clean Resident #17's mouth with a toothbrush and suction the substances from the resident's mouth. On 11/14/22 at 12:30 PM, the Administrator and the DON (Director of Nursing) were made aware of the resident's condition. Prior to the surveyor leaving for the day, Resident #17 was observed again. He/she was cleaned; however, he/she was not turned and repositioned. He/she was positioned on back. On 11/15/22 at 8:35 AM and throughout the day the resident was turned and repositioned. Resident #17 has a diagnosis of Dependent Respirator Ventilator and Tracheostomy. He/she has multiple wounds and is totally dependent for all ADLs (activities of daily living). 2. On 11/21/22 at 11:21 AM, Resident # 54 was observed in his/her room laying flat on her/his back. The resident was seen later that day at about 1:33 PM and resident had not been turned and repositioned. On Wed 11/23/22 the resident observed at 6:30 AM and visited every hour and he/she was not turned and/or repositioned. A pillow was under his/her back, and she/he remained on her/his back. There was an order on the chart for Resident #54 to be turned and repositioned every 2 hours. The resident is dependent on a respirator and has a tracheostomy. The resident is dependent for all ADLs (activities of daily living). The DON (Director of Nursing) and Registered Nurse (RN) #4 (Corporate Nurse) were made aware by this surveyor.

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** Based on staff interviews and review of medical record documentation including MDS assessments, the facility failed to ensure that 1/46 residents reviewed received accurate and effective care treatment and services related to pressure ulcer prevention when Resident #10 developed MASD that advanced to a stage 3 pressure ulcer with ineffective and incomplete assessments, inaccurate documentation including ulcer identification and staging, and ineffective care planning to mitigate the worsening status of a pressure ulcer. In a pattern, these failed processes increased the risk for resident harm. The facility was cited previously for noncompliant practices related to resident pressure ulcer management in survey dated 6/27/2019. The Findings include: Definitions The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate each resident's progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. The Minimum Data Set (MDS) assessments are an integral part of the RAI and include completion of standardized assessment questions. There are comprehensive MDS assessments and periodic non-comprehensive MDS assessments which facilities conduct to maintain an accurate understanding of each resident's most current needs and strengths, and to ensure care planning remains current and effective. Upon completion of a comprehensive MDS assessment, care areas trigger. In this regard the MDS assessment is a screening tool that triggers the Care Area Assessments (CAAs) where the triggered care areas are then assessed more fully. Moisture Associated Skin Damage (MASD) is a weakened skin condition caused by moisture exposure for an extended period of time. Presence of MASD is a risk factor for the development of pressure ulcers. If/when the most superficial skin layer breaks down exposing/ involving the second underlying (dermis) layer, then the open wound is no longer, only MASD. A pressure Ulcer/Injury is a localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. A stage 3 pressure ulcer has full thickness tissue loss. Subcutaneous fat may be visible; but bone, tendon or muscle is not exposed. Slough and/or eschar may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. A stage 4 pressure ulcer has full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Wound eschar tissue is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. The RAI Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. Review of the medical record on 11/18/22 starting at 11:00 AM, revealed that Resident #10 was admitted to the facility during August 2020. In the comprehensive MDS admission assessment with reference date of 8/17/20, facility staff coded that Resident #10 was admitted with no pressure ulcers evident, but that Resident #10 was at increased risk for pressure ulcers. Further review of the medical record revealed that during his/her admission month, the facility developed a care plan for Resident #10 for the risk for impaired skin integrity. Review of the medical record revealed a 2/26/21 nursing assessment note that documented new onset of Moisture Associated Skin Damage (MASD) and then on 3/2/21, the risk for impaired skin integrity care plan was updated regarding the MASD. The goal was documented, indicating that the patient's MASD will have decreased surface area and drainage by next review date. Approaches to be employed were to monitor for effectiveness; for staff to observe for changes and notify nurse, and for the nurse to perform weekly assessments, to document and to notify the provider. Further review of the medical record revealed a consulting physician, wound note dated 3/5/21. The consulting physician documented that Resident #10 had a sacral wound that measured 3.3 x 3.9 x 0.1 with 5% dermis involvement, with evidence of necrotic tissue in the wound bed, and treatment with an ointment was started. With the sacral location, skin breakdown evident, dermis involvement and necrotic tissue visualized, this documented wound was by definition at least a stage 3 pressure ulcer on 3/5/21. The consulting physician nonetheless inaccurately documented that the stage 3 pressure ulcer was still MASD. In interview on 11/22/21 the facility wound nurse (Staff #10), reported that she had worked as the facility wound nurse for four years and held a WWC certification (professional Wound Care Certification). She was able to accurately describe the differences between MASD and pressure ulcers, and between pressure ulcer stages. In her 3/5/21 wound evaluation note, Staff #10 documented that she assessed Resident #10 with sacral wound that measured 3.3cm x 3.9cm x 0.1cm, with an irregular wound edge and light serous drainage. However, she also inaccurately documented in her 3/5/21 note that the pressure ulcer was MASD. On 3/12/21, Resident #10 was seen in wound care rounds again by the wound physician and the certified wound nurse. The wound measured 0.1 x 0.2 x 0.1 and the physician documented 100% dermis. Nonetheless, the physician again inaccurately documented that the pressure ulcer was MASD; the professionally certified wound nurse and the care plan for skin integrity risk still communicated to all staff only that the resident's MASD will have decreased surface area and drainage by next review date. In a wound evaluation note that was signed on 3/19/21, facility staff documented that Resident #10 had another wound evaluation. No physician note was provided to the surveyor for this date but for the third consecutive time in three weekly evaluations, the certified wound nurse again inaccurately documented that the stage 3 pressure ulcer was MASD. Per the nursing evaluation, by this date the pressure ulcer had worsened further to measure 7.0 x 7.7 x 0.1. In interviews on 11/22/21, both the MDS Coordinator (Staff #15) and the wound care nurse (Staff #10) reported that they participate in the interdisciplinary team (IDT) meeting each morning. The wound nurse stated that new wounds are communicated to the team and the MDS Coordinator confirmed the same. Although pressure ulcers are serious adverse events reviewed during IDT meetings, no one from these IDT meetings updated the resident care plan on 3/5/21 to communicate to the care team including GNAs delivering care, that Resident #10 had additional needs related to an actual pressure ulcer. On 3/23/21, Resident #10 was discharged from the nursing home and transferred to a local hospital with an infection. The hospital record revealed that on 3/26/21, Resident #10 returned from the hospital with a six-week course of antibiotics planned. An MDS comprehensive Significant Change in Status (SCSA) assessment was required but was not conducted. After return from the hospital, a wound evaluation note on indicated that s/he returned with a new stage 3 pressure ulcer that was acquired in the hospital. However, the 3/5/21 wound documentation noted above had shown that the pressure ulcer with necrotic tissue was at stage 3 then, so according to the nursing home record, the stage 3 pressure ulcer was not newly acquired while in the hospital and the present on admission documentation was therefore not accurate. By 3/29/21 the sacral wound had worsened further measuring larger, 11.5 x 7.5 x 0.0, with undefined irregular edges; light serious drainage, with 26-50% necrotic tissue visualized. The required comprehensive assessment required by/within the RAI process was still not conducted to inform care planning for the pressure ulcer. Without the assessment, on 3/29/21, more than a month after the wound began, a new care plan was opened for the actual pressure ulcer. Once opened, the new care plan was also ineffective in that it instructed that staff provide treatment as ordered but failed to specify what treatment or in what frequency to provide it. The software system for the plan prompted staff in all caps to fill in SPECIFY TREATMENT AND FREQUENCY but this prompt in all caps was left in the plan exactly as written. The plan also instructed to observe site for changes without identifying which site or sites staff should observe. The facility then completed a noncomprehensive quarterly MDS assessment with an assessment reference date of 3/31/21. This was another mandated time point (when completing quarterly update assessments) when facilities are required to review if a comprehensive assessment was needed to understand the resident's needs to accurately inform care planning. The comprehensive assessment was required but was not conducted and the incomplete care plan remained in place. Another wound evaluation note dated 4/1/21, for the sacral ulcer revealed it was continuing to worsen. It measured 12.5 x 10.5 x 0.0, with an irregular edge; necrotic tissue still evident. Evidencing further decline, the physician evaluation on this date (4/1/21) revealed a new deep tissue injury (DTI) to the resident's right heel. With the new deep tissue injury evident the facility did not conduct the required SCSA. On 4/3/21 Resident #10 was discharged to the hospital again. Resident #10 had the sacral pressure ulcer dating back to early March, but on 4/5/21, staff inaccurately documented the goal that Resident #10 would maintain intact skin through the review period. On 4/22/21 Resident #10 returned to the nursing home from the hospital but the required comprehensive MDS assessment was still not conducted, and the incomplete pressure ulcer care plan remained in place. On 5/16/21 Resident #10 was sent to the hospital again. In that discharge assessment the facility coded that the sacral pressure had by then advanced to stage 4. When discharged on 5/16/21, no comprehensive SCSA had ever been conducted. The ineffective and incomplete care planning for risk of impaired skin integrity continued to maintain the documented goal that the resident would maintain intact skin until after the last resident discharge, until 5/23/21, when staff updated that the care plan was resolved. Cross Reference Federal Survey Tags F637, F638, F641, F656, and CO[DATE], 2910, 2950, and 2970

Feb 2019 15 deficiencies

CONCERN (D)

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 surveyor observation during facility environmental observations it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on 2 of 4 resident units. The findings include: On 2/21/2019 during an initial tour of the facility the following observations were made: 1) At 10:28 AM in room [ROOM NUMBER]N 270 a dried, yellow stain was observed on the floor under the bed closest to the window. The bottom panel of the air unit in this room was observed loose and protruding from the unit itself. 2) At 10:47 AM in room [ROOM NUMBER]S 205-1 the bottom panel of the air unit in this room was observed loose and protruding from the unit. The Administrator was made aware of these findings during the exit conference on 2/28/2019.

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 staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative. This was found to be evident for 2 out of 13 residents (Resident #106 and #113) reviewed for a facility-initiated transfer during the investigative portion of the survey. The findings include: 1. A medical record review for Resident #106 was conducted on 02/21/19. Review of the physician order written on 8/21/18, revealed that Resident #106 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfer to the resident, resident representative and the ombudsman. 2. A medical record review for Resident #113 was conducted on 02/22/19. Review of the physician order written on 1/4/19, revealed that Resident #113 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfer to the resident, and or the resident representative. This was revealed by a nurse's note dated on 1/5/19, at 12 AM that the resident representative was made aware by telephone after several failed attempts. The Administrator was made aware of this concern on 02/22/19, at 8:15 AM. The Administrator stated the facility did not notify the family in writing only verbally nor did they facility notify the ombudsman of the hospitalization. The new federal and state regulation for notification was started in October 2018.

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 review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident or their representative with a written notice of bed-hold policy, at the time of the resident transfer for hospitalization. This was evident for 1 of 13 residents (Resident #106) reviewed for hospitalization during an annual recertification survey. The findings include: Review of the medical record for Resident #106 revealed the resident was transferred to an acute care facility on 8/21/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed-hold policy upon transfer to the hospital. On 02/21/19 01:44 PM, the Administrator confirmed that Resident #106 and the Resident's responsible party did not receive the facility bed-hold policy when Resident #106 was transferred to the hospital.

CONCERN (D)

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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Based on medical record review it was determined that the facility failed to ensure the Pain Tool 2.1 assessment accurately reflected the resident's status. This was evident for 1 of 5 residents (Resident #144) reviewed for Pain Management. The findings include: The Pain Tool Assessment is used to document a resident's pain within the last 24 hours and includes the location and source of any pain identified. Resident #144's medical record was reviewed on 2/26/19 at 11:25 AM. A review of the resident ' s Pain Tool Assessment form dated 2/1/2019 at 10:50 PM stated that Resident #144 had not experienced pain within the last 24 hours. However, a review of the Pain Level Summary for Resident #144 indicated that on 2/1/19 at 6:21 PM, the resident expressed a pain level value of 8. In addition, the resident ' s Medication Administration Record confirmed the pain level of 8. (Pain Level Values ranging from 7-10 are characterized as severe) The Administrator was made aware of surveyor ' s findings during the exit conference on 2/28/2019.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview it was determined the facility staff failed to review and revise the care plan for Resident (#45) to reflect accurate and current interventions. This was evident for 1 of 1 residents reviewed for care plans during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and ensures the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Medical record review for Resident #45 revealed on 10/13/18 the facility staff initiated a care plan: Impaired circulation related to elevated cholesterol. At that time the facility staff initiated the intervention to monitor pedal pulses every shift. A pedal pulse is the heart beat felt in the foot or ankle area. Record review and interview with the Corporate Nurse on 2/27/19 at 1:00 PM revealed the facility staff failed to monitor the pedal pulse every shift as indicated on the care plan. Further record review revealed the facility staff assessed the resident and completed the MDS assessment on 12/5/18; however, failed to review and revise the care plan about the monitoring of the pedal pulse. Interview with Corporate Nurses on 2/28/19 at 1:30 PM confirmed the facility staff failed to review and revise a care plan for Resident #45 to reflect accurate and current interventions.

CONCERN (D)

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

Deficiency F0661 (Tag F0661)

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 a closed medical record, it was determined that the facility staff failed to provide a resident with a completed discharge summary before the resident was discharged home. This was evident for 1 of 1 resident (Resident #172) reviewed for discharge during an annual recertification survey. The findings include: Review of Resident #172's closed medical record on 2/26/19 revealed that Resident #172 was discharged home on [DATE]. Resident #172's medical record failed to reveal a completed discharge summary from Resident #172's attending physician that included: A recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-discharge medications with the post discharge medications, and a post discharge plan of care. On 02/26/19 09:56 AM, the Administrator confirmed that Resident #172 did not receive a completed discharge summary from Resident #172's attending physician.

CONCERN (D)

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 observation, medical record review and interview it was determined the facility staff failed to provide grooming and personal hygiene services. This is evident for 1 of 2 residents (Resident #107) selected for review for Activities of Daily Living (ADL) care during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. The MDS 3.0 captures information about the residents' comorbidities, physical, psychological and psychosocial functioning in addition to any treatments (e.g., hospice care, oxygen therapy, chemotherapy, dialysis) or therapies (e.g., physical, occupational, speech, restorative nursing) received. Observation of Resident #107 on 2/28/19 at 8:45 AM and at 10:30 AM revealed Resident #107 to have elongated fingernails with brown-black matter under them. Interview with the resident at that time revealed the resident stated the fingernails needed to be cut. The facility staff conducted a quarterly MDS assessment on 1/26/19 and coded the Resident in Section G Functional Status: G0110-Activities of Daily Living Assistance-J: Hygiene, how the resident combs hair, brush teeth, showers and wash/dry face. The facility staff assessed the resident and documented the resident was dependent on the facility staff for hygiene care; however, the facility staff failed to provide nail care to Resident #107. It is the expectation that nail care be provided to dependent residents when baths are provided. Interview with the 1st floor Unit Manager and Corporate Nurses on 2/28/19 at 1:30 PM confirmed the surveyor's findings.

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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Based on medical record review and interview, it was determined the facility staff failed to provide care to Residents (#45 and #108) in order to obtain or maintain optimal level of well-being. This was evident for 2 of 61 residents selected for review of quality of care during the annual survey. The findings include: 1. The facility staff failed to administer an antibiotic as ordered by the physician. Medical record review for Resident #45 revealed that on 2/16/19 the physician ordered: Levaquin 500 milligrams via PEG tube 1 time a day for 5 days for urinary tract infection. Levaquin is an antibiotic and is indicated for the treatment of complicated urinary tract infections. Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into the resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. This provides nutrition (making use of the natural digestion process of the gastrointestinal tract) despite bypassing the mouth PEG tubes are also used for the administration of medications and fluids. Review of the Medication Administration Record revealed the facility staff failed to administer the Levaquin on 2/16/19 and 2/18/19 as ordered. Review of nurses' documentation revealed the facility staff documented the medication was not available and therefore, could not be administered. Further investigation revealed the medication was in the facility and noted to be in the CUBIX. The CUBIX is a machine provided by pharmacy which contains frequently used or emergent medications that are in the facility and can be used at any time. Review of the CUBIX revealed Levaquin is in the CUBIX and available for administration. Interview with Corporate Nurses on 2/28/19 at 1:30 PM confirmed the facility staff failed to obtain and administer Levaquin to Resident #45 as ordered by the physician to obtain the optimal well- being. 2a. The facility staff failed to thoroughly assess and clarify a physician's order. Medical record review for Resident #108 revealed that on 2/17/19 the physician ordered: Oxycodone 5 milligrams via PEG tube as needed for pain level of 6-10 and would care, start 2/18/19. Oxycodone is used to treat moderate to severe pain. It can be used short term or long term, depending on the residents' condition. Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into the resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. The PEG tube can also be used to administer medications and fluids. Further record review revealed the facility staff failed to clarify the physician's order to determine the time frame of administration of the Oxycodone. It is the standard of practice for the physician to order a medication to be administered: i.e. every day, every 4 hours, every 6 hours, every 8 hours. The facility staff transcribed the Oxycodone order and conducted a 24-hour chart check and failed to clarify with the physician the time frame of Oxycodone administration. 2b. The facility staff failed to administer Oxycodone as ordered prior to a dressing change. Medical record review for Resident #108 revealed on 2/17/19 the physician ordered: Oxycodone 5 milligrams via PEG tube as needed for pain level of 6-10 and wound care, starting 2/18/19. Oxycodone is used to treat moderate to severe pain. It can be used short term or long term, depending on the residents' condition. Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into the resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. The PEG tube can also be used to administer medications and fluids. On 2/19/19 the physician ordered: Santyl ointment to sacrum every day shift for wound care. Santyl is used to help the healing of burns and skin ulcers. Santyl is an enzyme and it works by helping to break up and remove dead skin and tissue. The sacral region (sacrum) is at the bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone). Further review of the Medication Administration Record revealed the facility staff failed to administer the Oxycodone on 2/19/19, 2/20/19 and 2/21/19; however, documented the dressing change on those days. Interview with Corporate Nurses on 2/28/19 at 1:30 PM confirmed the facility staff failed to provide care to Resident #108 to obtain/maintain the highest well-being in failing to clarify the time frame with the physician of a pain medication and failing to administer pain medication as ordered prior to a dressing change.

CONCERN (D)

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 medical record review and interview, it was determined the facility staff failed to ensure a snack was provided to Resident (#151). This was evident for 1 of 8 residents selected for review of nutrition during the annual survey process. The findings include: Review of the medical record review for Resident #151 revealed on 1/25/19 the dietician communicated with the dietary department the following: please send high calorie house snack 2 times a day at 2:00 PM and hour of sleep (ice cream, cookies, magic cup). Review of the medical record on 2/26/19 at 11:00 AM revealed no evidence the facility staff was providing Resident #151 with the high calorie snack as ordered at 2:00 PM and hour of sleep. Although, the amount consumed was not ordered, it is the expectation that dietary supplements and the amount consumed be documented to ensure the resident is taking in the ordered number of calories to increase or maintain caloric intake. Interview with the Corporate Nurses on 2/28/19 at 1:30 PM confirmed the facility staff failed to ensure a snack was provided to Resident #151.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication and follow the physicians' orders for administration of that pain medication for residents. This was evident for 2 of 4 residents (Resident #68 and #92) selected for review of pain management during the annual survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. 1. The facility staff failed to administer pain medication as ordered by the physician. Review of the medical record for Resident #68 revealed on 2/6/19 the physician ordered Diluadid 2 milligrams (mgs) 1 tablet by mouth every 4 hours as needed for pain level 6-10. Diluadid is used to help relieve moderate to severe pain. Diluadid belongs to a class of drugs known as opioid (narcotic) analgesics and it works in the brain to change how the body feels and responds to pain. To ensure adequate response to pain medication, the resident is asked to rate their pain level from 1-10 with 10 being the worse pain. Review of the Medication Administration Record (MAR) revealed the following: 2/8/19 at 6:08 AM pain level 5, 2/19/19 at 9:25 AM pain level 5, 2/23/19 at 6:07 PM pain level 5 and 2/24/19 at 3:31 AM pain level 5; however, the facility staff documented the administration of the Diluadid when the pain level was noted to be below the ordered level of pain. 2. The facility staff failed to administer pain medication as ordered by the physician. Review of the medical record for Resident #92 revealed that on 1/4/19 the physician ordered: Oxycodone 5 mg via G tube every 4 hours as needed for pain level 6-10. Oxycodone is a strong narcotic pain-reliever like morphine, codeine, and hydrocodone. The precise mechanism of action is not known but may involve stimulation of opioid receptors in the brain. Oxycodone does not eliminate the sensation of pain but decreases discomfort by increasing the tolerance to pain. In addition to tolerance to pain, oxycodone also causes sedation and depression of respiration. It is prescribed to treat moderate to severe pain. Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. The PEG tube can also be used for the administration of medications and fluids for residents not able to take them by mouth. Review of the Medication Administration Record revealed the following documentation: on 2/11/19 the facility staff assessed the resident and documented 0 pain at 7:54 AM, on 2/23/19 at 9:38 AM pain level as 4 and on 1/14/19 at 6:28 AM, pain level as 4; however, documented the administration of the medication when the documented pain level was below the set parameter by the physician. Interview with the Corporate Nurses on 2/28/19 at 1:30 PM confirmed the facility staff failed to thoroughly assess the need for pain medication for Residents #68 and #92.

CONCERN (D)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

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Based on review of employee files and staff interview, it was determined that the facility failed to perform an annual performance review for a Geriatric Nursing Assistant (GNA #8). This was identified for 1 of 2 GNA staff members reviewed during a complaint investigation. The findings include: Review of GNA #8's employee and education records revealed he/she was hired on 8/23/17 and the file did not contain the required performance evaluation for 2018. During an interview with the facility administrator on 2/27/19 at 9:00 AM, the facility administrator confirmed that the facility had not conducted a yearly performance evaluation for GNA #8.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner for Resident (#151). This was evident for 1 of 61 residents selected for review of medication review and 1 of 61 selected for review during the annual survey process. The findings include: Medical record review for Resident #151 revealed the consultant pharmacist was in the facility 8/14/18 and made recommendations about the administration of Lorazepam. Lorazepam, sold under the brand name Ativan among others, is a benzodiazepine medication. It is used to treat anxiety disorders, trouble sleeping, active seizures including status epilepticus, alcohol withdrawal, and chemotherapy-induced nausea and vomiting. Further record review revealed the physician was in the facility in 8/14/18, 9/7/18, 10/12/18, 11/13/18, 11/27/18, 12/10/18, 1/24/19 and 2/27/19; however, failed to address the consultant pharmacist recommendation at that time. Interview with the Corporate Nurse on 2/28/19 at 1:30 PM confirmed the facility staff failed to act upon and respond to the consultant pharmacist recommendation in a timely manner for Resident #151.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation and interviews of facility staff, it was determined that food service employees failed to ensure that equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 2/27/2019 at 7:58 AM during a routine tour of the main kitchen, steam table pans were observed wet stacked on the drying rack. Pans and equipment must be thoroughly dried to ensure adequate sanitization. The Food Service Manager was immediately made aware of these findings and removed the wet stacked pans from the drying rack and placed them onto the soiled side of the 3 compartment sink to be washed again.

CONCERN (D)

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for a resident. This was evident for 1 of 61 residents (Resident #92) selected for medical record review during the annual survey process. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. 1a. The facility staff failed to document the administration of an antibiotic. Medical record review for Resident #92 revealed on 2/12/19 the physician ordered: Tigecycline 50 milligrams (mgs) intravenously (IV) for pneumonia for 7 days. Must give loading dose of 100 milligrams IV first, then 50 mgs every 12 hours. Tigecycline is an antibiotic for several bacterial infections and is administered intravenously. Intravenously is given directly into the vein for faster absorption of the medication. Review of the Medication Administration Record (MAR) revealed no evidence the facility staff administered the Tigecycline 100 mgs as ordered prior to the 50 mg. Interview with the Corporate Nurse on 2/27/19 at 10:00 AM revealed the pharmacy indicated the medication was sent to the facility; however, the medical record does not reflect the administration of the medication. 1b. The facility staff failed to document the administration of IV fluids as ordered by the physician. Medical record review for Resident #92 revealed that on 2/5/19 the physician ordered: sodium chloride solution .9%- rate of 999-wide open intravenously (IV) now for hydration for 2 liters. The word intravenous as a [NAME] refers to an intravenous fluid drip, a solution (usually a balanced electrolyte solution) administered directly into the venous circulation. Also called a drip, intravenous fluids can be used for the administration of antibiotics or fluids to maintain hydration. Review of the MAR on 2/5/19 revealed the facility staff documented the administration of IV fluids; however, there was no documentation that 2 liters were administered. Interview with the Corporate Nurses on 2/28/19 at 1:30 PM confirmed the facility staff failed to maintain the medical record for Resident #92 in the most complete and accurate form by failing to document the administration of Tigecycline 100 mg and the administration of 2 liters of IV fluids as ordered.

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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Based on observation and interview it was determined that the facility staff failed to provide a safe, sanitary environment to prevent the development and transmission of disease and infection. This was evident during the initial tour of the nursing units and was found to be evident for 2 out of 2 residents (Resident #46 and #106) reviewed during the investigative portion of the survey. The Findings Include: 1. On 02/21/19 01:30 PM, an observation revealed that outside Resident #46's room was a container that contained items necessary for isolation precautions, gowns, masks, and gloves. Nurse #14 was observed walking into the room and not washing or sanitizing his/her hands and without the proper isolation precautions such as gown and gloves that was required to prevent the transmission of disease and infection. Medical record review on 02/21/19, revealed: Contact Isolation for CRE, which stands for Carbapenem-resistant Enterobacteriaceae, which are a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. CRE are an important emerging threat to public health. 2. On 02/21/19 10:27 AM, an observation revealed that outside Resident #106's room was a container that contained items necessary for isolation precautions, gowns, masks, and gloves. GNA #1 was observed walking into the room and not washing or sanitizing his/her hands and without the proper isolation precautions such as gown and gloves that was required to prevent the transmission of disease and infection. The GNA #1 revealed during interview that isolation precautions were not followed because I was just answering the call light. On 02/21/19 10:33 AM, another observation revealed facility Staff #3 walking into Resident #106's room and not washing or sanitizing his/her hands and without the proper isolation precautions such as gown and gloves that was required to prevent the transmission of disease and infection. Facility Staff #3 was observed placing a name bracelet around Resident #106's wrist after she/he laid scissors and paper on Resident #106's bed. Medical record review on 02/21/19, revealed: Contact Isolation for ESBLs, an extended-spectrum b-lactamase (ESBL). ESBL such as Escherichia coli (E. coli) produces an enzyme making the germ harder to treat with antibiotics. ESBLs are spread via direct and indirect contact with colonized/infected patients and contaminated environmental surfaces. Interview with the Regional Nurse #10 on 02/21/19 at 10:45 AM confirmed the facility staff failed to follow contact isolation precautions.

Oct 2017 8 deficiencies

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility staff failed to consistently and accurately assess the resident using the MDS assessment tool (resident assessment instrument (RAI) specified by the state. This was evident for 1 of 33 residents (resident #81) selected for review during stage 2 of the survey process. The findings include: The MDS (Minimum Data Set) is an assessment tool used by health professionals to develop, review, and revive a resident plan of care. The MDS assessment directs the facility staff on issues that may need to be addressed. On [DATE] a review of Resident # 81's medical record was initiated. The concern exists that the MDS dated [DATE] and [DATE] Section E (Wandering-identifies a resident as exhibiting this behavior occurring 4-6 days but less than daily) and is at risk for wandering to a dangerous place. Further review of the MDS documentation reveals the Resident is coded in Section G (Activities of Daily Living) as a (4) (dependent in locomotion on and off the unit), and as an (8) -Walk in room and walk in corridor as this activity did not occur. On [DATE] at 11AM the MDS coordinator was interviewed and questioned about the coding in both sections and admitted there was an error in the MDS coding of this Resident's status. revealing the Resident is not at risk for wandering to a dangerous place and during this review time on the MDS was dependent on staff for locomotion on and off the unit. The Administrator and Director of Nursing were made aware of the error in the coding on the MDS.

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 medical record documentation review and facility staff interview, it was determined that the facility staff failed to develop a comprehensive person-centered care plan for the resident (#125). This was evident for 1 (Resident #125) of 33 residents reviewed during stage 2 of the Quality Indicator Survey. The findings include: Review of Resident #125's medical record revealed physician's order for Nortriptyline 10 milligram (mg) to be administered at bedtime for neuropathy. Further review of the care plans revealed a care plan for depression. No diagnosis of depression was found in the medical record. Interview of the Unit Manager #1 on October 27, 2017 at 10:35 AM confirmed that Resident #125 does not have diagnosis of depression, does not receive any treatment for depression,and should not have care plan for depression.

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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Based on the observation, medical record documentation review and facility staff interview, it was determined that the facility staff failed to: 1) follow physician's order for gastrostomy tube (GT) flushes; (Resident #22) 2) document wound care administration in the Treatment Administration Record (TAR); (Resident #177) 3) administer an antipsychotic medication for resident (#130) as ordered by the physician. This was evident for 3 of 33 residents reviewed during stage 2 of the Quality Indicator Survey. The findings include: 1. During medication administration conducted on October 27, 2017 at 8:15 AM, LPN #1 was observed administering medications to Resident #22 via GT. A gastrostomy tube is a tube inserted through the abdomen that delivers nutrition directly to the stomach. Oyster Calcium with Vit D tablet (nutritional supplement) was crushed, diluted with tap water and administered via GT. Then Pro-Stat (dietary supplement) 30 ml was administered without prior flush of the GT with water. Next, Miralax (a laxative)17 grams in 8 ounces (oz) of water was administered without prior flush of the GT with water. Review of the physician's orders revealed a physician order instructing nursing staff to flush GT with at least 5 milliliters (ml) of water between each medication. Unit Manager #1 was present during medication administration and confirmed findings. 2. Review of Resident #177's medical record revealed a pressure ulcer to sacral area. Further review of the medical record revealed a physician's order for sacral pressure ulcer care dated July 13, 2017 instructing nursing staff to cleanse the sacral wound with Dakin's Solution (antiseptic solution), apply Silver Alginate (wound dressing) and cover the wound with a dry dressing daily. Review of TAR for October, 2017 revealed that nursing staff did not document wound care was administered during the month of October, 2017. Interview of Unit Manager #1 on October 27, 2017 at 1 PM stated that the wound care was administered per physician's order, but licensed nursing staff failed to document an administration of the wound care. 3) The facility staff failed to administer Seroquel, an antipsychotic medication, to resident #130 as ordered by the physician. According to the medical record, the resident was admitted to the facility with diagnosis that included Dementia with combative behaviors. Review of the medical record revealed a physician order dated 7/13/17 for Seroquel 12.5mg by mouth every day and Seroquel 12.5mg at bedtime for behaviors. Review of the MAR (Medication Administration Record) revealed the medication was not signed off as being administered on August 1st thru August 8th, 2017 at 8 pm. During an interview with the Unit Manager, s/he stated the medication should have been given.

CONCERN (D)

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

Deficiency F0323 (Tag F0323)

Could have caused harm · This affected 1 resident

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Based on medical record review and facility staff interview, it was determined the facility staff failed to assure the safety of a resident during care. This was evident for 1 (Resident #22) of 33 residents reviewed during stage 2 of the Quality Indicator Survey. The findings include: Intake MD00117163 was investigated on October 25, 2017. On October 25, 2017, a review of Resident #22's medical record was initiated and revealed the facility incident report that was completed by the facility staff on June 17, 2017 at approximately 7:30 PM. The report indicated that the resident fell out of bed during care provided by a Licensed Practical Nurse (LPN). Further review of the medical record revealed the facility incident report completed by the facility staff on September 7, 2017 at approximately 3 PM, indicated that the resident fell out of bed when Geriatric Nursing Assistant (GNA) was providing care to the resident. 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. Review of Quarterly MDS with Assessment Reference Date (ARD) of June 8, 2017 and August 25, 2017, revealed that Resident #22 was coded at total dependence on two staff for bed mobility, which the facility staff failed to provide when falls on June 17, 2017 and September 7, 2017 occurred. The Administrator and the Corporate Nurse made aware of the findings prior the exit.

CONCERN (D)

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

Deficiency F0329 (Tag F0329)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined that the facility staff failed to ensure that sliding scale insulin was administered as ordered based on the blood sugar levels. This was found to be evident for one out of the 33 residents (Resident #198) reviewed during the survey. The findings include: On 10/26/17 review of Resident #198's medical record revealed orders for the resident's blood sugar [also known as a Finger Stick] to be checked before meals [6:30 AM, 11:30 AM, 4:00 PM] and at bed time [9:00 PM] and to administer insulin based on the blood sugar level as follows: 150-200 give 1 units 201-250 give 2 units 251-300 give 4 units 301 - 350 give 6 units 351-400 give 8 units Call MD if blood sugar is greater than 400 or less than 60. Review of the Medication Administration Record revealed: On 10/01/17 at 6:30 AM, the finger stick was completed and the value was recorded at 150; however, the one unit of Insulin was not administered. On 10/04/17 at 4:00 PM, the finger stick was completed and the value was recorded at 178; however, the one unit of Insulin was not administered. On 10/04/17 at 9:00 PM, the finger stick was completed and the value was recorded at 167; however, the one unit of Insulin was not administered. On 10/17/17 at 6:30 AM, the finger stick was completed and the value was recorded at 159; however, the one unit of Insulin was not administered. On 10/17/17 at 9:00 PM, the finger stick was completed and the value was recorded at 154; however, the one unit of Insulin was not administered. During interview with the Unit manager the findings were verified before exit.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of the nourishment room on unit 2 South, it was determined that the facility staff failed to remove expired enteral feeding supplies. This was evident for 1 of 4 units observed during stage 2 of the Quality indicator Survey. The findings include: Observation of the nourishment room on unit 2 South was conducted on [DATE] at 9:30 AM. Five 1 Liter containers of Jevity 1.2 with an expiration date of July, 2017 were observed in the cabinet. Unit Manager #2 was made aware and removed expired enteral feeding from stock as waste.

CONCERN (D)

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

Deficiency F0441 (Tag F0441)

Could have caused harm · This affected 1 resident

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Based on observations, it was determined that the facility staff failed to follow the hand hygiene procedures in a order to maintain a sanitary environment to prevent the development and transmission of disease and infection. This was evident during medication administration observation. The findings include: Medication administration observation wasconducted on October 27, 2017 at 8:15 AM on Unit 1. LPN #1 was observed by the surveyor in the presence of Unit manager #1: 1) LPN # 1 did not wash or sanitize his/her hands prior to applying a pair of gloves. 2) LPN #1 went to Resident #22's bathroom, poured tap water, and returned to administering medication with gloved hands without prior washing or sanitizing his/her hands. 3) LPN #1 accidentally dropped a lancet on the floor, picked thelancet up from the floor with a gloved hand and proceeded with a medication administration, without washing his/her hands. After surveyor intervention, LPN #1 discarded the lancet.

CONCERN (E)

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

Deficiency F0514 (Tag F0514)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) The facility staff failed to have a wound care order for a sacral pressure ulcer in the monthly physician order sheet. Review of Resident #177's medical record revealed a pressure ulcer to the sacral area. Further review of the medical record revealed a physician's order for sacral pressure ulcer wound care dated July 13, 2017 instructing nursing staff to cleanse the sacral wound with Dakin's Solution (antiseptic solution), apply Silver Alginate (wound dressing) and cover the wound with a dry dressing daily. Review of monthly physician's order sheet for month of September, 2017 and October, 2017 revealed no physician's order for wound care to sacral pressure ulcer. The findings were confirmed with Unit Manager #1 on October 27, 2017 at 1 PM. Based on review of medical record and interview with facility staff, it was determined that the facility staff failed to maintain complete and accurate medical records as evidenced by: 1) the physician failed to write notes in legible handwriting; (resident #204); 2) the facility staff failed to to document wounds as they were identified; (resident #297) 3)the facility staff continued to document a resident (#103) was receiving an antipsychotic medication that had been discontinued; and 4)The facility staff failed to have a wound care order for a sacral pressure ulcer in the monthly physician order sheet. (resident #177). This was true for 4 of 33 Residents (Residents #204, #297, #103, 177) reviewed during Stage 2 of the QIS survey. The findings include: 1) The physician failed to write notes in legible handwriting; (resident #204) During a review of residents' medical records that took place on 10/26/17 at 9:42 AM, the physician #1 discharge summary for Resident #204 was found to be illegible by 3 members of the survey team. After this review, the Director of Nursing, the Administrator and Regional Nurse #1 were asked to read the writing of Resident #204s discharge summary and all three were unable to transcribe it for the survey team. The authoring physician, Physician #1, was requested to transcribe this discharge summary on the same day at 11:30 AM. The Regional Nurse #1 stated that afternoon at 1:45 PM that Physician #1 was receiving education on legible handwriting from the facility and that all of this physician's medical record entries were being reviewed for legibility. 2) The facility staff failed to to document wounds as they were identified; (resident #297) During a review of Resident #297's chart, that took place on 10/26/17 at 8:45 AM, skin sheets including wound measurements and physician's orders including wound treatments were reviewed. There was a discrepancy between when wounds were identified based on physician order sheets and when wound skin sheets were completed which indicated nursing was aware of these wounds. On 9/5/17, the day of admission, three pressure wounds are identified for Resident #297: Right mid Back, Right Heel, and at the Sacrum. On 9/11/17, new orders are entered on physician order sheets by the wound care physician, Physician #2, for the three pressure sites noted at admission as well as eleven more sites: Left Shoulder, Right Elbow, Left Upper Back, Right Ischium, Left Ischium, Upper Back, Lower Back, Right Antecubital Elbow, Left Shin, Right Shin and Right Thigh. These pressure areas were not documented on skin care sheets until 9/14/17, three days later, where all additional 11 sites were assessed and treatment was documented. During an interview with Unit Manager #2 that took place on 10/27/17 at 11:45 AM, Unit Manager #2 stated that all wounds were to be documented on the electronic skin evaluation form at the time that the wounds were identified. Unit Manager #2 stated that wound care should also be documented here but that some nursing notes will include evidence of wound care and identification. All nursing notes that were written between Resident #297's admission and 9/14/17 (when the additional 11 sites were documented) and no nursing note mentioned the additional wounds that were identified. Because the wounds were known about on 9/11/17 as evidenced by Physician #2's order sheet, but wound skin sheets were not created until 9/14/17, there is a gap in complete documentation of these wounds. 3) The facility staff continued to document a resident (#103) was receiving an antipsychotic medication that had been discontinued. Review of Resident # 103's medical record revealed the resident was receiving Seroquel 12.5 mg every day until it was discontinued on 8/25/17; however, the Nurse Practioner continued to document on his/her assessment dated [DATE] and 10/12/17, the resident was receiving Seroquel 12.5 mg every morning. Interview with the Unit manager on one south on 10/27/17 at 9:52 am confirmed the findings.

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

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• 48 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
• $28,915 in fines. Higher than 94% of Maryland facilities, suggesting repeated compliance issues.
• Grade C (55/100). Below average facility with significant concerns.

Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.

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About This Facility

What is Future Care Irvington's CMS Rating?

CMS assigns FUTURE CARE IRVINGTON an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Maryland, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Future Care Irvington Staffed?

CMS rates FUTURE CARE IRVINGTON's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 52%, compared to the Maryland average of 46%.

What Have Inspectors Found at Future Care Irvington?

State health inspectors documented 48 deficiencies at FUTURE CARE IRVINGTON during 2017 to 2025. These included: 2 that caused actual resident harm, 45 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Future Care Irvington?

FUTURE CARE IRVINGTON 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 200 certified beds and approximately 179 residents (about 90% occupancy), it is a large facility located in BALTIMORE, Maryland.

How Does Future Care Irvington Compare to Other Maryland Nursing Homes?

Compared to the 100 nursing homes in Maryland, FUTURE CARE IRVINGTON's overall rating (4 stars) is above the state average of 3.0, staff turnover (52%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Future Care Irvington?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Future Care Irvington Safe?

Based on CMS inspection data, FUTURE CARE IRVINGTON 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 4-star overall rating and ranks #1 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 Future Care Irvington Stick Around?

FUTURE CARE IRVINGTON has a staff turnover rate of 52%, which is 6 percentage points above the Maryland average of 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 Future Care Irvington Ever Fined?

FUTURE CARE IRVINGTON has been fined $28,915 across 2 penalty actions. This is below the Maryland average of $33,368. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Future Care Irvington on Any Federal Watch List?

FUTURE CARE IRVINGTON 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: 200
Avg. Residents: 179
Occupancy: 89.6%
Ownership: For profit - Limited Liability company
Chain: FUTURE CARE/LIFEBRIDGE HEALTH
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
2 Actual Harm citations: -10
48 Deficiencies: -10
Fines ($28,915): -5
Final Score: 55/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 215219