WHITE OAK REHABILITATION AND NURSING CENTER
For profit - Limited Liability company
160 Beds
LIFEWORKS REHAB
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#218 of 219 in MD
Photo by Gruen Agency HCR - ManorCare
Photo by Gruen Agency HCR - ManorCare
Photo by Sv Flowers
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
White Oak Rehabilitation and Nursing Center currently holds a Trust Grade of F, indicating significant concerns about its quality of care. It ranks #218 out of 219 facilities in Maryland, placing it in the bottom half statewide and last in Prince George's County, meaning there are no local options that rank lower. The facility is facing a worsening trend, with issues increasing from 14 in 2024 to 21 in 2025. While staffing turnover is relatively low at 22%, suggesting stability, the overall staffing rating is below average at 2 out of 5 stars, and it has concerning RN coverage, being lower than 82% of Maryland facilities. Notably, the facility has incurred $129,636 in fines, higher than 90% of other Maryland facilities, indicating compliance problems. Specific incidents of concern include residents being subjected to involuntary seclusion, which caused distress and self-harm for some individuals. Additionally, a cognitively impaired resident was able to leave the facility unsupervised, which is a serious safety issue. While the facility has some strengths, such as low staff turnover, the significant number of critical deficiencies and high fines raise serious red flags for families considering this location for their loved ones.
- Trust Score
- F
- In Maryland
- #218/219
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 22% annual turnover. Excellent stability, 26 points below Maryland's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $129,636 in fines. Lower than most Maryland facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for Maryland. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 79 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 1%
Review needed
14 → 21 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 14 issues
2025: 21 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (22%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (22%)
26 points below Maryland average of 48%
Facility shows strength in quality measures, staff retention, fire safety.
The Bad
1-Star Overall Rating
Below Maryland average (3.0)
Significant quality concerns identified by CMS
Federal Fines: $129,636
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: LIFEWORKS REHAB
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 79 deficiencies on record
3 life-threatening
Apr 2025
21 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0603
(Tag F0603)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview with residents and staff, and other pertinent documents it was determined tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview with residents and staff, and other pertinent documents it was determined that the facility subjected residents to involuntary seclusion by restricting their ability to move freely. This was evident for 4 (Resident #17, #30, #102, #108) out of 15 residents residing in the locked area of the Med Bridge unit. Additionally, due to the restriction, Resident #108 experienced distress resulting in self-inflicted physical harm in an attempt to exit the locked unit.
As a result of the non-compliance an IJ (Immediate Jeopardy) was determined on 4/25/2025 at 3:30 PM. An IJ summary tool was provided to the facility on 4/25/25. The facility submitted a draft of their plan to remove the immediacy on 4/25/25 at 6:40pm, and it was not accepted. The facility submitted a second draft of their plan to remove the immediacy on 4/25/25 at 7:45pm and it was accepted by the State Agency on 4/25/2025 at 8:00pm. After removal of the immediacy, the deficient practice remained with a scope and severity of E.
The Immediate Jeopardy was removed on 4/29/25 after on-site confirmation of the completion of the facility's plan of removal.
The findings include:
During an interview with the NHA (Nursing Home Administrator), the ADON (Assistant Director of Nursing) and Staff #2 on 4/16/25 at 1:11pm, Staff #2 stated that the locked unit was initiated on 10/31/24 following an elopement incident involving a resident. At the time of the interview, the door to the unit was unlocked and opened and remained that way during the rest of the survey.
During record review on 4/25/25 at 11:40am, it was revealed that Resident #108 was observed by staff banging on the double doors of the locked portion of the Med Bridge unit on 11/6/24 at 7:00am. At 4:04pm, the resident had an X-ray performed which showed acute fractures of the distal radius and ulnar styloid. The resident was sent to the hospital on [DATE] for immobilization of the fractures. Prior to this incident, there had been no documentation to indicate Resident #108 had demonstrated similar behavior of banging on doors.
During observation rounds on 4/16/25 at 7:56am, 15 residents were observed to be behind a locked door when the surveyor conducted an initial tour of the facility. The surveyor questioned the unit manager (Staff #18) regarding the lock unit. Staff #18 stated the locked door was not actually a locked unit and that it was part of a skilled unit.
On 4/23/25 at 02:48pm, Staff #2 was interviewed for follow-up information regarding the decision to lock part of the Med Bridge unit. Staff #2 stated that the VPO (Vice President of Operations) initiated the locked portion of the unit as a temporary makeshift unit for the wandering residents.
Brief Interview for Mental Status (BIMS) is an assessment tool used to screen and identify resident cognitive status. Scores of 8-12 indicate moderate cognitive impairment, scores of 13 or above indicate cognition is intact.
BIMS scores were reviewed for all the residents residing in the locked area on 4/16/25. Three residents (#17, #30, #102) were identified to have BIMS scores above 11 indicating they would be interviewable. On 4/24/25 at 12:20 pm, interviews were conducted with the alert and oriented residents residing on the unit on 4/16/25 when the unit was found to be locked by the State Agency surveyors. Residents #17, #30, and #102 all stated they did not have the code to open the door and that when they needed to go off the unit that staff had to open the door for them. There was no evidence or documentation to indicate these residents needed to reside on a secure locked unit.
The other 11 residents on the unit were determined to be not interviewable by review of their BIMS scores and had no documentation in their medical records indicating that they needed a locked unit for their safety.
An immediate jeopardy was declared on 4/25/2025. The provision of the plan to remove the immediacy had a completion date of 4/25/25 and included the following:
1. The keypad on the doors was immediately disabled/deactivated and has remained open since 4/16/25
2. All residents in the facility, especially those who wander, have the potential to be affected. No doors in the facility except the door in question has a keypad. The keypad was deactivated on 4/16/25.
3. All double doors in resident care areas do not have keypad/unable to be locked except the doors referenced in this citation, which has been deactivated since 4/16/25. Residents who are noted to be wanderers are being monitored/redirected to their floors/units by the facility staff. All staff to be educated on resident's rights related to freedom from unnecessary restraint and seclusion. Training/in- service to be completed by 4/25/25
4. The facility administrator conducted an audit of all double doors in the resident care areas and no deficiency noted. This audit will continue daily x 4 weeks, weekly x 4 weeks and monthly x 3 months. Results of these audits will be submitted to the QA/QAPI committee for further recommendation(s)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4a. Record review of Resident #23's medical record on 4/16/25 at 10:15 AM revealed a smoking care plan was initiated on 7/27/22 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4a. Record review of Resident #23's medical record on 4/16/25 at 10:15 AM revealed a smoking care plan was initiated on 7/27/22 and revised on 2/5/25. It indicated the resident was a dependent smoker with the goal to monitor any issues or complications and assist the resident during smoking times. Additionally, on 5/22/23 a focus area was added to the care plan that the resident was non-compliant with wearing the recommended smoking vest and following the facility smoking policy; however, the goals and/or interventions did not address the resident's noncompliance.
During observation rounds 4/16/25 at 9am resident #23 was observed reclining back in the wheelchair in the courtyard located on the first floor. The resident was observed with a lit cigarette hanging from his/her mouth and was unsupervised.
On 4/17/25 at 8am Resident #23 was again observed by this surveyor in the upper level courtyard with his/her wheelchair reclined back. Resident #36 walked over to Resident #23 and put a lit cigarette in his/her mouth. At that time the Administrator was walking in the hall and verified the findings. The Administrator stated Resident #36 should not be giving Resident #23 or any other resident a cigarette. Review of Resident #36's record revealed s/he was assessed as being an independent smoker with a BIMs of 9 (moderately cognitive impaired).
4b. Review of Resident #125's medical record on 4/16/25 at 11am revealed the resident has a BIMs (brief interview of mental status) score of 7, (0-7 indicates severe cognitive impairment) as of 4/15/25. Continued review of the medical record revealed a Smoking-Safety Screen dated 2/4/25 assessing the resident as being an independent smoker.
Resident #125 was observed ambulating back and forth in the upper level (1st floor) courtyard with a lit cigarette in his/her hand and was unsupervised.
During an interview on 4/16/25 at 9:15am the Administrator and the Acting Director of Nursing were made aware of the observation. Both stated that dependent smoking residents should be monitored and should be going downstairs to the courtyard to smoke. It was verified by Both the Administrator and the ADON that resident #125 had been assessed as being a dependent smoker.
During an interview with the Activities Director on 4/16/25 at 9:30am, she stated that she has spoken to residents on several occasions about lighting dependent resident cigarettes. She stated Resident #23 was non-compliant with the smoking policy and has been told several times that the dependent residents are to smoke in the downstairs courtyard where they can be supervised. Based on record reviews, observations, and interviews with staff and residents, it was determined that the facility failed to:1) ensure a system was in place to prevent exit seeking residents from leaving the facility unsupervised. This was evident for 2 (Resident #105 and Resident #154) out of 22 residents reviewed for exit seeking; 2) Assess, Supervise and monitor residents while smoking. This was evident for 4 (Resident #106, #23, #125, and #51) out of 22 residents reviewed for smoking; 3) Assess and monitor residents with known wandering behaviors. This was evident for 1 (Resident # 108) out of 25 residents reviewed for wandering.
As a result of this deficient practice, an Immediate Jeopardy was identified on 4/25/2025 at 9:10 PM. An IJ summary tool was provided to the facility on 4/25/2025. The facility submitted the first plan to remove the Immediacy on 4/25/2025 at 11:18PM. The first plan was not accepted. The facility submitted a 2nd plan to remove the Immediacy on 4/26/2025 at 2:01AM. The 2nd plan was not accepted. The facility submitted a 3rd plan to remove the Immediacy on 4/26/2025 at 3:21AM. The 3rd plan was not accepted. The facility submitted a 4th plan to remove the immediacy on 4/26/2025 at 3:55AM which was accepted at 4:22AM. After removal of the immediacy, the deficient practice remained with a scope and severity of E.
The Immediate Jeopardy was removed on 4/29/25 at 3:15 PM after on-site confirmation of the completion of the facility's plan of removal.
The Findings Include:
Wandering is a pattern of aimless and often repetitive walking that significantly increases the risk of injury to the individual.
Elopement or exit seeking risk are those who are at risk for leaving a place unnoticed and unsupervised.
1. On 04/18/25 at 9:20 AM, a review of resident #154's medical record and facility investigation revealed a care plan focus area, created on 07/29/2022, stated that resident #154 has a risk for elopement and patient wanders related to Impaired Safety Awareness. The resident had a Brief Interview for Mental Status (BIMS) score of 02/15 on 10/21/2024, which indicated the resident was severely cognitively impaired. Further review of an Elopement Risk Tool assessment dated [DATE] revealed resident #154 was a high risk for elopement and exit seeking. A care plan focus area, created on 10/22/2024, stated the resident was at risk for elopement related to dementia and the patient wears a wander guard.
On 04/18/2025 at 10:00 AM a review of the facility investigation revealed that on 10/30/2024 approximately. 4:34 PM the facility was first made aware when a phone call from hospital alerting them that resident #154 was found and brought to the emergency room by Emergency Medical Services (EMS). EMS received a call from someone in the community that resident #154 was on their property, EMS responded and took the resident to the Emergency Room. Per facility investigation on 10/30/2024 the resident was last seen by Nurse staff #20 at 2:00 PM standing in the hallway of the unit. Staff #20 said he heard the back door alarm go off and responded immediately with other staff members and they went outside the door but did not see anyone, the alarm was deactivated and staff returned to the unit. The investigation revealed that the staff did not take any additional steps to validate that Resident #154 was still on the unit and in the facility. Further review of resident #154's medical record and facility investigation revealed that on 10/30/2024 at 7:30 PM Resident #154 returned to the facility from the emergency room and the Nurse Supervisor verified that the resident was wearing a wander guard, staff completed an assessment on resident and determined that resident had no injuries, facility placed a one on one caregiver with resident upon return to the facility.
On 04/22/2025 at 12:09 PM during an interview - Regional Consult for Clinical staff #2 stated on 10/30/2024, day of the elopement, it was on the downstairs unit, 2-3 staff members went through the first door on the unit leading to the stairwell to go to a training on another unit upstairs. The door closed and shortly after Resident # 154 went through the first door entering the stairwell, then Resident #154 went to the left and went through the second door that leads to the outside and staff responded to the alarm, they looked around outside and did not see anyone and came back into the center.
On 04/22/2025 at 1:45 PM during observation rounds of facility and interview with Maintenance Director staff #13, Assistant Director of Nursing staff #11 and Regional Consult for Clinical staff #2, the Maintenance Director stated the doors that Resident #154 eloped from were located on the lower level of the facility near room [ROOM NUMBER]. After the elopement of Resident #154 the keypad, release button on the inside of stairwell door and wander guard system leading out the first door into the stairwell was noted to be broken. The wander guard system only works if the resident is wearing a wander guard and presses the door handle. The second door that the resident went through leading to the outside of the building had not been connected to the fire alarm system but will now open and alarm only when the fire alarm is alarming. At the time of rounds the first door leading to the stairwell did alarm when the door was pressed while holding a wander guard device near the door and the second door was noted to be locked and able to be opened only by using the keypad with a code.
On 04/23/2025 at 9:48 AM during observation rounds with Maintenance Director staff #13 and Nursing Home Administrator staff # 1 revealed the wander guard systems did not alarm when a wander guard device was placed next to the doors which demonstrated that the wander guard system was not working for the following doors:
a. the upper East Wing door,
b. the lower level East Terrace door next to the physical therapy room,
c. the lower level East Terrace door between physical therapy room and DON office,
d. the upper level Main Dining Room door and the upper level door next to the Dietician office
2. On 4/22/2025 at 11:00AM, a review of Resident #105's electronic medical record revealed that the resident was admitted to the facility on [DATE] with a diagnosis of but not limited to dementia and anxiety. The resident had a Brief Interview for Mental Status (BIMS) score was 13/15, which indicated the resident was cognitively intact. There was a care plan focus created on 4/25/2023, which stated that the resident wanders related to impaired safety awareness secondary to Dementia. Further review revealed an admission Elopement Risk Assessment on 4/24/2023 which indicated the resident was at a high risk for elopement/exit seeking. The resident had physician orders dated 10/5/2023 for a wander guard on the right wrist, to check function weekly every day shift on Wednesdays, and to check placement every day, every shift and a quarterly Elopement Risk Assessment on 10/27/2023 which indicated the resident was at risk for elopement/exit seeking.
On 4/22/2025 at 10:45AM, a review of a facility reported incident (FRI) investigative file revealed that on 1/10/2024 at approximately 9PM, Resident #105 and a visitor were allowed out of the building by a Geriatric Nursing Assistant (GNA) staff member. The GNA staff member assumed the resident was going on a leave of absence with a family member. The GNA turned off the wander guard alarm at the main entrance door after the resident's wander guard triggered the alarm.
Further review of the FRI revealed that on 1/10/2024 at approximately 9:24PM, Resident #105 was returned to the facility accompanied by two police officers who saw the resident walking along the sidewalk down the street from the facility. The resident informed the officers that he/she resided at the facility and did not go out and wanted to take a walk. The resident sustained no injuries.
3. On 4/18/2025 at 7:37AM a review of the facility's current smokers list as of 4/7/2025, revealed Resident #106 was an independent smoker, indicating the resident did not need to be supervised while smoking.
During review of Resident #106's electronic medical record, the Surveyor discovered a quarterly smoking safety screen assessments with scores. Scores of 0-4 mean the resident may smoke unsupervised and scores 5 or greater means the resident requires supervision with smoking. Resident #106 was assessed as a smoker and had a smoking safety screen score of 0 on 4/17/2024, score of 7 on 7/17/2024, and a score of 2 on 10/18/2024. On a 1/20/2025 smoking safety screen assessment it documented the resident did not smoke and had a score of zero.
Further review of the electronic medical record revealed a care plan created on 4/14/2023 and updated on 3/26/2025 with a focus which stated the resident prefers to smoke with interventions for nursing staff to complete a smoking assessment as needed and all staff to supervise with smoking.
On 4/18/2025 at 7:00AM, the Surveyor observed Resident #23 and Resident #125 in the upper-level courtyard smoking unsupervised.
On 4/18/2025 at 7:50AM during an interview with Activity Director #12, the Surveyors were informed that she does the smoking assessments and that the nursing staff should follow up with them.
6. On 4/22/25 at 11:11 AM, during review of the medical record for Resident #108, the resident's care plan from 5/4/24 read as follows [Resident 108] is an elopement risk/wanderer related to impaired safety awareness. The following interventions were in place Monitor the resident while on the unit as indicated, Redirect the resident as needed. These interventions were in place to prevent Resident #108 from wandering into areas that could lead to an unsafe situation. Review of the previous care plans for Resident #108 showed that he/she was identified as a wanderer since being admitted in April 2023. The prior care plans were dated 5/9/23, 8/8/23 and 11/6/23 and all identified Resident #108 as a wanderer.
On 4/24/25 at 2:19pm, review of the progress notes for Resident #108 revealed that on 5/21/24 the resident had wandered into Resident #154's room and when asked to leave, Resident #108 took his/her shoe and threatened to hit Resident #154. Staff separated the residents and took Resident #108 back to his/her room. The resident care plan was not updated with any additional interventions after this incident.
The facility's investigation related to facility-reported incident MD00206662 was reviewed on 4/22/25 at 10:17 AM. In the investigation, the facility substantiated there was an altercation on 6/13/24 between Resident #108 and Resident #19. The investigation revealed that Resident #108 wandered into Resident #19's room. Resident #19, unable to call for help due to their medical condition, attempted to go into the hall for assistance and used an emergency whistle to get attention from staff. When no one came to assist, Resident #19 felt he/she was in danger and pepper sprayed Resident #108. Resident #108 had a BIMS (Brief Interview for Mental Status) score of 0 on the most recent assessment dated [DATE] prior to this incident. BIMS scores of 0-7 indicate severe cognitive impairment. Resident #108 was found by staff screaming and holding his/her hands over his/her eyes. The resident was evaluated by the physician at the facility and was ordered to be sent for further evaluation at the hospital. The resident was diagnosed with chemical burns of the eyes at the hospital and was prescribed eye drops for 5 days.
On 4/23/25 at 01:40pm, an interview with Resident #19 was conducted. He/she stated that the incident with Resident #108 was not the first time that a wandering resident had entered his/her room and that he/she had alerted administration and staff that it was a recurrent problem. He/She also said that he/she was pushed to the floor in the past by another resident who wandered into his/her room.
On 4/23/25 at 8:46am, the facility provided 2 more incident reports which involved Resident #108 wandering into other resident rooms. On 10/27/24 Resident #108 wandered into a resident's room and hit the resident with a plastic hanger, which was substantiated by a witness. The corrective actions related to this incident were to conduct staff in-service on close monitoring and redirection of wandering residents.
On 12/2/24, Resident #108 was involved in another incident where Resident #108 wandered into a different resident's room and allegedly kicked his/her leg but there were no other witnesses, and the altercation could not be substantiated. The facility's investigation found that staff did not see Resident #108 enter the other resident's room that night and no witnesses could confirm the event occurred. The corrective action for this incident was as follows, [Resident #108] is being monitored by staff. There were no modifications to the interventions in Resident #108's care plan following the incident on 6/13/24.
Further review of the progress notes showed that Resident #108 continued to wander into other residents' rooms with documented examples from the dates 11/21/24, 11/27/24, 12/5/24, 12/12/24, 1/2/25, 2/3/25, 2/20/25, 2/23/25, 3/23/25, and 4/19/25.
On 4/24/25 at 09:35am, an interview was conducted with the NHA (Nursing Home Administrator) who stated that the expectations for standard practice at this facility were to monitor the wandering residents anytime they are in the hallways.
An Immediate Jeopardy was identified on 4/25/2025. The provision of the plan to remove the Immediate Jeopardy immediacy had a completion date of 4/29/2025 and included the following:
1. Resident #154 no longer resides in the facility; Resident #105 still resides in the facility with a wander guard in place, functioning checked and the wander guard functioning properly.
2. Resident #23, #36, #125, and #51 still reside in the facility and will be supervised during smoking activity.
a. Resident # 23 will be provided reeducation on the designated smoke areas and times and was provided with the smoking acknowledgment form for compliance.
b. Resident #125 will be provided supervision during smoking activity. A designated staff member will be stationed at the upper-level courtyard door.
3. Wander guards are in place and working properly for Resident #141, 121, and #108.
Facility staff will supervise both smoking areas located in the upper and lower level of the facility throughout all scheduled smoke times whether dependent or independent.
4. All individuals identified as a smoker, wanderer, or at risk for elopement have the potential to be affected. A facility wide audit was conducted to verify accuracy of assessments for all residents completed by 4/29/2025.
5. All doors with the wander guard system were checked for proper functioning by the vendor on 4/24/2025 and the following was corrected:
a. Checked all secure units, lobby, east wing, exit to kitchen, stairwell by lounge, west by central supply, east terrace by smoking area, east terrace by rehab, main dining room, and exit by maintenance shop. Replaced strobe alarm at terrace smoking door. Disconnect door switch to allow alarm to activate. Verify alarms at all remaining doors while approaching the door.
6. All doors with a wander guard system were checked for proper functioning by the Maintenance Director on 4/26/2025 at 12:45AM and confirmed to be functioning properly.
7. All residents with the wander guard bracelets were checked for placement and function on 4/26/25 at 12:45AM.
8. All residents with wandering behavior will be provided monitoring to ensure safety and wellbeing with the use of an individual hourly monitoring log daily to be completed by nursing and care plan reviewed and revised accordingly.
9. To ensure the accuracy and use of appropriate safety devices, the facility will conduct a new assessment on all current wandering and elopement risk residents by 4/29/2025.
10. To accurately determine the level of assistance needed, all smoking residents will receive a new assessment for 4/29/2025.
11. To safeguard residents, staff will be trained on alarm response and thorough search procedures, followed by a headcount to ensure all are present and accounted for by 4/29/2025.
12. For resident safety, a designated staff member will always provide supervision for all residents during scheduled smoking times. Training will be provided to all staff on facility smoke policy by 4/29/2025.
13. All residents identified for wandering, elopement risk, and smoking will have behavior monitoring implemented as needed by 4/29/2025
a. Wander guard device functioning will be checked weekly by central supply
b. Wander guard device placement will be checked every shift by the charge nurse and/or the supervisor.
14. 100% audit was conducted of the wander guard door a;arm system and bracelets completed.
The Maintenance Director will complete a daily audit on exit doors x4 weeks, weekly audits x4, and monthly audits x3; daily monitoring of the smokers supported with an audit tool will be completed daily by the nursing staff daily x4 weeks, weekly x4 weeks, and monthly x3; Nursing will monitor all wandering residents Q hourly utilizing a monitoring log to ensure safety daily x4 weeks, weekly x4 weeks, and monthly x3; wander guard device placement audit will be conducted daily x4, weekly x4 and monthly x3 by central supply.
15. All results of the audits will be submitted to the QA/QAPI committee for further recommendation (s) monthly and as needed.
5. On 04/25/25 at 01:41 PM, review of resident records revealed that Resident #51's Smoking Safety Screen, dated 4/18/25, indicated that Resident #51 was a smoker, has dexterity problems, cannot use a lighter independently, requires a smoking apron/blanket while smoking, and must be supervised while smoking.
On 04/25/2025 at 1:43 PM, review of resident records revealed that Resident #51 has a medical diagnosis of ataxia and muscle weakness.
On 04/25/25 at 01:47 PM, review of resident records revealed that Resident #51's care plan indicated that Resident #51 must be supervised while smoking. Resident #51's care plan did not indicate that Resident #51 must use a smoking apron/blanket while smoking.
On 04/25/25 at 01:12 PM, during observation rounds on 4/16/25 and 4/17/25, Resident #51 was noted smoking unsupervised.
On 04/25/25 at 01:12 PM, during observation rounds on 4/18/25, 4/21/25, 4/22/25, 4/23/25 and 4/24/25 Resident #51 was observed smoking unsupervised without wearing a smoking apron/blanket.
On 04/25/25 at 2:18 PM, Activity Director staff #12 was interviewed. During the interview, staff #12 stated that many dependent smoking residents and independent smoking residents are non-compliant with following the smoking policy. Dependent smoking residents have been told several times that they must smoke in the downstairs courtyard where they can be supervised by staff as well as wear a smoking apron/blanket. Staff #12 also stated that they have told independent smokers not to light cigarettes for dependent smokers.
On 04/25/25 at 2:49 PM, Resident #51 was interviewed. During the interview, Resident #51 indicated that he/she was aware that they must be supervised by staff and must wear a smoking apron/blanket while smoking.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined that the facility staff failed to provide an environment that promotes dignity and respect for a resident (#16) while proving am care. This is evi...
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Based on observation and interview, it was determined that the facility staff failed to provide an environment that promotes dignity and respect for a resident (#16) while proving am care. This is evident for 1 of 15 residents reviewed during the survey.
The findings include:
During observation rounds on 4/16/25 at 8:48 AM Resident #16 was observed lying in bed, with the bed raised to its highest position. The resident was uncovered with a yellow brief exposed; the resident's curtain was only partially drawn. The resident could be seen by his/her roommate and any visitors entering the room.
During an interview on 4/16/25 at 9:00am with the Geriatric Nursing Assistant (GNA) staff (#24) she stated, I should have pulled the curtain completely shut.
During an interview with the Resident #16 at 10:30am s/he stated, they never close the curtain.
The Director of Nursing was made aware of the findings on 4/16/25 at 10:45. She stated the staff would be reeducated on privacy.
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 F0576
(Tag F0576)
Could have caused harm · This affected 1 resident
Based on staff interviews and review of facility records, it was determined that the facility failed to disseminate mail delivered to the facility for the residents. This was evident for 1 (Residents ...
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Based on staff interviews and review of facility records, it was determined that the facility failed to disseminate mail delivered to the facility for the residents. This was evident for 1 (Residents #167) out of 4 residents reviewed during the survey.
The findings are:
On 04/23/2025 at 10:58 AM, complaint MD00208416 was reviewed. Complaint MD00208416 indicated that Resident #167 mentioned that the facility's Business Office is holding resident mail longer than they should.
On 04/23/2025 at 11:31 AM, the surveyor attempted to contact Resident #167 via telephone for an interview. Resident #167 did not answer the telephone call; therefore, the surveyor left a voicemail message on 4/23/2025 at 11:33 AM. As of 4/29/25, Resident #167 had not returned the surveyor's phone call.
On 04/24/2025 at 9:25 AM, the Nursing Home Administrator staff #1 was interviewed. During the interview, the surveyor informed staff #1 of the complaint about the Business Office holding residents' mail.
On 04/24/2025 at 9:32 AM, the Business Office Manager staff #17 was interviewed. During the interview, staff #17 mentioned that when he/she started working at the facility in September 2024, the residents' mail in the Business Office was backed up. Staff #17 also stated that residents' mail was backed up because the former Business Office Manager worked mostly remotely and was not in the office to distribute the residents' mail. Also, staff #17 stated that when he/she first started working at the facility in September 2024, he/she distributed the backed-up resident mail.
On 04/29/2025 at 12:49 PM, review of facility records revealed that on page 18, in the Resident Handbook, under the Deliveries section, it states that mail, telegrams, gifts, and flowers will be promptly forwarded to the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on resident interviews and staff interviews and review of facility documentation, it was determined that the facility failed to protect the resident's property from loss. This was evident for 2 ...
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Based on resident interviews and staff interviews and review of facility documentation, it was determined that the facility failed to protect the resident's property from loss. This was evident for 2 (Resident #161 and #203) out of 6 residents reviewed during the survey.
The findings include:
A controlled drug log is delivered with the controlled medication. The log is completed as the medication is administered and once the medication is completed the form goes into the resident's medical record. Each form is designated to the packet of medications that it was delivered with. On a controlled drug log, the date the medication is delivered, the resident name, medication, amount that is delivered, dosage, and administration orders are all noted at the top of the form. As medication is administered, staff are to document date/time, dose, amount wasted if applicable, administered by, and amount remaining. Once a medication has been administered in its entirety, staff need to reorder the medication, and a new Controlled drug log will also be delivered with the corresponding medication.
1. Facility reported incident MD00207539 was reviewed on 4/25/27 at 7:30am. According to the facility's investigation, on 7/6/24 at 7:47am, Licensed Practical Nurse (LPN) staff #28 received and signed for a 30-tablet blister pack of PRN (when needed) Oxycodone IR 5mg for Resident #161. Staff #28 handed over the medication to LPN staff #29 who was assigned to the resident for 7am-3pm shift. Staff #29 handed over the medication to LPN staff #30 at 3:15pm during the change of shifts.
On 7/6/24 at 6:11pm, staff #28 received and signed with the pharmacy delivery driver 2 blister packs of Oxycodone IR 5mg, one containing (30) tablets and the other containing (28) tablets for routine order. Staff #28 handed over the medications to staff #30. Staff #30 noticed while counting the medication that staff #30 documented 60 tablets on the narcotic sheet instead of the 58 that was received. Staff #28 and #30 recounted the medication and corrected the count sheet to read 58 tablets.
On 7/6/24 at 10:58pm LPN staff #31 clocked in for night shift. Staff #30 gave staff #31 the keys to the medication cart in the hallway of the east Wing nurses station and left the facility at 11:03pm. Staff # 30 and Staff #31 did not count the controlled medications in the cart. A few minutes later staff # 31 handed the key to medication cart to the Supervisor RN (Registered Nurse) staff #32, after being assigned to another unit. Neither nurse counted the controlled medications in the cart.
On 7/6/24 at 11:54 pm LPN staff #33 clocked in and received the medication cart keys at the reception desk from the Supervisor staff #32. Neither nurse counted the controlled medications in the cart.
On 7/7/24 Staff #33 handed over the medication cart key in the morning to the oncoming nurse staff #29 after they counted the controlled medications together.
On 7/7/24 at about 8:15am staff #29 attempted to medicate Resident #161 prior to his/her treatment and noticed that the routine Oxycodone IR 5mg (30) tablets blister pack was not among the medications that she counted with staff #33 and the signing sheet was also missing. She called and confirmed delivery with the pharmacy and notified the morning RN Supervisor staff # 34.
Review of the medical record on 4/25/25 at 9am revealed a physician order dated 7/4/24 to administer Oxycodone 5 mg, one tablet by mouth two times a day and Oxycodone 5 mg, one tablet by mouth every 8 hours prn for pain.
During an interview on 4/25/25 at 10:30am with the Assistant Director of Nursing (ADON) she stated, it was verified that the resident pain medication was missing from the medication cart and all nurses involved were reported to the Maryland Board of Nursing.
2. MD00201418 was reviewed on 4/28/25 at 9:00 AM for misappropriation of resident funds of $260.00. Review of the facility investigation revealed the following: Resident #203 reported to the nursing manager (staff # 36) on Med bridge Unit that s/he gave his/her personal bank cards to a Geriatric Nursing Assistant (GNA) #35 to get one thousand three hundred dollars ($1300) from ATM for him/her. The resident reported that this transaction took place on December 19th, 2023.
The Resident reported that GNA #35 withdrew and returned the money and bank cards to him/her on 12/20/2023. According to the resident, The GNA proceeded to ask for a Two hundred and fifty dollars ($250) loan, and s/he loaned her Two hundred and Sixty dollars ($260) because the resident did not have change. The resident stated that s/he had a verbal agreement with the GNA #35 to return the money on 12/22/23. The resident stated that GNA #35 stopped taking his/her phone calls and refused to repay the money.
During an interview on 4/28/25 at 11am with Resident #203 via phone, s/he stated, the GNA #35 told him/her that she didn't have any furniture for her new apartment and Christmas was coming soon. She made me feel sorry for her.
During an interview with the ADON on 4/28/25 at 11:30 am she verified the incident took place. She stated the GNA #35 was terminated from the facility and the resident was repaid his/her money back by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
3. During an interview on 04/16/2025 at 12:00 PM Resident #50 stated that he/she reported to the facility that $20.00 was stolen from his/her room last year and no one had followed up with him/her as ...
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3. During an interview on 04/16/2025 at 12:00 PM Resident #50 stated that he/she reported to the facility that $20.00 was stolen from his/her room last year and no one had followed up with him/her as to what happened.
During an interview on 04/16/2025 at 1:00 PM staff #1 was made aware, by surveyor, that Resident #50 reported that there was money stolen from his/her room.
During an interview and review of facility documentation on 04/16/25 at 3:00 PM staff #1 submitted the Facility Reported Incident Initial Report Form (FRI) regarding Resident #50's missing money to surveyor. The (FRI) revealed that the facility documented having been aware of Resident #50 money missing on 10/03/24 but did not report it to the Office of Health Care Quality or other appropriate agencies within 24 hours of the time the money was reported missing.
During an interview on 04/22/2025 at 9:14 AM staff #12 stated that Resident #50 reported money missing from his/her room on 10/03/2024 to him/her and it was not reported to the Office of Health Care Quality or any other agencies by the facility.
Based on record review and interview with residents and facility staff, it was determined that the facility failed to timely report allegations of abuse within the required two-hour timeframe and failed to report an alleged violation of misappropriation of resident property/funds immediately or not later than 24 hours to the Survey Agency, the Office of Health Care Quality (OHCQ). This was evident for 3 resident's facility reported incidents (Resident #139, #353, and #50) out of 19 facility related incident reports reviewed during the survey.
The findings include:
1. On 4/21/25 at 12:43pm, the surveyor reviewed a facility reported incident which was related to possible abuse of Resident #139. According to the incident report filed with the State Agency, the Assistant Director of Nursing (ADON) was notified at 12:00am on 4/16/25, the NHA (Nursing Home Administrator) was made aware at 7am, and the initial report was submitted to the State Agency at 3:15pm.
2. On 4/22/25 at 8:11am, a record review of MD00212051 revealed that the DON (Director of Nursing) was made aware of the allegation of abuse involving Resident #353 on 11/21/24 at 11am, the administrator was notified at 11:30am, and the report was submitted to the State Agency on11/21/24 at 4pm.
The reporting to the State Agency of both allegations of abuse was outside the two-hour window.
On 4/22/25 at 12:54pm, during an interview with Staff #2 she reiterated that the expectation for abuse reporting is within 2 hours of being notified of the occurrence.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interviews, it was determined the facility failed to ensure that resident or resident's representative received in writing the facility bed-hold policy before ...
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Based on medical record review and staff interviews, it was determined the facility failed to ensure that resident or resident's representative received in writing the facility bed-hold policy before a resident was transferred to the hospital. This was evident for 1 resident (#156) out of 6 residents, reviewed during the survey.
The findings include the following:
Review of Resident #156's medical record on 04/21/25 at 10:51 AM revealed that resident was transferred to the hospital in August 2024 and before the transfer, there was no documentation found that resident or representative was notified of the facility bed-hold policy.
During an interview on 04/22/25 at 8:34 AM with staff #1 stated there was no bed hold policy paperwork or documentation given to the resident or resident representative by the facility before the resident 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
Based on observation, record review and interviews with staff, it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1...
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Based on observation, record review and interviews with staff, it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #105) out of 33 residents reviewed during the investigative portion of the survey.
The findings include:
On 4/16/2025 at 12:11PM, the Surveyor observed Resident #105 in his/her room sitting in a chair. The resident had a wander guard on the right wrist. The resident had been observed walking around the hallways of the East Wing and [NAME] Wing units on 4/16/2025, 4/17/2025, and 4/22/2025 with a wander guard bracelet on the right wrist.
Elopement or exit seeking risk are those who are at risk of leaving a place unnoticed and unsupervised.
On 4/22/2025 at 10:45AM, a review of a facility reported incident (FRI) investigative file for Resident #105 revealed that on 1/10/2024 the facility substantiated the resident's elopement from the facility at approximately 9:24PM.
A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.
On 4/22/2025 11:01AM, a review of Resident #105's electric medical record revealed an Elopement Risk Tool assessment on 1/11/2024 with a score of 11, which indicated that the resident was at high risk for elopement/exit seeking. A continued review revealed a care plan focus stating that [Resident #105] had a risk for elopement resident wanders related to impaired safety awareness secondary to dementia. [Resident #105] has a wander guard monitor on right wrist for placement /skin alteration created on 4/25/2023 with revisions on 1/12/2024 and interventions to include for elopement risk assessment, monitor wander guard for placement, and monitoring in progress. The Treatment Administration Record (TAR) for January 2024 confirmed that Resident #105's wander guard was checked for placement and function by nursing staff as ordered.
The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.
On 4/22/2025 at 11:46AM, during a review of the MDS quarterly assessment completed on 1/29/2024, the Surveyor discovered that Section E Behaviors revealed that there was no wandering behavior exhibited, and Section P Restraints revealed that the wander guard/alarm was not used.
During an interview with the Regional Director of Clinical #2 on 4/22/2025 at 12:44PM, the Surveyor was informed that if a resident was at risk or at high risk for elopement, then a wander guard will be placed on that resident.
During an interview with MDS Coordinator #19 on 4/23/2025 at 10:00AM, the Surveyor expressed the concern that the facility failed to ensure accuracy of an MDS assessment for a wandering resident after a substantiated elopement on 1/10/2024 and who was at the time a high elopement risk and had a wander guard bracelet. MDS Coordinator #19 confirmed that Resident #105 was not coded accurately for the use of a wander guard bracelet and wandering in their quarterly MDS assessment on 1/29/2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and interview with staff, it was determined that the facility failed to ensure residents were offered the opportunity to participate in their care planning process by holding ti...
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Based on record review and interview with staff, it was determined that the facility failed to ensure residents were offered the opportunity to participate in their care planning process by holding timely care plan meetings. This was evident for 1 (Resident #8) out of 4 residents reviewed for care planning during the survey.
The findings include:
A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.
The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs.
On 4/18/2025 at 12:10PM, an interview with Social Worker (SW) #23 revealed that care plan meetings are held quarterly after a quarterly or annual MDS assessments and as requested by family or residents. Since starting approximately 6 months ago, SW #23 identified an issue with timely care plan meetings for residents and was currently in the process of completing past due care plan meetings with residents and/or resident representatives.
On 4/21/2025 at 8:22AM, during a review of Resident #8's electronic medical record, the Surveyor discovered that that the resident had a quarterly MDS assessment on 8/22/2024 and 11/22/2024 and an annual MDS assessment on 1/19/2025.
Further review failed to reveal care plan meetings including the resident and resident representative following the quarterly and annual MDS assessments for 8/6/2024, 11/22/2024, and 1/19/2025.
On 4/21/2025 at 9:30AM during an interview with SW #23, the Surveyor expressed the concern that Resident #8 did not have care plan meetings after their MDS assessment on 8/6/2024, 11/22/2024, and 1/19/2025. The Surveyor requested documentation to verify that Resident #8 had care plan meetings on those dated MDS assessments.
On 4/21/2025 at 10:00AM, the Surveyor and SW #23 confirmed that Resident #8 did not have care plan meetings after MDS assessment on 8/6/2024, 11/22/2024, and 1/19/2025. SW #23 provided documentation of a care plan meeting for Resident #8 scheduled on 5/1/2025 at 11:00AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff, it was determined that the facility failed to meet professional standards of ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff, it was determined that the facility failed to meet professional standards of care by ensuring a resident's cardiology follow up appointment was scheduled as ordered by physician. This was evident for 1 (Resident #303) out of 33 facility residents reviewed during the investigative phase of the survey.
The findings include:
On 4/18/2025 at 10:21, a review of Resident #303's electronic medical record revealed a physician order, dated 2/15/2025, for the resident to follow up with his/her cardiologist in 12 weeks. During further review, the Surveyor discovered that the resident was admitted to the facility on [DATE] after being hospitalized for a stroke.
On 4/22/2025 at 9:50AM, the Surveyor requested documentation of Resident #303's follow up appointment with his/her cardiologist as ordered on 2/15/2025.
During an interview conducted with the Assistant Director of Nursing (ADON) #11 on 4/23/2025 at 9:30AM, the Surveyor was informed that when a resident is admitted to the facility, the nurses reconcile all orders from the discharge summary. If the resident has a doctor's appointment ordered on the discharge summary and was placed in the electronic health record, the unit manager reviews the order and will inform the unit clerk to schedule the appointment for the resident. The Surveyor requested documentation to verify that the unit clerk tried to schedule an appointment prior to this day.
On 4/23/2025 at 9:50AM, an interview with Unit Clerk #26 confirmed that Resident #303 had a cardiology appointment scheduled for 6/3/2025. The Surveyor discovered that Unit Clerk #26 cannot access the electronic health record to see orders for appointments, so the unit managers inform her when a resident has an appointment that needs to be scheduled. Unit Clerk #26 informed the Surveyor that she just found out about Resident #303's need for a cardiologist appointment on 4/22/2025 and scheduled the appointment that day for 6/3/2025.
On 4/23/2025 at 9:55AM, the ADON provided the Surveyor with a copy of the new physician order dated 4/22/2025 at 11:09AM for Resident #303's cardiology appointment scheduled for 6/3/2025 at 11:30AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on medical record review, observation, and staff interview it was determined the facility failed to administer medication to a resident as ordered by the physician. This was evident for 1 reside...
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Based on medical record review, observation, and staff interview it was determined the facility failed to administer medication to a resident as ordered by the physician. This was evident for 1 resident #106 out of 7 residents reviewed for orders during the survey.
The findings include:
Review of Resident #106's medical record on 04/18/2025 at 6:30 AM revealed a physician's order stating that Resident #106 was to receive a controlled substance medication Lacosamide 150mg 1 tablet by mouth twice daily.
During observation rounds and review of Resident #106's medical records on 04/18/2025 at 6:32 AM on the [NAME] wing medication cart #1 with staff #5, a controlled substance count of Resident #106's medication Lacosamide 150mg tablet blister pack was counted to have a total of 8 tablets. A review of the facility medication-controlled substance count sheet revealed that on 04/17/2025 at 9:00 PM staff #6 signed that Resident #106 received 1 tablet of medication Lacosamide 150mg and there was a total of 7 tablets left.
During an interview on 04/18/2025 at 6:35 AM staff #5 stated that Resident #106 had not received medication Lacosamide 150mg during his/her shift yet and confirmed that the controlled substance blister pack count for medication Lacosamide was incorrect compared to the controlled substance medication Lacosamide count sheet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on medical record review, observation and staff interview, it was determined that the facility failed to perform accurate reconciliation of resident controlled substance medications. This was ev...
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Based on medical record review, observation and staff interview, it was determined that the facility failed to perform accurate reconciliation of resident controlled substance medications. This was evident for 1 resident (#106) out of 7 residents reviewed for medications during survey.
The findings include the following:
Review of Resident #106 medical's record on 04/18/2025 at 6:30 AM revealed a physician's order stating that Resident #106 was to receive controlled substance medication Lacosamide 150mg 1 tablet by mouth twice daily.
During observation rounds, review Resident #106's medical records and facility medical records on 04/18/2025 at 6:32 AM on the [NAME] wing medication cart #1 with staff #5, revealed a controlled substance count of Resident #106's medication Lacosamide 150mg tablet blister pack was counted to have a total of 8 tablets.
A review of the facility medication controlled substance count sheet revealed that on 04/17/2025 at 9:00 PM staff #6 signed that Resident #106 received 1 tablet of medication Lacosamide 150mg and there was a total of 7 tablets left. The facility shift count for all controlled substances reveled that on 4/17/25 on the 11:00 PM - 7:00 AM shift staff #5 and #6 signed that the status of the controlled substances count was exact. On further review staff #5 had already signed the shift count sheet on 4/18/25 for 7:00 AM - 3:00 PM shift as completed but the count sheet was not completed with another nurse.
During an interview on 04/18/2025 at 6:35 AM staff #5 stated and confirmed that the controlled substance medication Lacosamide blister pack count for Resident #106 was incorrect compared to the controlled substance medication Lacosamide count sheet and the medication was not administered 04/17/2025 on the 11:00 PM to 7:00 AM shift. Staff #5 further stated that the shift count sheet on 04/18/2025 7:00 AM - 3:00 PM should not have been signed off by him/her without doing the count with another nurse at the time of change of shift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
Based on observation and interviews it was determined that the facility staff failed to ensure a resident received dental care. This deficient practice was evidenced in 1 (#39) of 2 residents assessed...
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Based on observation and interviews it was determined that the facility staff failed to ensure a resident received dental care. This deficient practice was evidenced in 1 (#39) of 2 residents assessed for dental care during the survey.
The findings include:
On 4/16/25 at 9am while speaking with Resident #39, s/he stated, I was seen by the dentist and would like these teeth pulled. I can only eat soft foods.
On 4/16/25 at 9:30am the unit manager (staff #18) was made aware of the resident request. She stated the resident was seen by the dentist and she would follow up on it.
Review of Resident #39's medical record on 4/22/25 at 11am revealed a dental consult dated 4/2/25 from a Prosthodontist which read please evaluate and treat for full mouth rehabilitation; resident strongly wants implants. A Prosthodontist is a dental specialist who focuses on tooth restoration and replacement, including the design and fitting of prosthetics. They are trained in areas like dental implants, crowns bridges and dentures. The referral indicated resident #39 needed several surgical extractions.
During an interview with the Administrator on 4/22/25 at 11:30am, he stated that the amount for the dental work the resident was requiring was thousands of dollars and the resident was not insured for the procedure.
During an interview on 4/22/25 at 12pm with the ADON she stated that the resident was seen by the Prosthodontist for possible dental work and she would investigate it.
During an interview with the Business Office Manager on 4/22/25 at 1pm, he stated there was a program that the resident can apply for and he would speak to the resident regarding the cost.
On 4/24/25 at 11am the surveyor received a copy of a National Preventive Solutions Corp Senior Dental Plan Application dated 4/24/25; which applied for dental insurance and an email that stated, could you please process this as soon as possible and request a visit for this resident. The form and email were completed and sent by the Business Office Manager. When asked why this referral was not done sooner, he stated he was not aware of the dental issue until this surveyor spoke to him about it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
3. A Brief Interview for Mental Status (BIMS) is a standardized cognitive screening tool used in long-term care facilities to quickly assess a resident's cognitive function. The score ranges from 0 to...
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3. A Brief Interview for Mental Status (BIMS) is a standardized cognitive screening tool used in long-term care facilities to quickly assess a resident's cognitive function. The score ranges from 0 to 15, and different ranges suggest varying levels of cognitive impairment. A score of 13-15 generally indicates intact cognition, 8-12 suggests moderate impairment, and 0-7 indicates severe impairment.
A smoking screen and/or assessments in long-term care facilities focus on evaluating residents' ability to safely smoke without posing a risk to themselves or others. These assessments typically consider cognitive ability, judgement, manual dexterity, mobility, and physical diagnoses that could impact smoking safety.
During review of Resident #54's medical record on 04/17/2025 at 1:30 PM revealed on 03/03/2025 Resident (#54) had a Brief Interview for Mental Status (BIMS) assessment score of (99). A score of (99) is entered when a resident is unable to complete the interview, but the assessment revealed answers that a resident was able to complete the interview with answers that showed the resident had severe impairment. Further review of Resident #54's record revealed a Smoking Safety Screen V2-V4 dated 2/11/2025 question A. COGNITIVE - Does resident have cognitive loss; the answer is documented No.
During an interview on 04/23/2025 at 2:00 PM staff (#19) stated that residents #54 Minimum Data Set Assessment BIMS for 03/03/2025 score was not filled out correctly.
During review of Resident #54's medical record on 04/25/2025 at 3:10 PM revealed that after surveyor intervention the facility completed a Brief Interview and Staff assessment on 04/25/2025 at 14:50 PM on Resident #54 and resident scored a 14 out of 15.
4. During review of Resident #27's medical record on 04/17/2025 at 2:30 PM revealed on 01/19/2025 Resident #27 had a Brief Interview for Mental Status (BIMS) assessment score of (99). A score of (99) is entered when a resident is unable to complete the interview, but the assessment reveals answers that a resident was able to complete the interview with answers that showed the resident had severe impairment. Further review of Resident #19's record revealed a Smoking Safety Screen V2-V4 dated 2/13/2025 question A. COGNITIVE - Does resident have cognitive loss; the question was not answered and was blank. Question C. Dexterity - Does the resident have any dexterity problems; the question was not answered and was blank.
During an interview on 04/23/2025 at 2:30 PM staff #19 stated Resident #27's Minimum Data Set Assessment BIMS for 03/03/2025 score was not filled out correctly.
During review of Resident #27's medical record on 04/25/2025 at 3:10 PM revealed that after surveyor intervention the facility completed a Brief Interview and Staff assessment on 04/18/2025 on Resident #27 and resident scored 15 out of 15.
5. Review of Resident #74's medical record on 04/21/25 at 11:40 AM revealed a care plan dated 03/06/2025 that documented Resident #74 was a Full Code and Do Not Resuscitate.
During an interview on 04/21/2025 at 3:35 PM with staff #11 verified and stated that Residents #74 care plan dated 03/06/2025 did have that resident was a Full Code and Do Not Resuscitate and this would be corrected.
Based on record review and interviews with the residents and staff, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards of practice. This was evident for 5 (Resident #8, #22, #54, #27 and #74) residents out of 66 resident records reviewed during the survey.
The findings include:
1. On 4/21/2025 at 10:51AM during a review of Resident #8's electronic medical record, the Surveyor discovered that the resident was dependent on staff for showering and shower transfers.
On 4/21/2025 at 11:00AM, the Surveyor reviewed a complaint from January 2025 which stated that the resident had not had a shower in 3 years.
On 4/22/2025 at 11:30AM, the Surveyor requested shower sheets for Resident #8 from the Assistance Director of Nursing (ADON). The Surveyor was informed that shower sheets are filled out on the days the residents are to receive a shower. If they refuse, the GNA's would document on the sheet and document if the resident received a bed bath instead. The GNA's also document in the electronic medical record under the point of care tab when they give a shower on the designated shower days.
On 4/22/2025 at 12:09PM, a review of Resident #8's Geriatric Nursing Assistant (GNA) point of care documentation for January 2025 revealed that the resident had a shower on 1/9/2025 with the assistance of GNA #36. A review of a shower sheet for Resident #8 dated 1/9/2025, revealed that the resident did not have a shower and was given a bed bath by GNA #36.
2. On 4/16/2025 at 12:54PM, an interview with Resident #22 revealed that he/she has been having issues with receiving her medications on time or even at all for several months. The resident stated that he/she was supposed to get certain supplements and a muscle relaxer 4 times a day and that he/she has been missing doses.
On 4/16/2025 at 1:00PM, during an interview, the Surveyor asked LPN #15 the process for documenting the administration of a medication. LPN #15 stated that the resident's medication administration record is pulled up in electronic health record. The medication is then pulled from the medication cart and the right medication, dose, time, and resident are confirmed. The medication is first signed that it was pulled (administration time) and then signed again (doc'd time) to say that it was taken by the resident. It is signed twice to confirm that the resident received the medication.
During an interview with the Nursing Home Administrator (NHA) conducted on 4/18/2025 at approximately 1:00PM, the Surveyor expressed the concerns that Resident #22 stated that he/she receives his/her medications late or sometimes not at all. The NHA stated that he would have a conversation with the resident.
During a review of the electronic medical record on 4/21/2025 at 12:00PM for Resident #22, the Surveyor discovered that the resident has an order for D5 Mucuna (supplement) 4 times a day to be given at 9AM, 1PM, 5PM, and 9PM and Baclofen (muscle relaxer) 4 times a day to be given at 9AM, 1PM, 5PM, and 9PM.
Further review of the electronic medical record on 4/21/2025 at 12:10PM revealed documentation of a check mark (which equals administered according to the key) in the resident's medication administration record for Baclofen on 4/1/2025 at 9AM, 1PM, 5PM, and 9PM; 4/2/2025 at 9AM, 1PM, 5PM, and 9PM; 4/3/2025 at 9AM, 1PM, 5PM, and 9PM; 4/12/2025 at 9AM, 1PM, 5PM, and 9PM; 4/13/2025 at 9AM, 1PM, and 5PM; 4/15/2025 at 5PM, and 9PM; 4/16/2025 at 9AM, 1PM, 5PM, and 9PM; 4/18/2025 at 9AM, 1PM, 5PM, and 9PM; and 4/21/2025 at 9AM, 1PM, 5PM, and 9PM.
On 4/23/2025 at 1:50PM, the Surveyor reviewed Resident #22's Medication Administration Audit report for April 2025. The report showed that on 4/1/2025, the 9AM dose of D5 Mucuna and Baclofen had an administration time and Doc'd time of 3:33PM and the 1PM dose of D5 Mucuna and Baclofen had an administration time and Doc'd time of 3:33PM; on 4/2/2025 the 5PM dose of D5 Mucuna and Baclofen had an administration time 10:06PM and a Doc'd time of 12:07AM on 4/3/2025 and the 9PM dose had an administration time of 10:07PM and a Doc'd time of 12:07AM on 4/3/2025; on 4/3/2025 the 5PM dose of D5 Mucuna and Baclofen had an administration time and Doc'd time of 8:36PM and the 9PM dose had an administration time and Doc'd time of 8:36PM; on 4/12/2025 the 9AM dose of D5 Mucuna and Baclofen had an administration time of 12:15PM and a Doc'd time of 12:57PM and the 1PM dose had an administration time of 12:21PM and a Doc'd time of 12:57PM; on 4/13/2025 the 9AM dose of D5 Mucuna and Baclofen had an administration time of 2:30PM and a Doc'd time of 2:31PM and the 1PM dose had an administration and a Doc'd time of 2:31PM; on 4/15/2025 the 5PM dose of D5 Mucuna and Baclofen had an administration and Doc'd time of 8:22PM and the 9PM had an administration and Doc'd time of of 8:22PM; on 4/16/2025 the 5PM dose of D5 Mucuna and Baclofen had a administration and Doc'd time of 8:49PM and the 9PM dose had an administration and Doc'd time of 8:49PM; on 4/18/2025 the 5PM dose of D5 Mucuna and Baclofen had an administration and Doc'd time of 10:38PM and the 9PM dose had an administration and Doc'd time of 10:38PM; and on 4/21/2025 the 5PM dose of D5 Mucuna and Baclofen had an administration and Doc'd time of 10:38PM and the 9PM dose had an administration and Doc'd time of 10:38PM.
On 4/23/2025 at 2:00PM the Surveyor reviewed Resident #22's grievance form, completed by the NHA and reviewed with the resident on 4/23/2025, which included the resident's concern that he/she does not get the medication sometimes. The facility staff signed off in-service education related to resident's rights, abuse prevention, and customer service.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and interview with staff, it was determined that the facility failed to ensure a resident's tracheostomy extension tubing and drainage bag were not touching the floor. This was ev...
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Based on observation and interview with staff, it was determined that the facility failed to ensure a resident's tracheostomy extension tubing and drainage bag were not touching the floor. This was evident for 1 (Resident #88) out of 2 residents observed with tracheostomy's during the survey.
The findings include:
On 4/16/2025 at 8:38AM during a tour of the east wing nursing unit, the Surveyor observed Resident #88 in his/her room. The Surveyor observed the oxygen delivery system located along the wall to the right of the door. The tracheostomy extension tubing, with drainage bag, stretched across the floor and connected to the resident's trach collar.
On 4/17/2025 at 9:00AM, the Surveyor observed Resident #88 's tracheostomy extension tubing and drainage bag stretched across the floor and connected to the resident's trach collar.
On 4/24/2025 at 12:00PM, during an interview with Unit Manager #25 of the west wing nursing unit in Resident #88's room, the Surveyor was informed that the tracheostomy extension tubing and drainage bag should not be touching the floor, however, the east wing nursing unit was not the his unit, and he was just covering for the actual unit manager.
On 4/28/2025 at 11:35AM, the Surveyor observed Resident #88's tracheostomy extension tubing and drainage bag stretched across the floor and was connected to the resident's trach collar.
On 4/28/2025 at approximately 12:30PM during an interview with the Infection Preventionist (IP) #3, the Surveyor expressed the concern that the tracheostomy tubing was observed stretched across the floor and connected to the resident's trach collar on 4/16/2025, 4/17/2025, and 4/28/2025 even after mentioning it to Unit Manager #25 on 4/24/2025. IP #3 confirmed the tracheostomy extension tubing and drainage bag should not be touching the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, comfortable environme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to maintain a safe, comfortable environment for residents. This was evident for 2 resident bathrooms observed during the survey.
The findings include:
On 04/16/25 at 08:33 AM during observation rounds, room [ROOM NUMBER]'s bathroom was observed to have a missing cove base at the bottom of the wall.
On 04/16/25 at 08:47 AM during observation rounds, room [ROOM NUMBER]'s bathroom was observed to have peeling paint on the floor.
On 04/16/2025 at 01:25 PM, the Nursing Home Administrator staff #1 and the Assistant Director of Nursing staff #11 were interviewed. During the interview, the surveyor informed staff #1 and staff #11 about the missing cove base on the wall in room [ROOM NUMBER]'s bathroom and the peeling paint on the floor in room [ROOM NUMBER]'s bathroom.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
Based on record review and an interview, it was determined that the facility failed to ensure a Resident was offered information for an Advance Directive. This was evident for 4 (Residents #85, #108, ...
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Based on record review and an interview, it was determined that the facility failed to ensure a Resident was offered information for an Advance Directive. This was evident for 4 (Residents #85, #108, #109, #135) out of 6 residents reviewed for Advance Directives.
The findings include:
According to the Centers for Medicare and Medicaid (CMS) the definition of an Advance Directive is a document that appoints an agent and records a patient's medical treatment wishes based on their values and preferences. Advance Directives can be different from state to state.
A record review on 04/17/25 at 07:38am showed there was not an Advance Directive found or documentation that Advance Directive information was offered in the electronic medical record of Residents #85, #108, #109, or #135.
On 4/17/25 at 10:02am, while interviewing Staff #23, the surveyor requested assistance locating the Advance Directives for the selected residents in the electronic medical record. Staff #23 explained that she had begun an audit of the residents that needed Advance Directives and started reaching out to residents and their responsible parties. Staff #23 confirmed that this had not been done consistently. This surveyor made Staff #23 aware of the concern that Residents #85, #108, #109, and #135 did not have an Advance Directive in his/her electronic medical record, and did not have documentation that the Resident was offered information for an Advance Directive.
On 4/17/25 at 11:17am, Staff #23 confirmed that the 4 residents did not have the required documentation. Documentation was provided at this time of attempts to contact the responsible parties on 4/17/25 for these residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observation rounds on 04/16/2025 the following concerns were found:
3. At 8:09 AM room [ROOM NUMBER]: The resident bathr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observation rounds on 04/16/2025 the following concerns were found:
3. At 8:09 AM room [ROOM NUMBER]: The resident bathroom sink was found to be loosely hanging from the wall and the base of the toilet, where the toilet meets the floor, was brown in color with no seal leaving a hole between the base of the toilet and the floor.
4. At 8:20 AM room [ROOM NUMBER]: The resident bathroom floor was noted to have several areas of a brown in color substance that had a strong foul odor and the base of the toilet, where the toilet meets the floor, was brown in color with no seal. The bathroom wallpaper was ripped from the wall in several places.
5. At 8:28 AM room [ROOM NUMBER]: The door frame of the bathroom and the connected wall were separated, not allowing for the bathroom door to be safely used.
6. At 8:35 AM room [ROOM NUMBER]: The bathroom walls were noted to have brown stains on the upper area of the walls on the wallpaper, the exhaust fan was missing dry wall around it, the wall under the residents TV was noted to have several areas of marring.
During an interview on 04/16/2025 at approximately 8:45 AM the Nursing Home Administrator, staff #1, was made aware of concerns found in resident rooms #34, #38, #39 and #40. Staff #1 stated that maintenance will be made aware and will look into the concerns.
Based on observation and interviews with facility staff it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable homelike environment. This was observed on the second floor in 1 resident room (room [ROOM NUMBER]) on the east wing unit and 5 resident rooms (Rooom #29, #34, #38, #39, and #40) on the west wing unit during the survey.
The findings include:
1. On 4/16/2025 at 8:55AM during a tour of the east wing nursing unit, the Surveyor observed room [ROOM NUMBER]. Resident #110 was in the first bed by the door. The resident was in his/her bed with the right side of the bed along the wall and was facing the door. The chair railing on the wall, next to the bed, was a plastic like cream material. There were strips of gray duct tape like material on the chair railing near the head of Resident #110's bed.
On 4/17/2025 at 11:56AM the Surveyor made the Nursing Home Administrator (NHA) aware of the findings at the bedside of Resident #110 in room [ROOM NUMBER]. The NHA stated he would have the maintenance staff look into the concerns.
On 4/18/2025 at 8:57AM, the NHA informed the Surveyor that the wall chair railing was repaired.
2. On 4/17/2025 at 11:06 AM, during an interview with Resident #22 in room [ROOM NUMBER], the Surveyor was informed that the resident likes to have his/her window open to get some fresh air and because the resident gets warm at times. The resident was in the bed closest to the window. The Surveyor observed cobwebs, dead insects, and a black like dirt like substance in the window between the screen and the glass.
On 4/17/2025 at 11:56AM the Surveyor made the Nursing Home Administrator (NHA) aware of the findings in room [ROOM NUMBER]. The NHA stated he would have the maintenance staff look into the concerns.
On 4/18/2025 at 8:57AM, the NHA informed the Surveyor that the window was cleaned between the screen and the glass.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/16/25 at 9am while speaking with Resident #39, s/he stated, I was seen by the dentist and would like these teeth pulled....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/16/25 at 9am while speaking with Resident #39, s/he stated, I was seen by the dentist and would like these teeth pulled. I can only eat soft foods.
On 4/16/25 at 9:30am the unit manager (staff #18) was made aware of the resident request. She stated the resident was seen by the dentist and she would follow up on it.
Review of Resident #39's medical record on 4/22/25 at 11am revealed a dental consult dated 4/2/25 from a Prosthodontist, which read please evaluate and treat for full mouth rehabilitation; resident strongly wants implants. A Prosthodontist is a dental specialist who focuses on tooth restoration and replacement, including the design and fitting of prosthetics. They are trained in areas like dental implants, crowns bridges and dentures. The referral indicated Resident #39 needed several teeth surgically extracted. Further review of the medical record on 4/22/25 at 11:15am, failed to reveal a care plan to address the resident dental issues.
Based on medical record review and staff interview, it was determined the facility failed to develop and implement a person-centered care plan to meet a resident's medical, nursing, mental, and psychosocial needs. This was evident for 4 out of 66 residents (Resident #74, #39, #141, #51, #108) reviewed during the survey.
The findings include:
1. Review of Resident #74's medical record on 04/21/2025 at 11:38 AM revealed that Resident #74 was admitted to Hospice care on 02/13/2025 and Resident #74's care plan dated 03/06/2025 was not updated documenting that he/she was receiving Hospice care.
During an interview on 04/21/2025 at 3:30 PM staff #11 stated and verified that Resident #74 was receiving Hospice care and that Resident #74's care plan dated 03/06/2025 was not updated that resident was receiving Hospice care.
3. A Wander Guard bracelet is a device that residents at risk for wandering or elopement wear to trigger alarms where the system is activated and can lock monitored doors to prevent the resident from leaving unattended.
On 4/22/2025 at 12:09PM, during an interview conducted with the Regional Director of Clinical #2, the Surveyors were informed that every resident who is assessed as at risk or at high risk for elopement/exit seeking, will wear a wander guard bracelet for safety.
On 4/25/2025 at 8:10AM, during a review of Resident #141's electronic medical record, the Surveyor discovered an elopement risk assessment dated [DATE] with a score of 14 which indicated that the resident was a high risk for elopement/exit seeking. An additional review revealed physician orders that the resident had a Wander Guard on the right lower leg, to check function weekly every Wednesday, and to check placement every shift. Further review failed to reveal a care plan focus for wandering and exit seeking behaviors with interventions to implement for the resident monitoring and safety.
On 4/25/2025 at 9:30AM, during an interview conducted with the Nursing Home Administrator (NHA), the Surveyor requested Resident #141's care plan for wandering and exit seeking.
On 4/25/2025 at 9:49AM, the NHA confirmed that Resident #141 did not have a care plan implemented for wandering and exit seeking and that the nursing staff would create one.
4. Ataxia is a neurological disorder characterized by a lack of coordination and control over muscle movement.
On 04/25/25 at 01:12 PM, during observation rounds on 4/16/25 and 4/17/25, Resident #51 was noted smoking without supervision.
On 04/25/25 at 01:12 PM, during observation rounds on 4/18/25, 4/21/25, 4/22/25, 4/23/25 and 4/24/25 Resident #51 was observed smoking without supervision and not wearing a smoking apron/blanket.
On 04/25/25 at 01:41 PM, review of resident records revealed that Resident #51's Smoking Safety Screen, dated 4/18/25, indicated that Resident #51 was a smoker, had dexterity problems, unable to use a lighter independently, required a smoking apron/blanket while smoking, and required supervision while smoking.
On 04/25/2025 at 1:43 PM, review of resident records revealed that Resident #51 had a medical diagnosis of ataxia and muscle weakness.
On 04/25/25 at 01:47 PM, review of resident records revealed that Resident #51's care plan indicates that Resident #51 required supervision while smoking. Resident #51's care plan did not indicate that Resident #51 required a smoking apron/blanket while smoking as stated in the Smoking Safety Screen.
On 04/25/25 at 2:18 PM, Activity Director staff #12 was interviewed. During the interview, staff #12 stated that many dependent smoking residents and independent smoking residents are non-compliant with following the smoking policy. Dependent smoking residents have been told several times that they must smoke in the downstairs courtyard where they can be supervised by staff as well as wear a smoking apron/blanket. Staff #12 also stated that they have told independent smokers not to light cigarettes for dependent smokers.
On 04/25/25 at 2:49 PM, Resident #51 was interviewed. During the interview, Resident #51 indicated that he/she was aware that they must be supervised by staff and must wear a smoking apron/blanket while smoking.
5. On 04/25/2025 at 1:32 PM, review of resident records revealed that Resident #108's care plan indicated that, on 4/24/23, Resident #108 was care planned as being an elopement risk/wanderer and had behavior of removing his/her elopement band. Also, the care plan's intervention mentioned to check Resident #108's elopement band's function weekly and replace the elopement band as needed.
On 04/25/2025 at 1:44 PM, Review of resident records revealed that Resident #108's Medication Administration and Treatment Administration Records, from 1/1/24 until 4/25/25, indicate that Resident #108 was monitored for the following behaviors: itching; picking at the skin; restlessness (agitation); hitting; increase in complaints; biting; kicking; spitting; cussing; racial slurs; elopement; stealing; delusions; hallucinations; psychosis; aggression and refusing care.
On 04/25/2025 at 1:47 PM, Review of resident records revealed that Resident #108's Medication Administration and Treatment Administration Records indicate that during the evening shift on 11/7/24, it was documented that Resident #108 displayed at least one of the following behaviors: itching; picking at the skin; restlessness (agitation); hitting; increase in complaints; biting; kicking; spitting; cussing; racial slurs; elopement; stealing; delusions; hallucinations; psychosis; aggression and refusing care.
On 04/25/2025 at 1:51 PM, Review of resident records revealed that Resident #108's Medication Administration and Treatment Administration Records, for January 2024, indicate that there was an order to check Resident's 108's wander prevention band every shift for monitoring, which started on 1/31/24 and discontinued on 2/7/24. Also, it was documented on the Medication Administration and Treatment Administration Records, for January 2024 and February 2024, that Resident #108's wander prevention band was checked on: the evening and night shifts on 1/31/24; the day, evening and night shifts from 2/1/24 through 2/6/24; and the day shift of 2/7/24. However the care plan was not updated to reflect the discontinuation of testing the wanderguard band weekly.
On 04/25/2025 at 1:56 PM, Review of resident records revealed that Resident #108's Medication Administration and Treatment Administration Records, for April 2025, indicate that there was an new order to check the function of Resident's 108's left leg Wanderguard weekly, every dayshift on Wednesdays for elopement prevention, which started on 4/14/25. Also, it was documented on the Medication Administration and Treatment Administration Records, for April 2025, that Resident #108's left leg Wanderguard was checked at 11:00 AM on the dayshifts of 4/16/25 and 4/23/25 and evening and night shifts of 4/14/25 and the dayshift on 4/25/25.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews and facility policy review, it was determined that the facility failed to store food in accordance with professional standards for food service safety.
The findings ...
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Based on observations, interviews and facility policy review, it was determined that the facility failed to store food in accordance with professional standards for food service safety.
The findings include:
During observation rounds with Dietary Aide staff #7 on 04/16/25 at 08:04 AM, the kitchen's dry goods storage room was observed to have sealed bins of white flour, white rice, brown rice, and sugar with expired use-by dates labeled on them. The white flour had an expired use-by date of 3/1/25. The white rice had an expired use-by date of 2/5/25. The brown rice had an expired use-by date of 3/5/25. The sugar had an expired use-by date of 3/5/25.
During observation rounds with Dietary Aide staff #7 on 04/16/25 at 08:11 AM, the kitchen's freezer was observed to have an have opened, frozen bag of pepperoni that was not labeled when it was opened and when it would expire.
On 04/16/2025 at 10:22 AM, the Dietary Director staff #8 and Regional Food Service Director staff #9 were interviewed. During the interview, the surveyor informed staff #8 and #9 that the kitchen's dry goods storage room was observed to have sealed bins of white flour, white rice, brown rice, and sugar with expired use-by dates labeled on them. Also, the surveyor informed staff #8 and #9 that the kitchen's freezer was observed to have an opened, frozen bag of pepperoni that was not labeled when it was opened and when it would expire.
On 04/16/2025 at 01:25 PM, the Nursing Home Administrator staff #1 was interviewed. During the interview, the surveyor informed staff #1 that the kitchen's dry goods storage room was observed to have sealed bins of white flour, white rice, brown rice, and sugar with expired use-by dates labeled on them. Also, the surveyor informed staff #1 that the kitchen's freezer was observed to have an opened, frozen bag of pepperoni that was not labeled when it was opened and when it would expire.
On 04/16/25 at 10:49 AM, the facility's Food Storage Chart policy was reviewed. The facility's Food Storage Chart policy states that the expiration dates printed by the manufacturer apply until the food product is opened. Rice, flour and sugar have an expiration date of 6 months once opened, unless the manufacturer's date is sooner. All frozen food items have an expiration date of 3 months once opened, unless the manufacturer's date is sooner. Also, the opened food item must be labeled with the date it was opened to determine the expiration date.
MINOR
(B)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on observation and interviews, it was determined that the facility failed to post the required staffing information in a prominent and readily accessible location for all residents and visitors....
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Based on observation and interviews, it was determined that the facility failed to post the required staffing information in a prominent and readily accessible location for all residents and visitors. This was evident for 17 out of 32 residents on the Med Bridge unit.
The findings include:
During observation rounds on 4/16/25 at 7:56am, 15 residents were observed to be behind a locked door on the Med Bridge unit when the surveyor conducted an initial tour of the facility. The Med Bridge unit had 32 residents in total with 17 of them residing on the unlocked portion of the unit. The white dry erase board with the daily staffing schedule was not posted so that visitors and residents could easily visualize the information from the unlocked side. It was on the wall inside the locked side of the unit and could only be seen through a slim rectangular window on the side of the door. The surveyor found the sign was only visible from a difficult angle, making it inaccessible to most ambulatory residents.
The surveyor questioned the unit manager (Staff #18) regarding the ability of all residents to see the posted staffing information. Staff #18 confirmed that the staffing information was posted on the locked side and explained that staff are expected to inform residents of their assigned caregivers at shift start.
On 4/16/25 at 1:11pm, the NHA (Nursing Home Administrator), ADON (Assistant Director of Nursing) and Staff #2 were informed of the concerns regarding 17 residents on Med Bridge unit not having nurse staffing information posted in a prominent place readily accessible to residents and visitors. At this time the unit was unlocked, and all residents and visitors were able to view the signage.
Jan 2024
14 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of an active and closed medical record, and staff interviews, it was determined that
the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of an active and closed medical record, and staff interviews, it was determined that
the facility failed to 1) to report an allegation of sexual abuse (Resident # 18), 2) create a facility reported
incident for a resident (Resident # 19) who fell outside on the facility grounds, and 3) report an injury of
unknown source to the State survey agency. This was evident for 3 (Residents #18, #19, #30) of 55 residents
reviewed during a complaint survey.
The findings include:
1) Review of Resident #18 medical records on 1/18/24 at 11:00 am revealed the resident was admitted to the facility on [DATE] for long term care after receiving a diagnosis of dementia. Medical record documentation on
4/1/22 revealed the resident was assessed with a Brief Interview of Mental Status (BIMS) of 3 and emotional
distress from his/her adjustment to living in a long-term care facility. On 4/1/22, the facility ordered medication
for agitation and a psychiatric evaluation after the resident became agitated after his/her transfer to the facility.
Further review of resident#18's medical records on 1/18/24 at 11:13 am revealed the resident's representative alleged the resident was sexually abused in the facility on 4/3/22 and voluntarily transferred to a local hospital for assessment. Resident #18's medical records also contained a bed hold document dated 4/4/22 which was not completed and had a note from the facility medical records department which stated that the resident #18's representative told the facility that the resident would not return to the facility. No other transfer documents were found in the medical record.
An interview with the Director of Nursing (DON) on 1/18/24 at 1:00 PM revealed the facility failed to report an
allegation of sexual abuse because the resident #18's representative took the resident out of the facility before the
facility could assess the resident after the allegation of sexual abuse. The surveyor asked the DON if the facility
investigate the sexual abuse allegation. The DON stated the facility also failed to investigate the allegation
because the resident was not available for assessment and interview after the resident #18's representative alleged
sexual abuse. The surveyor expressed concern that the facility failed to report and investigate an allegation of
sexual abuse. The DON stated that he/she understood.
2) Resident # 19 was admitted to the facility on [DATE]. Resident came to the facility for wound care and rehab.
According to MDS dated [DATE], resident is dependent for toileting, transferring from bed to wheelchair and
back, bed mobility and eating. Resident does not walk.
On 8/4/22 resident went outside and wheeled herself towards the street. A passerby saw resident fall out of the
resident #39's wheelchair and called 911. When EMS responded they went inside the facility and asked if this
person was a resident of [NAME] Oak. Resident # 19 was a resident of [NAME] Oak. Resident was assessed and no
injury was found. Resident complained of headache and back pain. EMS was prepared to take resident to
hospital, but resident refused to go. Resident did receive pain medication and Doctor was notified. The
following day, resident was still complaining of headache and back pain and 911 was called and resident went
to the hospital and returned later that day. There were no injuries. This surveyor asked Director of Nursing
where the incident report was and DON stated he didn't think he had to submit an incident report to OHCQ
because he knew what happened. Director of nursing is aware of citation. for no facility incident report filed.
3) Review of complaint MD00187543 on 01/04/25 revealed an allegation Resident #30 received an injury to
his/her right arm on 01/08/23 and the staff could not identify the cause of the injury. Resident #30 suffers from
cognitive decline and could not describe how the injury occurred. Resident #30 informed the family member
that a guard tried to sit him/her up and cut his/her arm.
Review of Resident #30's closed medical record on 01/04/24 revealed nursing progress notes, dated 01/06/23 at 7:30 am detailing that during the morning rounds Resident #30 was noted with a skin tear to the right forearm.
A nursing assessment was documented and measured the right forearm skin tear was 5.3 centimeters (cm) long
by 0.4 cm wide, by 0.2 cm deep, and a width of 1.5 cm. The 01/06/23 nursing assessment indicated that
Resident #30's family and physician was notified, the skin tear was cleaned and dressed, and Resident #30 was unable to describe how the right forearm skin tear occurred.
Review of the facility investigation into Resident #30's 01/06/23 right arm skin tear on 01/18/24 revealed that
Resident #30 was oriented to person only, there were no predisposing environmental or situational factors
identified. The investigation named a predisposing physiological factor of fragile skin. The investigation did not
identify and witnesses during the investigation.
In an interview with the facility director of nurses (DON) on 01/18/24 at 1:20 PM, the DON stated that Resident
#30's skin tear was not reported to the State survey agency as an injury of unknown source because of Resident #30's history of scratching behaviors.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to thoroughly investigate allegation of resident abuse (reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to thoroughly investigate allegation of resident abuse (resident #5 and #18). This was evident in 2 of 18 residents reviewed during a complaint survey.
Findings includes:
1.
The State of Maryland's Office of Health Care Quality received a facility report which reported resident #5 alleged resident #52 committed sexual abuse toward resident #5. Review of resident #5's medical records on 1/10/24 at 12:30 pm revealed the resident was admitted to the facility on [DATE] for long-term care related to a diagnosis of multiple sclerosis. Review of resident #52's medical record revealed the resident was admitted to the facility on [DATE] for long-term care related to Parkinson's disease and stroke. Additional review of both resident #5 and resident #52's medical records on 1/10/24 at 1:00 pm revealed the resident's rooms were not on the same unit. No other information was found in the electronic record regarding an allegation of sexual abuse in either resident's medical records.
On 1/16/24 at 9:00 am, the Director of Nursing (DON) admitted that he/she was unable to locate the investigation of resident #5's allegation of sexual abuse. The surveyor expressed concern that the facility failed to toughly investigate a resident's claims. The DON stated that he/she understood.
2.
Review of Resident #18's medical records on 1/18/24 at 11:00 am revealed the resident was admitted to the facility on [DATE] for long term care after receiving a diagnosis of dementia. Medical record documentation on 4/1/22 revealed the resident was assessed with a Brief Interview of Mental Status (BIMS) of 3 and emotional distress from his/her adjustment to living in a long-term care facility. On 4/1/22, the facility ordered medication for agitation and a psychiatric evaluation after the resident became agitated after his/her transfer to the facility.
Further review of resident's #18's medical records on 1/18/24 at 11:13 am revealed the resident's representative alleged the resident was sexually abused in the facility on 4/3/22 and voluntarily transferred to a local hospital for assessment. Resident #18's medical records also contained a bed hold document dated 4/4/22 which was not completed and had a note from the facility medical records department which stated that the resident's representative told the facility that the resident would not return to the facility. No other transfer documents were found in the medical record.
An interview with the Director of Nursing (DON) on 1/18/24 at 1:00 pm revealed the facility failed to report an allegation of sexual abuse because the resident's representative took the resident out of the facility before the facility could assess the resident after the allegation of sexual abuse. The surveyor asked the DON if the facility investigate the sexual abuse allegation. The DON stated the facility also failed to investigate the allegation because the resident was not available for assessment and interview after the resident's representative alleged sexual abuse. The surveyor expressed concern that the facility failed to report and investigate an allegation of sexual abuse. The DON stated that he/she understood.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide written notice to the resident or resident represen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide written notice to the resident or resident representative of bed hold policy. (Resident # 18). This was evident in 1 of 18 residents reviewed during a complaint survey.
Findings includes:
Review of Resident #18's medical records on 1/18/24 at 11:00 am revealed the resident was admitted to the facility on [DATE] for long term care after receiving a diagnosis of dementia. Medical record documentation on 4/1/22 revealed the resident was assessed with a Brief Interview of Mental Status (BIMS) of 3 and emotional distress from his/her adjustment to living in a long-term care facility. On 4/1/22, the facility ordered medication for agitation and a psychiatric evaluation after the resident became agitated after his/her transfer to the facility.
Further review of resident's #18's medical records on 1/18/24 at 11:13 am revealed the resident's representative alleged the resident was sexually abused in the facility on 4/3/22 and voluntarily transferred to a local hospital for assessment. Resident #18's medical records also contained a bed hold document dated 4/4/22 which was not completed and had a note from the facility medical records department which stated that the resident's representative told the facility that the resident would not return to the facility. No other transfer documents were found in the medical record.
An interview with the Director of Nursing (DON) on 1/18/24 at 1:00 pm revealed the facility failed to complete the discharge process for resident #18 after the resident, and the facility failed to mail the bed hold document to the resident's representative. The surveyor informed the DON that the bed hold document dated 4/4/22 was not complete.
Interview with the Administrator on 1/18/22 at 1:30 pm confirmed the facility failed to complete the bed hold document, mail the bed hold document to the resident's representative, and complete the discharge process after the resident no longer resided in the facility for more than 30 days. The surveyor expressed concerns regarding the facility's failure to complete the bed hold document and discharge process. The Administrator stated that he/she understood.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete the discharge process when the resident (Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete the discharge process when the resident (Resident # 18) failed to reside in the facility for more than 30 days. This was evident in 1 of 18 residents reviewed during a complaint survey.
Findings includes:
Review of Resident #18's medical records on 1/18/24 at 11:00 am revealed the resident was admitted to the facility on [DATE] for long term care after receiving a diagnosis of dementia. Medical record documentation on 4/1/22 revealed the resident was assessed with a Brief Interview of Mental Status (BIMS) of 3 and emotional distress from his/her adjustment to living in a long-term care facility. On 4/1/22, the facility ordered medication for agitation and a psychiatric evaluation after the resident became agitated after his/her transfer to the facility.
Further review of resident's #18's medical records on 1/18/24 at 11:13 am revealed the resident's representative alleged the resident was sexually abused in the facility on 4/3/22 and voluntarily transferred to a local hospital for assessment. Resident #18's medical records also contained a bed hold document dated 4/4/22 which was not completed and had a note from the facility medical records department which stated that the resident's representative told the facility that the resident would not return to the facility. No other transfer documents were found in the medical record.
An interview with the Director of Nursing (DON) on 1/18/24 at 1:00 pm revealed the facility failed to complete the discharge process for resident #18 after the resident, and the facility failed to mail the bed hold document to the resident's representative. The surveyor informed the DON that the bed hold document dated 4/4/22 was not complete.
Interview with the Administrator on 1/18/22 at 1:30 pm confirmed the facility failed to complete the bed hold document, mail the bed hold document to the resident's representative, and complete the discharge process after the resident no longer resided in the facility for more than 30 days. The surveyor expressed concerns regarding the facility's failure to complete the bed hold document and discharge process. The Administrator stated that he/she understood.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to 1. update care plans based on medica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to 1. update care plans based on medication use, and 2. initiate identified concerns for a resident after they were sent to the hospital for an extended admission, 3) initiate a care plan for a resident with a history of opiod disorder. This was evident for 3 of 4 residents (#14, #39 and # 41) reviewed during a complaint survey.
The findings include:
1. Review of the medical record for Resident # 14 on 1/4/24 at 9:24 AM revealed diagnosis including schizophrenia and neuromuscular dysfunction of the bladder.
Further review of Resident #14's medical record and physician orders noted no medications in place or order related to the resident's psychiatric diagnosis. Medical records indicate that s/he is followed by psychiatry and that the medication s/he was on was discontinued on 11/5/2021. However, review of the care plans in place on 1/4/24 at 12:43 PM noted active care plans in place to monitor behaviors related to antipsychotic medication use last reviewed on 11/16/23 with target date of 2/14/24.
This identified concern was reviewed with the DON on 1/4/24 at 1:10 PM and again during exit on 1/18/24.
2. Review of the medical record for Resident #41 on 1/5/24 at 9:28 AM revealed diagnosis including seizures, paraplegia, stenosis of the larynx and dependence on oxygen via tracheostomy tube.
Further review of Resident #41's medical record failed to reveal care plans in place related to his/her current and active diagnosis.
Interview on 1/8/24 at 9:32 AM with the Minimum Data Set (MDS) coordinator staff # 13 revealed that there was an error in the coding of the resident's discharge when they went to the hospital in the fall. That triggered their care plans to be 'canceled' or 'resolved,' instead of being held open until the resident returns from their respective hospital stay.
Upon Resident #41's return to the facility in November 2023, the previously active care plans were no longer 'active' or re-initiated. The only active care plans for Resident #41 with their plethora of complex medical issues included activities, weight loss and respiratory infection.
These identified concerns were reviewed with the facility DON and the MDS Coordinator on 1/8/24 at 9:45 AM and again during exit on 1/18/24.
3. Review of the medical record for Resident #39 on 01/03/24 at 11:59 AM revealed that Resident #39 was ordered the medication Methadone for the diagnosis of Opioid Use Disorder upon admission on [DATE].
Further review of Resident #39's medical record failed to reveal a care plan in place related to his/her current and active diagnosis of Opioid Use Disorder.
These identified concerns were reviewed with the facility DON and the MDS Coordinator on 01/18/24 during the exit conference.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined that that facility failed to hold care plan meetings every quarter and include the resident and or the representative. This was evident ...
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Based on medical record review and interview, it was determined that that facility failed to hold care plan meetings every quarter and include the resident and or the representative. This was evident for 1 of 3 reviewed (Resident #1) for care plan meetings during the complaint process.
The findings include:
Review on 1/10/24 at 12:12 PM of the medical record for Resident # 1 secondary to a complaint, revealed admission to the facility for diagnosis including peripheral vascular disease, dystonia (movement disorder that causes the muscles to contract involuntarily) and disc degeneration.
Further review of the complaint revealed concerns related to care plan meetings and the scheduling and holding of the care plan meetings.
Interview on 1/10/24 at 10:02 AM with Resident #1 revealed that [the facility] never schedules care plan meetings .' and that s/he 'has never had one.'
Interview on 1/10/24 with staff #23 the facility Director of Social work was interviewed regarding Resident #1's concerns. She stated that the resident only likes to have the meetings if everyone on the list will be in attendance.
A review of the social work documentation of care plan meetings revealed that from 7/28/22 through 9/21/23, there were no documented care plan meetings held. Additionally, prior to 7/28/22, only discussions about discharge planning were documented, no official care plan meeting was held.
The concern that quarterly care plan meetings were not held or scheduled in the identified time frame were reviewed with the facility Director of Social work, the Director of Nursing, and the facility Nursing Home Administrator throughout the survey and again during exit on 1/18/24.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview with Director of Nursing and review of the GNA [NAME], it was determined that resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview with Director of Nursing and review of the GNA [NAME], it was determined that resident # 12 did not receive toileting care on the following dates. This was evident for 1 out of 5 residents reviewed for toileting.
Findings include:
The GNA [NAME] is a record the GNA (Geriatric Nursing Assistant) fills out on the care provided to residents. The following dates were discovered on the GNA [NAME] in which the GNA did not provide toileting care to resident # 12.
[NAME] for toileting indicated on
Oct. 2021
No toileting documented for the night shift.
10/24/21 day shift 10/15-19, and 10/22/21- 26.
Nov. 2021
No toileting documented for:
11/6, 11, 15, 18, 20, 21, and 26-day shift
11/13, 16, 19, 22, and 27-night shift
Dec. 2021 no toileting documented for:
12/1, 2, 9, 10, 22, 26, and 27-day shift
12/3, 7, 11, 14, 17- night shift
Jan. 2022 no toileting documented for:
1/4/22 and 5-day shift
1/28/22 night shift
DON (Director Of Nursing) made aware and said nothing, but that there were agency personal at the time.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the facility nursing staff f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the facility nursing staff failed to administer an intravenous antibiotic timely. This was evident for 1 (Resident #30) of 55 residents reviewed during a complaint survey.
The findings include:
Review of complaint MD00194081 on 01/10/24 revealed an allegation Resident #30 did not receive quality of care.
Review of Resident #30's closed medical record on 01/10/24 revealed that Resident #30 was sent to the hospital on [DATE] due to a change in condition. Nursing progress notes, dated 07/28/23 at 10:05 AM, indicated that Resident #30 was observed coughing and became short of breath. Resident #30 was also noted with difficulty swallowing. The nurse notified Resident #30's physician and obtained the following orders: obtain a chest x-ray, obtain blood and urine laboratory specimens for encephalopathy, do not give anything by mouth, obtain a speech and language consult for dysphagia, start and IV and administer IV fluids continuously, place Resident #30 on oxygen 2 lpm by nasal cannula, if oxygen saturations drops below 93%, place a midline IV for antibiotics, and administer the antibiotic Ceftriaxone, 1 Gram, IV, every 12 hours for 7 days. The order for the IV, Ceftriaxone antibiotic was entered into the pharmacy system at 4:29 PM on 07/28/23. A second order for the IV antibiotic Ceftriaxone was placed into the pharmacy system at 9:08 PM on 07/28/23. On 07/28/23 at 10:16 PM, nursing documented that Resident #30's IV had been successfully started and was infusing.
Further review revealed that the facility pharmacy was notified regarding when the arrival of the IV antibiotics would arrive for Resident #30 at 1:57 PM on 07/29/23. At 2:40 PM on 07/29/23 a second phone call was made placed to the facility pharmacy inquiring as to when Resident #30's IV antibiotics would arrive. The nursing staff documented that the pharmacy indicated the medication would arrive anytime now. At 4:46 PM on 07/29/23, the nursing staff obtained an axillary temperature of 100.1 Fahrenheit. The nursing staff administered a dose of Acetaminophen to Resident #30 at that time. The nursing staff also notified Resident #30's physician at 5 PM on 07/29/23 who then instructed the nurse to send Resident #30 to the emergency room. Resident #30 had not received a dose of the IV antibiotic on 07/28/23 or 07/29/23 before being sent to the hospital at 5 PM on 07/29/23.
In an interview with the facility director of nurses (DON) on 01/11/24 at 11:28 AM, the DON presented the nurse surveyor with an inventory list of the medications available in the Omnicell medication dispensing system. The antibiotic Ceftriaxone, IV fluids, and IV tubing are on the inventory list as being available to the nursing staff for administration.
A tour of the facility was conducted on 01/12/24 at 10:40 AM with the maintenance director and the facility administrator. During the tour, the facility Omnicell medication dispensing system was accessed by the nursing staff. 4 doses of unmixed/powdered Ceftriaxone, IV tubing, and 100 ml bags of solution were available to the nursing staff to mix and administer IV medications.
In an interview with Resident #30's, 07/29/23, day shift nurse, staff member #26, on 01/18/24 at 11:34 AM, staff member #26 confirmed he/she wrote the nursing progress notes about calling the pharmacy for Resident #30's IV antibiotic dose. Staff member #26 stated that he/she was aware there was an Omnicell medication dispensing system on premises that held antibiotics, IV fluids, and IV tubing. Staff member #26 stated that he/she was not sure what the problem was with the pharmacy delivering Resident #30's antibiotics. Staff member #30 confirmed that he/she did not administer a dose of antibiotics to Resident #30 on 07/29/23. Resident #30 went 20 hours without a dose of the IV antibiotic Ceftriaxone from the time the antibiotic was ordered until the time Resident #30 was sent to the emergency room. Resident #30 had not improved, developed a fever, and subsequently was sent to the emergency room.
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 F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide psychiatric evaluation for a resident (resident #26...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide psychiatric evaluation for a resident (resident #26) who had a history of Post Traumatic Stress Disorder (PTSD) and Schizophrenia. This is evident in 1 of 18 residents reviewed during a complaint survey.
Findings includes:
Review of Resident #26's medical records on 1/9/24 at 10:00 am revealed the resident was admitted to the facility on [DATE] for rehabilitation after a stroke. Review of the care plan records revealed the facility placed the interventions of providing psychiatric services and providing psychiatric medication as ordered as a remedy for behaviors related to the resident's diagnosis of Schizophrenia and PTSD. Review of the resident's medical record found no evidence that the resident received psychiatric services during his/her stay in the facility.
An interview with the Director of Nursing (DON) on 1/9/24 at 1:18 pm revealed the facility failed to provide a psychiatric evaluation as written as an intervention in the resident #26's care plan. The DON stated that the resident was not taking any psychiatric medication during his/her visit, so the psychiatric evaluation was unnecessary. The surveyor asked the DON why the resident's care plan had the intervention of a psychiatric evaluation to assist in providing the resident with psycho-social well-being. The DON was unable to answer the surveyor's question. The surveyor expressed concerns regarding the facility's failure to provide the resident with a psychiatric evaluation to ensure the resident's well-being. The DON stated that he/she understood.
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 F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that facility staff failed to offer and provide the influenza vacc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that facility staff failed to offer and provide the influenza vaccine to a resident (resident #3) during his/her stay. This deficient practice was evident for 1 of 18 residents reviewed during a complaint survey.
The findings include:
A review of resident #3 medical records on 1/18/24 at 9:30 am revealed the resident was admitted to the facility on [DATE] for rehabilitation after a stroke. Review of resident #3's vaccination records revealed the resident received only tuberculosis vaccines when admitted to the facility. Review of orders revealed the resident was ordered to be offered the influenza vaccine on 7/23/21. Further review of medical records found no evidence that the resident was offered the influenza vaccine.
An interview with the Director of Nursing (DON) on 1/18/24 at 11:30 am revealed all residents are supposed to be offered the influenza vaccine when admitted . The DON admitted that he/she was unable to locate evidence that resident #3 was offered or received the influenza vaccine. The surveyor expressed concern that resident #3 was not offered the influenza vaccine. The DON understood.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, it was determined that the facility nursing staff failed to ensure that all medications were stored in a locked compartment or room. This was observed during ...
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Based on observation and staff interview, it was determined that the facility nursing staff failed to ensure that all medications were stored in a locked compartment or room. This was observed during a tour of the facility.
The findings include:
During a tour of the facility on 01/12/24 at 10:40 am on the Terrace Unit, with the facility maintenance director and the facility administrator, the nurse survey observed the bottom of what appeared to be a black jacket hanging out of the medication rooms door exactly at the height of the door handle. The nurse surveyor was able to easily push the door to an open position. A woman's black winter coat and black purse were observed on the right-hand side of the sink. Further observation of the medication room's door handle revealed that someone had stuffed brown colored hand tissues into the area that would house the door latch bolt. Placing the brown colored hand tissues into the door latch bolt area prevented the door from locking properly. Inside the medication room the surveyor observed 2 large, fully filled, gray colored pharmacy bags seated on the left-hand side of the sink. The facility administrator was immediately made aware and removed any items from the door handle that prevented the door from securely closing and locking.
In an interview with the Terrace Unit's day shift charge nurse, staff member/LPN #22, accompanied by the facility director of nurses, on 01/12/24 at 1:58 PM, LPN #22 stated that she forgot to lock the medication room door. LPN #22 stated she was aware that medication rooms were to be always locked and was aware the nursing facility had staff locker rooms available to secure their belongings while working. Lastly, LPN #22 stated that she was not aware of how the brown colored hand tissue became stuffed into the door latch bolt area on the medication room door.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to 1) complete the
daily assessme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to 1) complete the
daily assessments and documentation accurately, 2) have dental consults readily available on the chart, and 3)
address a documented 41-pound weight gain discrepancy in one month, and 4) accurately document a resident observed skin assessment after admission. This was evident during the review of 4 of 55 (Residents #8, #45,
#36 and #55) residents reviewed during a complaint survey.
The findings include:
1) Review of the medical record for Resident #8 on 1/4/24 at 10:49 AM revealed admission for rehabilitation
following multiple injuries from a motor vehicular collision including a sub-arachnoid hemorrhage (bleeding
around the brain), rib fracture, left elbow dislocation, right knee dislocation, tracheostomy placement,
percutaneous endoscopic gastrostomy (a tube placed in the abdomen for feeding). The resident arrived at the
facility assessed as non-verbal.
Further review noted that 23 of 29 assessments completed, noted to be completed by licensed practical nurses,
all documented Resident #8 as being alert and oriented x3 and able to communicate verbally, speech is coherent
and clear and able to move all extremities.
Those assessments completed by Registered Nurses, the remainder 6, all documented Resident #8 correctly that
s/he was not alert or able to obey commands at baseline secondary to neurological defects, but would respond to
tactile stimulation, in addition, could not communicate verbally and was not able to move all extremities, had
weakness and impairment secondary to noted injuries.
According to a speech language pathology (SLP) assessment completed on 2/25/22, Resident #8 was only able
to respond with minimal accuracy when working with word association and colors and required max cues. The
2/28/22 SLP assessment noted Resident #8 responded with intelligible hand gestures.
These identified concerns were brought to the attention of the facility DON on 1/4/24 at 12:56 PM and again
during exit on 1/18/24.
2) The medical record for Resident # 45 on 1/4/24 at 1:34 PM was reviewed secondary to a complaint regarding
dental care.
Through the progress notes and uploaded documents no dental care records for Resident #45 were found and
therefore were requested from the DON on 1/5/24. The DON reported that he had to contact the dental practice
to see where the paperwork is.
On 1/8/24 the DON was able to provide a consult report from the dentist that the resident was seen, however,
the concern remained that the consult was not on the chart. There were no recommendations.
These identified concerns were reviewed with the DON at that time and again during exit on 1/18/24.
3) Review of Resident #55's medical record on 01/17/24 revealed the nursing staff documented the following
weights:
12/01/23 - 121.5 pounds.
01/05/24 - 162.5 pounds.
A review of Resident #55's dietary note dated, 01/12/24, revealed that the facility dietician addresses the 41-
pound weight gain and noted the weight discrepancy may be due to the use of 2 different scales (seated scale
and a lift scale). There were no other progress notes before the 01/12/24 dietician note addressing the significant
weight change for Resident #55. A subsequent reweight was obtained on 01/12/24 which indicated Resident
#55 weighed 121.4 pounds.
In an interview with the facility director of nurses (DON) on 01/18/24 at 1:20 PM, the DON stated that the
nurse unit manager for Resident #55 placed the wrong weight data for Resident #55 on 01/05/24.
4) Review of Resident #36's closed medical record on 01/03/24 revealed that Resident #36 was admitted to the
facility form the hospital on [DATE]. The 03/17/23, 8:43 PM, nursing admission assessment of Resident #36's
skin indicated no skin impairments, dry and moist. On 03/17/23, the nursing staff documented a Braden skin
assessment of 11 which indicated Resident #36 was a high risk for skin breakdown.
Further review revealed a wound consultant assessment progress note, dated 03/20/23 at 10:35 am, that
indicated Resident #36 was observed with an evolving deep tissue injury to the sacral area.
On 03/24/23 at 11:46 am, Resident #36's physician documented that Resident #36's skin was intact.
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
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint and observation, it was determined that the facility failed to maintain all patient care equipment in proper ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint and observation, it was determined that the facility failed to maintain all patient care equipment in proper working function by 1) not having enough batteries available for resident lifts, 2) not having enough battery charging receptacles available for the resident lifts, and 3) the rest room fan in room [ROOM NUMBER] is in disrepair by making loud grinding noises. This was observed on the Terrace and [NAME] nursing units during an observation tour of the facility.
The findings include:
Review of complaint MD00186774 on 01/03/24 revealed an allegation the nursing hoyer lifts have been broken before Thanksgiving 2023.
1) During a tour of the facility on 01/12/24 at 10:40 am on the terrace unit, with the facility maintenance director and the facility administrator, the nurse survey observed an Arjo-Sara lift that was nonfunctioning. In an interview with the facility maintenance director at the time, the facility maintenance director stated that the lift needed a charged battery to function and that some of the lift battery charging receptacles were nonfunctioning.
During the continued observational tour of the facility, the nurse surveyor observed 2 hoyer lifts, located in a small hallway on the west hall, that had signs hanging from them that indicated the 2 lifts were out of service. The facility administrator was made aware of the observation.
2) Also during the observational tour of the facility revealed that the toilet seat, in the Terrace Unit central shower room, was in disrepair, worn, and with a discolored appearance.
3) During an observation of the rest room in room [ROOM NUMBER], the nurse surveyor observed the rest room fan to be in disrepair. When the rest room light switch was placed in the on position, the rest room fan started making loud grinding noises. The maintenance director was made aware of the observation.
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 F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility staff failed to maintain the resident call system ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order. This was evident for 1 of 4 nursing units observed during a revisit survey.
The findings include:
During an observation of the facility on 01/12/24 at 10:40 AM with Director of Maintenance and the facility Administrator, the nurse surveyor observed the following resident room call bells missing or in disrepair:
1) No resident call bell, wall mounted or handheld, was observed in the shared rest room between rooms [ROOM NUMBERS]. The facility administrator was immediately made aware of the observation.
2) The rest room cables in rooms:
a) #70 was observed in disrepair. The cable had been cut and did not reach all the way to the floor.
b) #72 is totally missing a cable.
c) #7 is totally missing a cable.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe and sanitary environment for a resident through failin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe and sanitary environment for a resident through failing ensure an electrical outlet was safe (resident #1). This deficient practice affected 1 of 1 resident reviewed during a complaint survey.
The findings include:
On 8/10/23, the State of Maryland's Office of Health Care Quality received a complaint (MD00195366) alleging the facility failed to maintain a clean environment for its residents, failed to have working air conditioning, and resident #1 failed to have a fall mat on his/her floor when it was ordered.
On 8/11/23 at 12:00 PM, the surveyor with the Administrator and Maintenance Assistant #3 toured the facility. Resident #1's room was visited. The surveyor observed the electrical outlet with the TV plugged into it was exposed and did not have a cover over the outlet. Maintenance Assistant [NAME] acknowledged that the outlet should have a cover.
On 8/11/23 at 1:45 PM, the surveyor expressed concern that Resident #1 room had a outlet that had exposed without a cover. The Administrator stated the outlet would be fixed that day.
Dec 2022
5 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, it was determined that the facility failed to prevent a cognitively impaire...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, it was determined that the facility failed to prevent a cognitively impaired resident with exit seeking behaviors from leaving the facility. This was evident for 1 (Resident#1) out of 1 resident reviewed for accidents.
The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified verbally and in writing of this determination at 7:15 PM on 01/26/2023. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 12:15 AM on 01/27/2023.
The findings include:
On 01/26/2023 at approximately 10:27 AM, the survey team had exited the facility after the completion of the environmental survey. At which time the survey team observed 3 County police vehicles and 1 K-9-unit Sports Untility Vehicle (SUV) parked in front of the facility. The Surveyor asked the Director of Nursing (DON) why the police were in the facility, the DON stated he was unsure.
During an interview conducted on 01/26/2023 at approximately 10:29 AM, the Surveyor asked the K-9-unit Police Officer #20 why s/he was in the facility. The Police Officer stated, there is a missing resident.
During an interview conducted on 01/26/2023 at approximately 10:33 AM, the surveyor asked the DON if he was aware that there was a missing resident. The DON stated when he arrived at the facility at approximately 8:30 AM he was advised that Resident #1 with a diagnosis of dementia was missing and the staff was searching the facility and grounds for the resident. The DON further stated he had just learned the resident exited the facility through the double doors that led to the smoker's courtyard on the bottom floor of the facility.
On 01/26/2023 at approximately 10:34 AM the surveyors conducted an observation of the set of two glass double doors where the resident exited the facility. The first set of double glass doors had a fire safety egress statement that read push unit alarm sounds, door can be opened in 15 seconds. On the left wall located near the first set of the glass double doors was a wanderguard sensor and a door alarm system with a keypad.
During the continued observation, the Activities Director #10 was observed using a key fob to open the glass double doors to allow the smokers to go outside to the smoker's courtyard.
During an interview conducted on 01/26/2023 at approximately 10: 36 AM, the Activities Director #10 stated the glass double doors can either be opened with the key fob or if the door handle is pushed for a period of 15 seconds. She also stated the doors will open automatically if the door handle is pushed for 15 seconds due to the fire safety egress. The Activities Director then pushed the door handle for 15 seconds, the audible door alarm triggered, and both sets of glass double doors opened to the smokers outside courtyard.
During the observation of the smoker's courtyard on 01/26/2023 at approximately 10:37 AM, the surveyors observed a 5-foot wooden fence with 3 exit gates. The observation of the gates showed two of the exit gates were secured with zip ties and one gate was secured with a master lock.
On 01/26/2023 at approximately 10:50 AM a review of the facility's camera footage revealed the camera's current time was behind by 20 minutes of the actual time. The footage showed the resident had made an unsuccessful attempt to exit the facility from the glass double doors that led to the smokers outside courtyard on 01/26/2023 at 5:19 AM. The resident was seen returning to the same doors and exiting the facility on 01/26/2023 at 5:34 AM. However, the actual real time the resident first attempted to exit the facility occurred on 01/26/2023 at 4:59 AM and the second and successful attempt to exit the facility occurred on 01/26/2023 at 5:14 AM.
During an interview conducted on 01/26/2023 at approximately 11:05 AM, the K-9 Police Officer #20 stated the camera footage showed the top of the resident's head on the other side of the 5-foot wooden fence of the smokers' courtyard around 5:36 AM.
A medical record review for Resident #1 was conducted on 01/26/2023 at approximately 11:08 AM revealed the resident was diagnosed with Dementia.
According to the Centers of Medicare and Medicaid Services (CMS) 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. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. All assessments are completed within specific guidelines and time frames. In most cases, participants in the assessment process are licensed health care professionals employed by the nursing home. MDS information is transmitted electronically by resident nursing homes to the national MDS database at CMS.
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 now. 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.
A review of Resident #1's quarterly MDS assessment was conducted on 01/26/2023 at approximately 11:10 AM. The MDS quarterly assessment dated [DATE] revealed the resident's BIMS assessment revealed a score of 9.
A continued review of Resident #1's medical records revealed progress notes that stated on 07/29/2022 s/he wanted to go home and attempted to exit the front door. The resident was redirected several times and a wanderguard was placed on the right wrist. Another note dated 08/02/2022 stated the resident attempted to exit the front door and was redirected.
Review of Resident #1's elopement risk assessment dated [DATE] indicated the resident scored a nine. A score of 8-9 placed the resident at risk for elopement and exit seeking.
A review of Resident #1's care plan initiated on 07/29/2022 showed a care plan for General Safety Risk related to impaired cognition with an intervention for wander alert.
Review of the Treatment Administration Record (TAR) revealed documentation that staff checked for placement and functionality for the wanderguard from 01/01/2023 - 01/25/2023.
On 01/26/2023 at approximately 11:26 AM the surveyors conducted a second tour of the smoker's courtyard; the surveyors observed 5 residents in the courtyard unsupervised and the zip ties on the right gate now cut and no longer secure. The surveyors were able to freely push the gate open that led to the outside grounds of the facility.
During an interview conducted on 01/26/2023 at approximately 11:30 AM, the DON stated the police cut the zip ties to gain entry to the grounds, he also stated he would have maintenance replace the zip ties. The surveyors continued to observe the unmanned and unsecured gate from 11:30 AM to 12:34 PM until the DON provided coverage to supervise the unsecured gate.
On 01/26/2023 at approximately 12:35 PM the surveyors observed the DON check the wanderguard system for the double doors that Resident #1 exited. The surveyors observed the door alarm audibly trigger when the door handle was pushed and an audible wanderguard alarm triggered when the DON went through the doors that led to the smokers outside courtyard. The DON confirmed that once the door is alarmed the door can be freely pushed open even while wearing a wanderguard.
During the continued tour of the facility on 01/26/2023 at approximately 12:45 PM, the surveyors and DON identified an emergency exit door located on the East Terrace wing that was unlocked. The surveyors pushed on the door handle and the doors freely opened. The doors led to another set of doors that when pushed opened freely to the outside of the facility. The DON called Maintenance Director #13 to come to the East Terrace emergency exit. The Maintenance Director attempted multiple times to lock the doors by putting a code on the keypad located on the wall next to the doors but was unsuccessful. The DON assigned Floor Tech # 8 to guard the emergency exit doors until the door was secure.
During an interview conducted on 01/26/2023 at approximately 12:47 PM, the Maintenance Director #13 confirmed he had not performed daily audits on the facility exit doors to ensure they were secure since his employment of about one and half weeks.
During an interview conducted on 01/26/2023 at approximately 12:48 PM with the DON and Administrator, the DON stated the last time door audits had been performed were conducted by the previous Maintenance Director. The Administrator stated he would have the door audit logbook located and provided to the surveyor. The door logs were provided to the surveyor and confirmed the last door audit was performed on 12/27/2022.
On 01/26/2023 at approximately 1:10 PM the DON advised the surveyors that the emergency exit doors located on the East Terrace had been repaired, were now locked, and the alarm was activated. The DON further stated the wires had been cut inside the panel for the doors that activated the lock and alarm.
On 01/26/2023 at approximately 1:35 PM the DON advised the surveyors that the resident had been found on 01/26/2023 at approximately 1:30 PM at the County Mall by the Occupational Therapist #9, who was there to get lunch. Review of the local map of the area revealed the mall was located approximately 1.9 miles from the facility. The Mall's area had heavy traffic areas that included major roadways that had a span of 4 traffic lanes as well as a creek.
During an observation on 01/26/2023 at approximately 2:30 PM the DON advised the surveyors that Resident #1's wanderguard was functional at the time of the elopement. The DON then directed Resident #1 to walk to the glass double doors that led to the smokers outside courtyard. The resident walked to the door and attempted to push on the door handle, the door opened, and the audible door alarm was triggered. The double doors opened, and the resident entered through the first set of double doors which triggered an audible wanderguard alarm.
The resident diagnosed with dementia, wandering and exit seeking behaviors eloped and had wandered the community for approximately 7 hours before being found. The resident had potential for serious injury, serious harm, or death during that time.
The facility provided a plan to remove the immediacy while the surveyors were onsite. An initial plan of removal was submitted to the surveyor team and the Office of Health Care Quality for review on January 26, 2023, at approximately 8:43 PM and was rejected. The 2nd plan of removal was given to the surveyor team and the Office of Health Care Quality for review on January 26, 2023, at approximately 9:34 PM and was rejected. The 3rd plan of removal was given to the surveyor team and the Office of Health Care Quality on January 26, 2023, at approximately 11:07 PM and was rejected. The 4th plan of removal was accepted, and the Immediate Jeopardy was removed on January 27, 2023, at approximately 12:15 AM by the surveyor team and the Office of Health Care Quality.
The plan included an audit of all exit doors to ensure the doors are secured and the wanderguard system was functional. The glass double doors that led to the smokers outside courtyard was monitored by an employee throughout each shift until the 15 second fire safety egress was removed by the vendor. The emergency exit door located on the East Terrace Wing was repaired to allow the door to lock and alarm. Mandatory training was conducted for all staff for Elopement and Accident Prevention /Supervision. A process was implemented to identify patterns of residents for elopement risk and accidents to be referred to the Quality Assurance Improvement Plan (QAPI). The plan also included a replacement of the 5-foot wooden fence that enclosed the smokers outside courtyard to a 6 -foot fence.
The facility's compliance date for the plan of removal was January 30, 2023. The survey team verified the facility met its date of compliance on January 31, 2023.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medications in designated carts on the nursing unit. This was...
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Based on observations and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medications in designated carts on the nursing unit. This was found to be evident for 3 out of 4 medication carts on a nursing unit observed during a tour of the facility.
The findings include:
On 1/31/2023 at 5:54 AM, the surveyor observed an unlocked and unattended medication cart labeled [NAME] Wing
1) Further observation revealed a medication cup with two pills sitting on top of that cart.
On 1/31/2023 at approximately 5:55 AM, the surveyor observed Licensed Practical Nurse (LPN) #17 walk over to the medication cart from the nurse's station. Prior to walking over to the medication cart, LPN #17 was in a location in the nurses' station where she was not able to visualize the [NAME] Wing 1 medication cart. During an interview, LPN #17 confirmed that she was responsible for the [NAME] Wing 1 cart and explained that she had stepped away to attend to the pharmacy delivery at the request of her supervisor. LPN #17 was able to identify the medications in the medicine cup as omeprazole (used to treat acid reflux) and levothyroxine (used to treat dysfunctions of the thyroid) and that the medicine cup was intended for Resident #6.
On 1/31/2023 at approximately 5:56 AM, the surveyor interviewed Registered Nurse (RN) #18, the Unit Manager. RN #18 stated she had instructed LPN #17 to attend to the pharmacy delivery but stated leaving the medication on top of the medication cart unattended and leaving the medication cart unlocked was unacceptable.
2) On 01/31/2023 at approximately 5:55 AM, the surveyor observed an unlocked and unattended medication cart located on the [NAME] Wing nursing unit. The surveyor was able to open each medication drawer that had labeled medications packets with the resident's name and room number, insulin pens, in-house liquid medications, and eye drops. At approximately 5:56 AM the surveyor observed Licensed Practical Nurse (LPN) #16 walk out of resident #8's room.
During an interview conducted on 01/31/2023 at approximately 5:56 AM, LPN #16 stated that Resident #8 had requested care, she left the medication cart to provide care for the resident and failed to lock the medication cart prior to entering the resident's room. The LPN further stated that the facility's policy was to always lock the medication cart when unattended.
During an interview conducted on 01/26/2023 at approximately 8:30 AM, the surveyor advised the Director of Nursing of the findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on medical record review and interviews it was determined the facility failed to ensure accurate medical records in accordance with accepted professional standards as evidenced by a resident blo...
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Based on medical record review and interviews it was determined the facility failed to ensure accurate medical records in accordance with accepted professional standards as evidenced by a resident blood glucose level was documented as measured for a resident that was not in the facility at the time. This was found to be evident for 1 (Resident #1) out of 1 resident reviewed for elopement.
The findings include:
During an interview conducted on 01/26/2023 at approximately 10:33 AM, the Director of Nursing (DON) stated that Resident #1, with a diagnosis of Dementia, eloped on 01/26/2023.
On 01/26/2023 at approximately 10:50 AM a review of the facility's camera footage confirmed the resident exited the facility on 01/26/2023. The review of the camera's footage showed the current time was behind by 20 minutes of the actual time. The camera footage time stamped the resident exiting the facility at 5:34 AM. However, the actual real time that Resident #1 exited the facility was at 5:14 AM.
According to the World Health Organization diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood glucose.
A review of Resident #1's diagnoses conducted on 01/26/2023 at approximately 11:00 AM revealed Resident #1 was diagnosed with diabetes mellitus.
On 01/26/2023 at approximately 11:02 AM, a review of Resident #1's Medication Administration Record (MAR) revealed that Registered Nurse (RN) #3 documented a blood glucose level of 156 for the resident on 01/26/2023 at 6:00 AM. However, the resident had eloped from the facility on 01/26/2023 at 5:14 AM.
On 01/27/2023 at approximately 6:35 AM, RN #3 stated that she last saw the resident in the facility at around 6:40 AM and as such had obtained the resident's blood glucose level at 6:00 AM.
On 01/27/2023 at approximately 12:00 PM, the surveyor advised the Administrator and Director of Nursing (DON) of the findings.
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 F0940
(Tag F0940)
Could have caused harm · This affected 1 resident
Based on employee record reviews, and interviews with facility staff it was determined that the facility failed to maintain an effective training program for existing staff. This was found evident for...
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Based on employee record reviews, and interviews with facility staff it was determined that the facility failed to maintain an effective training program for existing staff. This was found evident for 3 out of 6 employee records reviewed for required training during an extended survey.
The findings include:
On 1/30/2023 at 10 AM, the surveyor interviewed Registered Nurse (RN) #15, the Staff Development Nurse and Infection Preventionist. During the interview RN #15 reported that the facility's required education is assigned to staff through a computer system called Relias as well as in-service trainings that are offered throughout the year. RN #15 indicated that each staff has a month to complete assigned trainings and an email is sent to notify staff that their training is due to be completed. RN #15 reported that the human resource department is responsible for identifying staff who have not completed their required annual trainings.
On 1/30/2023 at 10:10 AM, the surveyor conducted an interview with the Director of Nursing (DON). The DON revealed that his expectation is for the human resource department to notify the department heads of any staff that are not up to date on assigned annual and mandatory trainings.
On 1/30/2023 at 10:11 AM, the surveyor interviewed the Human Resource Director Staff #14. Staff #14 stated the human resource department runs monthly reports of employees and notifies the department heads if a staff member,whom they oversee, is not up to date on the training requirements. Staff #14 confirmed that the report was not done last month in December and that some current staff had not completed mandatory trainings.
On 1/30/2023 at 11:19 AM, RN #15 provided an in-service binder with education offered with attendance logs. Abuse training was provided on 8/3/22, where 12 staff signed the attendance log and again on 9/7/22, where 29 staff signed the attendance log. RN #15 stated that she was aware that some signatures were missing but had more sign in sheets in her office. On 1/30/23 at 11:55 AM, staff #15 brought additional signature sheets to add to the binder. Staff #15 reported that if staff were not able to attend the in-services the department heads would be aware.
On 1/30/2023 at 11:25 AM, the surveyor reviewed the printout, provided by Staff #14, listing the required training for all staff to complete upon hire and each year. Abuse, Infection Control and Prevention, and Resident Rights were part of the list. However, staff #14 was unable to produce a list of the required annual training assigned to each specific department.
On 1/30/2023 at 11:30 AM, the surveyor reviewed the Relias education transcripts for Staff #5, #19 and #3. The review revealed the transcripts of completion as follows:
Staff #5' Relias transcripts:
Understanding Abuse and Neglect completed on 3/29/21.
Infection Control and Prevention completed on 3/29/21.
No record could be found for education on Resident's Rights.
Geriatric Nursing Assistant (GNA) #19 Relias transcripts:
Abuse and Neglect was last completed on 11/28/20.
RN #3 Relias transcripts:
Abuse and Neglect was completed on 1/24/21.
Alzheimer's Disease and Related Disorders: was completed on 7/10/21.
Corporate Compliance and Ethics was completed on 9/29/21.
Dementia Care: was completed on 5/31/21.
Infection Control and Prevention was completed on 2/22/21.
Resident's Rights was last completed on 8/26/21.
The review of Staff #5, #19 and #3's transcripts revealed that all three staff had not been trained on the topic of abuse for over a year. The in-service on abuse, provided by Staff #15, was offered after the annual training for abuse was due for Staff #5, #19 & #3.
Further review of the transcripts revealed that Staff #5 and RN #3 had not completed their required annual training on Resident Rights for the current year.
On 1/30/2023 at approximately 11:35 AM, the surveyor reviewed these concerns regarding the lack of maintaining and monitoring of the facility's training program for staff as well as the overdue training on required annual trainings with the DON.
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 F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, it was determined the facility failed to ensure staff members received the annual performance evaluation as evidenced by a review of employee files did not show...
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Based on record reviews and interviews, it was determined the facility failed to ensure staff members received the annual performance evaluation as evidenced by a review of employee files did not show a record of an annual performance evaluation. This was evident for 5 (GNA #21, #23, #28, #29, & #30) out 5 staff members reviewed during the extended survey.
The findings include:
On 01/30/2023 at approximately 10:15 AM a review of the employee files was conducted for Geriatric Nursing Assistant (GNA) #21, #23, #28, #29, & #30. The employee files did not show an annual performance evaluation.
During an interview conducted on 01/30/2023 at approximately 10:50 AM, the Human Resource (HR) Director # 14 stated that he provides a monthly spreadsheet to each department manager for the upcoming annual performance evaluations. The department manager will complete the evaluation, review it with the employee and send it to the HR Director. Once the HR Director has reviewed the evaluation it is sent to the Administrator. The HR Director confirmed that GNAs # 21, #23, #28, #29, & 30 annual performance evaluations had not been completed and were overdue.
A review of a listing of GNA's overdue for the annual performance evaluation was conducted on 1/31/2023 at approximately 10:57 AM. The list revealed 28 GNAs out of 50 GNAs were overdue for the annual performance evaluation.
During an interview conducted on 01/23/2023 at approximately 11:30 AM. The surveyor advised the Director of Nursing (DON) of the findings and concerns.
May 2021
36 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
3) The facility's staff failed to provide proper bedding for Resident #99.
05/26/21 at 09:15 AM, the surveyor observed Resident #99 lying directly on his /her mattress. The resident's mattress did no...
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3) The facility's staff failed to provide proper bedding for Resident #99.
05/26/21 at 09:15 AM, the surveyor observed Resident #99 lying directly on his /her mattress. The resident's mattress did not have a fitted sheet to cover the mattress, and the resident's door was open and visible from the hallway of the [NAME] Wing nursing unit.
During the interview on 5/26/21 at 09:18 AM, staff # 31 (LPN) confirmed that Resident #99 was lying on his/her mattress without a fitted sheet. The Licensed Practical Nurse (LPN) stated that he/she would provide appropriate bedding for Resident #99.
2) The facility failed to provide clean clothes and or linen for residents due to broken equipment. (washing machine). This has affected all residents in the building.
On 5/25/21 at 1 PM a Resident Counsel meeting was held. During the meeting, residents complained that they do not have a laundry schedule of when soiled clothes will be picked up and washed. Surveyor # 37586 spoke with the Director of Housekeeping and laundry staff (# 37) who stated they have a laundry schedule, but right now the facility has only one washing machine in operation. On 4/28/21 a laundry equipment sales and service vendor came to the facility to check the broken washing machine, and stated that the repair would cost more then buying a new washer. The Corporation has the laundry service report and is deciding what to do at this time. In the mean while the facility cleans linen and they wash cloths when they can. This affects all residents in the facility because they do not have clean clothes to wear and their personal laundry is piling up as an affect of this disrepair.
Based on observations, medical record reviews, and interviews during a tour of the facility, it was determined that the facility failed to maintain and enhance the dignity of the residents: 1) by failing to provide privacy and rendering care to resident (#4) , 2) failed to provide clean clothes and or linen for resident (#37) due to broken equipment and, 3 ) failed to provide proper bedding for resident (#99). This occurred in three of three sampled residents for dignity.
The findings include:
The facility failed to maintain and enhance dignity for resident #4 by failing to provide privacy after rendering am care.
1a) On 5/18/21 at 9:00 AM during a tour of the facility this surveyor observed resident (# 4) lying in bed on the left side uncovered with brief exposed. The bed was in the highest position. The resident's feeding tube tubing was lying over his/her left arm attached to the feeding pump. The resident had a crème-colored dried substance on the left side of the sheets. The feeding pump was off, and the total volume infused from the feeding pump was1350 (ml) milliliters.
During an interview with the Charge Nurse (staff #16) on 5/18/21 at 9:15 AM s/he stated the resident should not have been left uncovered and the bed in its highest position is in error. She stated the resident's feeding tube tubing should have been discounted at 8 AM. After surveyor intervention staff #16 lowered the bed, disconnected the feeding tube, and instructed GNA (Geriatric Nursing Assistant) (staff #38) to reposition and change Resident #4-bed linen.
During the interview with GNA #38 on 5/8/21 at 9:30 AM, she stated she was performing incontinence care on the resident and had gone to get linen.
A review of the medical records on 5/18/21 at 11:00 AM, revealed that Resident # 4 was admitted to the facility in 2020 for long-term care and with a diagnosis that included a PEG Tube secondary dysphagia. PEG stands for percutaneous endoscopic gastrostomy, a procedure in which a flexible tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids, and/or medications to be put directly into the stomach, bypassing the mouth and the esophagus.
Continued review of the medical record revealed a physician order dated 9/17/2020 to administer Glucerna 1.5 with a rate of 75ml/hr. Start at 2 PM and run for 18hrs or until 1350ml has infused.
1b) During follow-up observation rounds 5/26/21 at 11:30 AM, Surveyor #21859 knocked on Resident (#4's) door and was told to come in by GNA (staff #33). Upon entrance resident (#4) roommate was sitting in the chair at his/her bedside. Resident (#4) bed was observed raised in its highest position. The resident was uncovered and staff #33 was rendering care. No privacy curtains were hanging in the room. The GNA stated the maintenance staff removed the privacy curtains to wash them.
All findings were discussed during the survey process and during the exit on 5/28/21.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations and interviews it was determined the facility failed to: 1) ensure that Resident (#68) was provided proper storage for personal belongings, and 2) ensure that (residents #69, #11...
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Based on observations and interviews it was determined the facility failed to: 1) ensure that Resident (#68) was provided proper storage for personal belongings, and 2) ensure that (residents #69, #114, #116) have access to the facility's communication system (call bell). This was found to be evident for 4 out of 56 residents reviewed during the annual survey.
The findings include:
Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities.
1) On 05/18/21 at 1:40 PM, the surveyor observed that Resident # 68's clothing was piled on the floor next to his/her bedside. The resident stated that he/she did not have an armoire closet for storage of his clothing. The resident stated that the dresser in his room had wound care supplies in it and could not be used for his/her clothing.
During an interview on 05/25/21 at 10:30 AM, the surveyor advised the Administrator that Resident #68's clothing was observed piled on the floor in his/her assigned room. The Administrator advised the surveyor that he/she would provide an armoire closet.
On 05/25/21 at 11:30 AM, the surveyor observed that Resident #68's clothing was stored in a dresser.
2) On 05/25/21 at 10:35 AM, the surveyor observed Resident # 69 in his/her assigned room lying in his/her bed. The resident's call bell was observed hanging around the light fixture behind the resident's bed. According to the resident's quarterly MDS record, dated 03/18/2021, the resident required extensive assistance for bed mobility and locomotion.
On 5/25/2021 at 10:36 AM, the surveyor observed Resident # 114 in his/her assigned room lying in his/her bed. The resident's call bell was observed lying on the floor on the left side of the bed. According to the resident's quarterly MDS record dated 02/09/2021, the resident required extensive assistance for bed mobility and locomotion.
During the interview conducted on 05/25/21 at 10:38 AM, staff # 21 (LPN) confirmed the location of the call bells for residents #69 and #114. The Licensed Practical Nurse (LPN) stated that the GNAs moved the call bells when they removed the breakfast trays and failed to place the call bells back within reach for each resident. The surveyor observed the LPN place the call bells within reach for Resident #69 and Resident #114.
The facility failed to ensure that resident #116's call bells were placed within the resident's reach.
3) The survey team conducted an initial tour of the facility on the morning of 5/18/21. During the initial tour at 11:01 AM the surveyor observed Resident #116's room. Resident #116 was in bed at the time. The resident's call bell was noted to be on a nightstand placed against the wall behind the head of the bed. The call bell was beyond the resident's reach and out of the resident's line of sight. There was an over-the-bed table beside the resident where the call bell could have been placed for easy reach. The surveyor asked the resident to locate the call bell and s/he could not. Then, after the surveyor informed the resident where the call bell was, the surveyor asked the resident to try to reach it. The resident could not reach the call bell. The surveyor asked the resident if s/he would like the call bell to be placed next to him/her and s/he stated, 'yes.'
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on discussions with the residents during the Resident Council Meeting held on 5/25/21 at 1 PM, the facility staff do not respond to all the concerns the residents had. This was evident for all r...
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Based on discussions with the residents during the Resident Council Meeting held on 5/25/21 at 1 PM, the facility staff do not respond to all the concerns the residents had. This was evident for all residents who attended the resident council meetings.
The findings include:
On 5/24/21 at 9:15 AM this surveyor reviewed the minutes prior to attending the Resident Council Meeting held on 5/25/21 at 1 PM. The Activity Director, staff # 8, stated that the facility just recently started the resident council meeting in March and April 2021. Record review indicated that during the March 3/30/21 meeting residents wanted to know if they will have to sign a new admissions package because the company was sold in March 2020. They, also, wanted to know what the new laundry schedule is. The residents would also like to know what the policies and procedures are for the new company, Vita. Those items were not documented as addressed to the Resident Council.
Further review of the resident council notes for the April 27,2021 meeting, it was revealed that residents wanted to know why some residents can go outside for fresh air while others cannot? The residents reported that they are not happy with the food stating it is cold, the meat is too hard to chew and that the meals are very salty. Record review revealed that residents, also, stated that they felt they were getting children's food portions, and that the laundry was not picking up the residents' personal clothes to be washed. Those issues were presented to the Administrator after the surveyor attended a Resident Council Meeting on 5-25-21 at 1 PM.
The Administrator stated that a new food service chef would be hired, and that the facility was working to having new menus developed. The Surveyor stated to the Administrator that those issues must be addressed effectively by the staff to the residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that equipment involved in a resident's artificial feeding was maintained in a clean, sanitary, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that equipment involved in a resident's artificial feeding was maintained in a clean, sanitary, and homelike manner for Resident #84.
2) The surveyor reviewed Resident #84's medical record on 5/28/21 at 9:00 AM. The review revealed that Resident #84 received tube feeding as his/her only source of nutrition, was unresponsive, and was totally dependent on staff for care.
The surveyor observed Resident #84's room, including the equipment set up to provide tube feeding to the resident, on 5/28/21 at 9:22 AM. The observation revealed that the resident's tube feeding pump was soiled. Dried, brown material covered the face and top surfaces of the pump. The surveyor noted that the resident was unresponsive and appeared entirely dependent on staff for care, meaning that it would not have been possible for the resident to have caused the soiling of the tube feeding pump.
The surveyor notified the Director of Nursing (DON) of these findings on 5/28/21 at 11:00 AM.
The surveyor spoke with the Environmental Staff #48 on 5/28/21 at 11:15 AM. The staff confirmed that the pump was dirty and stated that it would be cleaned.
Based on observations and staff interviews it was determined the facility failed to: 1) provide housekeeping and maintenance services to keep the resident's environment clean and in good repair on the first floor nursing unit, and . 2) failed to ensure that equipment involved in a resident's artificial feeding was maintained in a clean, sanitary, and homelike manner for Resident #84.
The findings include:
The following environmental concerns were observed during the survey:
On May 18, 2021, at 9 AM during observation rounds:
room [ROOM NUMBER]B: There were multiple brown and black stains on the privacy curtain. The base molding by the radiator had approximately 8 inches pulled away from the wall by the radiator. There was a dried crème bottom sheet on the left side.
room [ROOM NUMBER]: the bathroom had rust around the toilet bolts that hold the toilet seat down. There were several tiles cracked in front of the bathroom sink.
room [ROOM NUMBER] B: The window blind on the left was covered with dark brown and black stains that covered the entire blind. The radiator ductwork behind the resident bed was broken in half with sharp edges sticking out. There was a suction machine, which was dirty with a crème-colored substance dried on the front of the machine. The machine looked as if it had never been wiped off. The front screen of the tube feeding machine was sticky with dried crème colored drip marks. The gray pole that housed the tube feeding machine had dried drip marks that ran down the pole.
The Surveyor discussed the observations with the administrative teams on 5/18/21 at 11:24 AM. The current administrative team stated the process was, if anyone sees something broken or torn it was to be put on the maintenance log and the Maintenance Director will round each day and get it fixed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Employment Screening
(Tag F0606)
Could have caused harm · This affected 1 resident
Based on review of facility staff records and interview with the administrator, the facility failed to present background checks for employees that have been employed by the facility prior to March 20...
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Based on review of facility staff records and interview with the administrator, the facility failed to present background checks for employees that have been employed by the facility prior to March 2020. This was evident for 2 out of 5 staff checked for background checks (Staff # 16 and 17).
The findings include:
On 5/25/21 at 9 AM Surveyor # 375867 requested the employee records for 5 staff members, that included staff # 16, # 17, # 18, #19, and # 20. A review of the records indicated that there was no background check information documents available for staff #16 and staff #17. The Administrator was called at 12:10 PM on 5/25/21 and asked where the staff background check information was. The Administrator stated that when the old company left, in March 2020, they took with them all the employee records, including the background checks and the skills competency check list.
The Administrator stated that she does not know where they are and will accept a deficiency tag for this.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
2) The facility failed to timely report the investigation to the Survey Agency, which was the Office of Health Care Quality (OHCQ) within 24 hours of an alleged incident and the final report within 5 ...
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2) The facility failed to timely report the investigation to the Survey Agency, which was the Office of Health Care Quality (OHCQ) within 24 hours of an alleged incident and the final report within 5 working days.
05/27/21 at 12:57 PM, review of the facility incident report, dated 12/27/20, revealed documentation that Resident #8 went into Resident #28's assigned room and attempted to hit him/her with a tray table. The facility notified the Police department and received a police report.
During an interview, on 05/27/21 at 1:19 PM, Resident #28 stated that Resident #8 came into his/her assigned room, hit him/her on the arm and pushed the resident out of his/her wheelchair. The resident further stated that he/she was not hurt however, he/she still wanted to press charges.
During an interview conducted on 05/27/21 at 2:07 PM, the Director of Nursing (DON) confirmed that an investigation was not conducted because the incident report did not show that Resident #8 physically harmed Resident #28. The DON stated that he/she would interview Resident #28.
During an interview on 05/28/21 at 9:07 AM, the DON stated that, after the interview with Resident #28, he/she confirmed Resident #28's complaint that he /she was hit and pushed out of his/her wheelchair on 12/27/20 by Resident #8. The DON stated that a self-report would be made to the Office of Health Care Quality (OHCQ) today (05/28/21).
Based on medical record review, review of facility statements, and interviews, it was determined the facility staff failed to report an incident to the Office of Health Care Quality (OHCQ) and local law enforcement as required in a timely manner. This was evident for 2 (Resident #433 and #8 ) out of 43 residents reviewed during a complaint survey.
The findings include:
1) On 5/24/2021 at 9:00 AM complaint MD00158325 was reviewed. This complaint alleged that Resident #433 was assaulted by another resident. Review of Resident #433's medical record revealed that on 8/4/2020 Resident #433 was punched on the side of the head by another resident in the hallway but sustained no injuries. At 9:40 AM the Administrator provided the facility's investigation into the incident on 8/4/2020. The facility's investigation included the Comprehensive & Extended Care Facilities Self-Report Form which must be filed with OHCQ within 2 hours if serious bodily harm resulted and within 24 hours for all other incidents, as stated on the bottom of the form. According to the Self-Report form the facility did not submit the form to OHCQ until 8/10/2020, 6 days after the incident occurred. This was confirmed by OHCQ's complaint staff on 5/25/2021 at 10:02 AM.
During interview with the Administrator on 5/25/2021 at 10:05 AM, the administrator was shown that the incident was not reported to OHCQ until 6 days after and there was no evidence it had been reported to law enforcement despite the facility marking that they had reported it to law enforcement on the self-report form.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Minimum Data Set (MDS) Assessment material and interview with facility staff, it was determined that the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Minimum Data Set (MDS) Assessment material and interview with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 1 (Resident #1) of 2 residents reviewed for resident assessment.
The findings include:
The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments are completed at differing intervals but never further than 92 days apart as long as a resident remains at a facility. Each assessment must be encoded within seven days and transmitted within fourteen days of the assessment being performed.
On 5/20/21 at 12:50 PM, the surveyor reviewed information from the Centers for Medicare and Medicaid (CMS) regarding transmission of Minimum Data Set (MDS) Assessments. The review revealed that no assessment information had been transferred for Resident #1 from the facility to CMS in over 120 days (and that no transmitted assessment indicated that the resident had been discharged ).
The surveyor reviewed Resident #1's medical record on 5/20/21 at 1:00 PM. The review revealed that the resident was admitted to the facility at the beginning of December, 2020. A Discharge - Return not Anticipated MDS assessment was found dated 2/28/21.
The surveyor interviewed the MDS Coordinators (Staff #43 and #44) on 5/20/21 at 1:31 PM. During the interview, the MDS Coordinators indicated that Resident #1's Discharge - return not Anticipated MDS assessment dated [DATE] had not been transmitted to CMS and that a correction to the assessment would be required. The MDS Coordinators stated on 5/20/21 at 1:53 PM that the correction had been completed. The corrected MDS assessment was provided to the survey team on 5/21/21.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that a resident whose stay at the facility exceeded 30 days had a new Preadmission Screening and Resident Review (PASARR) Level 1 screening completed within 40 days of admission. This was evident for 1 (Resident #116) of 4 residents reviewed for PASARR.
The findings include:
The PASARR level 1 screening is federally mandated and must be completed for all applicants to nursing facilities which participate in the Maryland Medical Assistance Program regardless of an applicant's payment source. The purpose of the screening is to help ensure that residents are not inappropriately placed in nursing homes for long term care. The program assists in the placement and provision of services for individuals with severe mental illness and/or intellectual disability. The screening form only needs to be partly completed if a resident is expected to remain in a nursing facility for fewer than 30 days, but if the resident remains longer than 30 days, a completed level 1 screen must be completed within 40 days of admission.
The surveyor reviewed Resident #116's medical record on 5/18/21 at 11:37 AM. During the review, the surveyor noted that Resident #116 was admitted to the facility on [DATE]. A PASARR level 1 screening was found that was dated 11/2/20. The assessment had been completed by answering all three questions in part A with 'yes,' including the question, Has the attending physician certified before admission to the NF (nursing facility) that the resident is likely to require less than 30 days NF services? No other questions on the screening had been completed. Although the resident remained at the facility for longer than 40 days, a second level 1 screening could not be found in the resident's chart.
The surveyor interviewed the Director of Social Services (Staff #22) on 5/27/21 at 10:51 AM. During the interview, the Director of Social Services stated that one of the Director's roles was to complete PASARR forms for residents, although she was not the Director at the time of Resident #116's admission or when the resident required a second PASARR level 1 screen to be completed. The Director indicated that the facility had identified that some residents had incomplete PASARR. The Director stated that a Social Services Director from a sister facility was assisting the facility in ensuring residents' PASARR screenings were completed and were accurate.
On 5/27/21 at 2:12 PM, the survey team was presented with a completed PASARR level 1 screening that had been completed for Resident #116 and was dated 5/21/21.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the ...
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Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan. This was evident for 1 (Resident #116) of 4 residents reviewed for Bladder and Bowel Incontinence.
The findings include:
Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable).
The surveyor reviewed Resident #116's medical record on 5/18/21 at 11:37 AM. The review revealed that Resident #116 had a quarterly MDS assessment completed on 2/7/21 and 5/10/21. Review of the resident's care plan revealed that all care plan topics and goals had been revised on 5/3/21 or 5/4/21. There was no evidence in the medical record that a care plan meeting had been held with the resident and the interdisciplinary team around the time of either quarterly MDS assessment or at the time of care plan revision. The only note indicating that the resident was met with by facility staff for the purpose of discussing the resident's plan of care was one note written by the Social Services Director and dated 5/18/21 at 2058 that stated, Writer met with resident, MOLST was reviewed and updated.
The surveyor interviewed the Director of Social Services on 5/27/21 at 10:51 AM. During the interview, the Social Services Director indicated that social services staff were responsible for coordinating the care plan meeting with residents. In reference to the note written on 5/18/21, the Director stated that note did not constitute a care plan meeting and had occurred exclusively to review the resident's MOLST (Maryland Orders for Life Sustaining Treatment). The surveyor requested that the Director provide the survey team with any evidence that care plan meetings had taken place for Resident #116. No such records were provided to the survey team by the time of survey exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on medical record review, it was determined that the facility staff failed to provide a resident with a completed discharge summary. This was evident for 1 (Resident #432) of 43 residents review...
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Based on medical record review, it was determined that the facility staff failed to provide a resident with a completed discharge summary. This was evident for 1 (Resident #432) of 43 residents reviewed during an annual recertification survey.
The findings include:
Review of Resident #432's closed medical record on 5/25/2021 revealed that Resident #432 was discharged from the facility on 11/28/2019. Resident #432's electronic medical record and paper record failed to reveal a completed discharge summary from Resident #432'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.
The Administrator and Director of Nursing were made aware of this issue during the exit conference on 5/28/2021.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice. This was evident for ...
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Based on medical record review and staff interview it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice. This was evident for 2 (#432, #430) of 43 residents reviewed during the survey
The findings include:
1.
On 5/25/2021 complaint MD00148458, which alleged that Resident #432 was not receiving their Acetaminophen as ordered, was reviewed. Review of Resident #432's medical record at 12:00 PM revealed physicians orders for Acetaminophen Liquid, give 10.15 mL by mouth every 6 hours as needed for pain scale of 1-3 and Acetaminophen Tablet, give 650 mg by mouth every 7 hours as needed for pain of 1-3. Further review of Resident #432's pain level documentation revealed a pain level of 3 on 11/26/2019 at 4:56 PM, however, no pain medication was given according to the facility's medication administration report.
2.
On 5/24/2021 at 12:08 PM, Resident #430's medical record was reviewed in regards to complaint MD00146201. Review of Resident #430's medical record revealed an order for Carbohydrate controlled, low sodium cardiac diet, dysphagia mechanically altered texture starting 9/19/2019 but no diagnosis of dysphagia was found for Resident #430. In an interview with the facility's ex-dietician on 5/27/2021 at 10:20 AM, the dietician stated they would have ordered a dysphagia/mechanically altered diet based on the resident's incoming hospital chart or if the resident had a history of dysphagia. Review of Resident #430's outpatient hospital notes from 9/11/2019 revealed a history of Dysphagia following cerebral infarction and dysphagia, oropharyngeal phase that was not accurately transcribed into the resident's medical record upon admission.
The Administrator and Director of Nursing were made aware of this issue during the exit conference on 5/28/2021.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on the record review on 5/19/21 at 11:54 AM, resident interview on 5/18/21 at 9:16 AM, and complaint # MD00160765, staff failed to put hearing aids in Resident # 98's ears on a routine basis. Th...
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Based on the record review on 5/19/21 at 11:54 AM, resident interview on 5/18/21 at 9:16 AM, and complaint # MD00160765, staff failed to put hearing aids in Resident # 98's ears on a routine basis. This was evident for 1 out of 3 residents with hearing loss.
The findings include:
On 5/18/21 at 9:16 AM an interview was conducted with Resident # 98. The resident had trouble answering the questions the surveyor asked her because she stated the she was hard of hearing. Resident # 98 stated that she wears hearing aids and they were not in. Resident # 98 proceeded to say that her hearing aids are located in her dresser drawer which was located behind her bed, which the resident could not reach. The resident, also, stated that she had a stroke which makes her hands shaky so it was impossible for Resident # 98 to place her own hearing aid in the right ear.
Resident #98 was observed multiple times during this survey to make sure that her hearing aids were placed in her ear. The hearing aids were not placed in her ear on 5/18/21, 5/27/21 and 5/28/21. On 5/28/2021 the surveyor spoke with Registered Nurse (RN # 6) to discuss these issues. RN #6 stated that the resident has her hearing aids placed in her ears after the resident is washed up.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
Based on medical record review and interviews, it was determined the Nurse Practitioner and Resident #4's primary physician failed to supervise Resident #4's care as evidenced by their failure to deve...
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Based on medical record review and interviews, it was determined the Nurse Practitioner and Resident #4's primary physician failed to supervise Resident #4's care as evidenced by their failure to develop a comprehensive plan to manage heparin therapy, including monitoring for increased risk of bleeding and making dosage adjustments. This was evident for one (Resident #4) of 16 residents reviewed during the annual survey.
The findings included:
Heparin injection is a blood-thinning medication used to treat and prevent blood clots. Heparin has a risk of increased bleeding and is monitored by a blood test called a PTT (Partial thromboplastin time). PTT is a blood test that measures the time it takes your blood to clot. A PTT test can be used to check for bleeding problems. The therapeutic PTT range for heparin is 60 to 100 seconds, with lower intensity dosing in the range of 60-80. Elevated levels indicate an increased risk of bleeding.
According to the EMR(electronic medical record), Resident #4 was admitted to the facility in September 2020 [deleted comma] for Long Term Care with diagnoses that included severe head trauma, craniectomy, diabetes, impaired immobility, [added comma] hemiparesis (complete paralysis of half of the body), aphasia (a condition characterized by either partial or total loss of the ability to communicate verbally or using written words due to brain injury), and aphagia (refusal or inability to swallow). [added period] The resident was also admitted with a gastrostomy tube (delivers nutrients and fluids through a tube directly into the stomach).
A review of Resident #4's medical record on 5/20/21 at 11 am revealed a physician order dated 9/16/20 to administer heparin injection subcutaneously three times a day for DVT (Deep Venous Thrombosis).
Further review of the medical record revealed that Resident #4's Primary Physician [added space] (Staff#25) documented he saw the resident on 11/10/2020, [added space] 12/3/2020, 12/18/20, [added space] 2/2/21, [added space], and 4/30/21; and the NP (Nurse Practitioner) (Staff #27) documented he saw the resident on 3/8/21, 4/6/21, and 5/20/21. [added period] However, Resident #4's heparin regimen was not mentioned in any of the progress notes for these visits.
Further review of the medical record revealed that the Primary Physician (Staff #25) and the Nurse Practitioner (Staff #27) continued to sign the monthly orders that included heparin despite no plan to monitor for the risk of bleeding. A review of the Medication Administration Record revealed that the resident received [deleted 'heparin'] 5000units/ml of heparin from 9/17/20 through the present.
A continued review of the medical record revealed no plan was developed by the Primary Physician and/ or the Nurse Practitioner for [deleted 'the'] nursing staff to monitor for signs and symptoms of bleeding. A review of [deleted 'the'] nurses' notes revealed no documentation concerning monitoring for signs and symptoms of bleeding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined that what the Nurse Practitioner documented in the resident's progress notes, did not accurately reflect what was in the resident's...
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Based on medical record review and staff interview it was determined that what the Nurse Practitioner documented in the resident's progress notes, did not accurately reflect what was in the resident's medical records. This was evident for 1 (#4) of 16 residents.
The findings include:
1.Review of Resident #4 medical record on 5/20/21 at 11 AM, revealed two (NP) Nurse Practitioner (staff#27) progress notes dated 4/6/21 and 5/20/21. Both Nurse Practitioner progress notes documented the resident was receiving hemoglobin A1C every three months and Humalog per sliding scale. Further review of the medical record failed to reveal an order to obtain Resident (#4's) hemoglobin A1C every three months, however, the medical record revealed a physician order dated 2/3/21 to discontinue the Humalog per sliding scale per pharmacy recommendation.
Interview with the Nurse Practitioner on 5/20/19 at 1:30 PM he stated, the progress notes are incorrect, clearly no labs are being done.
2. Review of Resident #4 medical record on 5/22/21 at 1 PM revealed a Podiatrist (staff # 45) progress note dated 5/6/21, which revealed the resident requested to be seen by the Podiatrist. The patient is seen for debridement of the painful toenail. The chart was reviewed. She was in a wheelchair. She mentioned that she was planning on seeing a Dermatologist for her skin condition. Further review of Resident #4's medical record revealed, the resident was not seen by a Podiatrist on 5/6/21, the resident is also nonverbal and bedridden.
During the interview with the Charge Nurse (staff #16) stated there is a Podiatry list for each of his visits and the resident was not seen on 5/6/21 by the Podiatrist. During an interview with the Podiatrist on 5/23/21, he stated that he had documented on the wrong residents 'medical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on resident interviews during the resident council meeting, the facility failed to answer the call lights in a timely manner. This had the potential to affect all residents at the facility.
The...
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Based on resident interviews during the resident council meeting, the facility failed to answer the call lights in a timely manner. This had the potential to affect all residents at the facility.
The findings include:
During the resident council meeting on 5/25/21 at 1PM resident #'s 105, 145, 129, 36, and 97 expressed having to wait for long periods of time for staff to answer the call bells, timely. They are met with responses such as, Go ask your nurse, I am not your nurse today or I am too busy now. This issue was addressed by the Administrator who provided an in-service to staff on 4/16/21. However, the residents stated that the staff were not educated properly, as they continued to act the same way. In addition, the resident council meeting attendees stated that the call bells are being answered now because the state is in the building. The residents stated as soon as the state leaves, staff will go back to their old ways.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on review of staff hire documents and training programs, 1out of 1 staff members did not have 12 hours of documented dementia training in their records.
The findings include:
On May 24, 2021 at ...
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Based on review of staff hire documents and training programs, 1out of 1 staff members did not have 12 hours of documented dementia training in their records.
The findings include:
On May 24, 2021 at approximately 12:30 PM, a review of 5 employee records were reviewed. One out of 5 staff members, staff # 20, did not receive the dementia training of 12 hours.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation and interview with residents and facility staff, it was determined that the facility failed to ensure that posted nursing staff information was accurate. This was true for 1 of 4 ...
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Based on observation and interview with residents and facility staff, it was determined that the facility failed to ensure that posted nursing staff information was accurate. This was true for 1 of 4 units in the facility.
The findings include:
On 5/19/21 at 11:50 AM, the surveyor interviewed Resident #97 who stated that the resident's assigned nurse was not administering time-sensitive medication to him/her.
On 5/19/21 at 12:00 PM, the surveyor made an observation of the nursing assignment board which indicated that Licensed Practical Nurse (LPN, Staff #60) was assigned to Resident #97. LPN #60 was interviewed at that time and stated that a change in the assignment had been made. Now, LPN #21 was assigned to Resident #97. LPN #21 was also interviewed at that time and confirmed that she was now assigned to Resident #97 but that the assignment board was not updated. LPN #21 stated that she would administer Resident #97's medication then.
The surveyor interviewed the Assistant Director of Nursing (ADON) on 5/19/21 at 12:29 PM. The ADON stated that the assignment had been changed because Resident #97 had a disagreement with LPN #60 and that the change in assignment was made with the resident's interest in mind. However, Resident #97 had stated that s/he had not been told of the switch and the surveyor's observation of the nursing assignment board revealed that the board did not reflect that a change of assignment had been made. The ADON acknowledged these observations and stated that he would make corrections.
The ADON provided an updated staffing assignment sheet at 12:35 PM that had LPN #60's assignment correct but did not include whom Resident #97 was assigned to. The ADON said that he had spoken with Resident #97.
The Director of Nursing (DON) was interviewed on 5/19/21 at 12:40 PM. The DON provided a second updated copy at that time that included Resident #97 on LPN #21's assignment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and staff interview it was determined that the facility staff failed to ensure that medication carts were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and staff interview it was determined that the facility staff failed to ensure that medication carts were locked. This was evident for 2 out of the 8 medication carts.
The findings are:
This surveyor observed on 5/25/21 at 7:58 AM two unlocked medication carts between rooms [ROOM NUMBERS]. This surveyor was able to open two drawers. Staff #42 walked through the fire doors and upon seeing this surveyor asked what was wrong. She was told that the carts were unlocked. Staff #42 said she would find the nurse and walked to the first room past the intersection. She found the nurse (Staff #21) and told her. Staff #42 then came back and locked the carts.
This surveyor observed a medication cart located outside of room [ROOM NUMBER] unlocked on 5/26/21 at 8:37 AM. Two drawers were pulled open by this surveyor and the nurse (Staff #21) came out of room [ROOM NUMBER] within a few seconds of the drawers being opened. She immediately locked the medication cart.
The Administrator was informed of the findings on 5/26/21.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview and record review it was determined that the facility failed to provide a meal that met a resident's special dietary needs and preferences. This was eviden...
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Based on resident interview, staff interview and record review it was determined that the facility failed to provide a meal that met a resident's special dietary needs and preferences. This was evident for 1 (Resident #97) of 43 residents reviewed during the survey.
The findings include:
On 5/19/2021 at 10:47 AM an interview with Resident #97 revealed concerns with the facility's food service. A test tray was ordered on 5/26/2021 for the lunchtime meal service. Observation of Resident #97's meal tray on 5/26/2021 at 12:40 PM revealed 3 packets of pure cane sugar, a cup of orange juice and a piece of white cake. The test tray brought to surveyors also contained 3 packets of pure cane sugar, a cup of orange juice and a piece of white cake. The tray ticket on Resident #97's tray did not specify what type of diet the resident is ordered, nor did it state which specific food items should be on the tray.
Review of Resident #97's medical record on 5/26/2021 revealed a diagnoses of Type 1 diabetes and an order for CHO (carbohydrate) Controlled Low Sodium Cardiac Diet, Regular texture. Carbohydrate controlled diets aim to limit carbohydrate intake in order to maintain stable blood glucose levels. Orange juice, pure can sugar and cake all have a high glycemic index meaning they cause blood glucose levels to rise rapidly in the bloodstream.
The Administrator and Director of Nursing were made aware of this issue during the exit conference on 5/28/2021.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, it was determined that the facility failed to ensure that the facility stored food in accordance with professional standards for food service safety. This was evident for 1 of 2 ...
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Based on observation, it was determined that the facility failed to ensure that the facility stored food in accordance with professional standards for food service safety. This was evident for 1 of 2 observaitons of the kitchen.
The findings include:
During the initial tour of the kitchen that took place on 5/18/21 at 8:14 AM, it was observed that the facility had stored an unmarked, unlabeled salad in the refrigerator that contained sliced lunch meat. It was also observed that, in the dried foods storage area, dried foods were being stored in boxes directly on the floor without being stored on dunnage crates at least six inches off the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation it was determined the facility staff failed to dispose of garbage and refuse properly.
The findings include:
On 5/20/2021 at 9:12 AM the facility's dumpster area was observed wit...
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Based on observation it was determined the facility staff failed to dispose of garbage and refuse properly.
The findings include:
On 5/20/2021 at 9:12 AM the facility's dumpster area was observed with discarded gloves, plastic litter and debris on the ground. Plastic wrappers and trash was also observed on the side of the building near the kitchen exit.
These findings were reviewed with the Administrator and Director of Nursing during the exit conference on 5/28/2021.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
Based on record review and staff interview it was determined the facility failed to provide specialized rehabilitative services. This was evident for 1 (Resident #435) of 43 residents in the final sam...
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Based on record review and staff interview it was determined the facility failed to provide specialized rehabilitative services. This was evident for 1 (Resident #435) of 43 residents in the final sample.
The findings include:
On 5/21/2021 at 9:10 AM a review of complaint MD00157036 was started which alleged that Resident #435 was not receiving specialized rehabilitative services while at the facility. Review of Resident #435's electronic medical record revealed orders for PT (physical therapy) EVAL AND TREAT AS INDICATED and OT (occupational therapy) EVAL AND TREAT AS INDICATED created on 7/17/2020, the day Resident #435 was admitted . No record of physical or occupational therapy was found in the resident's electronic medical record. During an interview on 5/25/2021 at 12:25 PM the Administrator stated that she spoke with her Physical Therapy team and the facility did not screen the resident upon admission. The facility was unable to provide any evidence that Resident #435 was provided with rehabilitative services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on a review of the Quality Assurance Program and interview, the Quality Assurance Committee failed to identify issues related to quality assessment activities, failed to recognize gaps in system...
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Based on a review of the Quality Assurance Program and interview, the Quality Assurance Committee failed to identify issues related to quality assessment activities, failed to recognize gaps in systems or processes, monitor and ensure implementation of plans of action to correct deficiencies.
The findings are:
Although the facility's Quality Assurance Committee is required to meet monthly, there is no evidence that the current deficiencies had been identified and appropriate plans of action had been implemented.
Refer to:
F550, F558, F565, F 584, F 606, F609, F610, F623, F640, F641, F645, F655, F656, F657, F661, F684, F685, F689, F711, F725, F726, F730, F732, F775, F761, F800, F812, F814, F825, F842 and F867.
Interview with the Director of Nursing and Nursing Home Administrator confirmed the findings on 5/28/21 at 1 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on a review of the Quality Assurance (QA) attendance records and staff interviews it was revealed that the required facility staff is not attending the QA meetings.
The findings include:
A revi...
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Based on a review of the Quality Assurance (QA) attendance records and staff interviews it was revealed that the required facility staff is not attending the QA meetings.
The findings include:
A review of the monthly QA attendance sheets revealed that the GNA (geriatric nursing assistant) only attended 1 of the 12 monthly meetings.
Further review of the monthly attendance sheets failed to reveal that in August 2020, September 2020, December 2020, and January 2021, the required QA meeting was not held.
During an interview with the DON (Director of Nursing) on 5/28/21 at 1:00 PM, she revealed that she is new to the facility and the QA committee. The DON acknowledged that the GNA did not attend the required meetings, and the sign-in sheets for August 2020, September 2020, December 2020, and January 2021 could not be located. She stated, moving forward the meetings would be conducted as required. She also revealed that the QA is a work in progress and more staff will be involved.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that handrails were secure to provide a safe environment. This...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that handrails were secure to provide a safe environment. This was evident for 1 out of 15 handrails observed during the annual survey.
The findings include:
During a tour of the facility conducted on 05/18/21 at 8:32 AM, the surveyor observed a handrail hanging in a downward position away from the wall located in the hallway between resident rooms [ROOM NUMBERS] of the [NAME] Wing.
During an interview on 05/18/2021 at 9:23 AM, the surveyor advised the Administrator of the observation of the loose hanging handrail.
On 05/18/2021 at 9:47 AM, the surveyor observed (Staff #5) the Maintenance Director repair the handrail located between resident rooms [ROOM NUMBERS] of the [NAME] Wing.
On 05/18/2021 at 11:30 AM, the Surveyor confirmed that the handrail was secured to the wall.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
2) The facility failed to thoroughly investigate an incident of alleged physical abuse for Resident #28.
05/27/21 at 12:57 PM, a review of the facility incident report, dated 12/27/20, revealed docum...
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2) The facility failed to thoroughly investigate an incident of alleged physical abuse for Resident #28.
05/27/21 at 12:57 PM, a review of the facility incident report, dated 12/27/20, revealed documentation that Resident #8 went into Resident #28's assigned room and attempted to hit him/her with a tray table. The facility notified the Police department and received a police report.
During an interview on 05/27/21 at 1:19 PM, Resident #28 stated that Resident #8 came into his/her assigned room, hit him/her on the arm and pushed the resident out of his/her wheelchair. The resident further stated he/she was not hurt, however, s/he wanted to press charges.
During an interview conducted on 05/27/21 at 2:07 PM, the DON confirmed that an investigation was not conducted because the incident report did not show that Resident #8 physically harmed Resident #28. The DON stated he/she would interview Resident #28.
During an interview on 05/28/21 at 9:07 AM, the DON stated that, after the interview with Resident #28, he/she confirmed Resident #28's complaint that he /she was hit and pushed out of his/her wheelchair on 12/27/20 by Resident #8. The DON stated a self-report will be made to the Office of Health Care Quality (OHCQ) today (05/28/21) and an investigation will be conducted.
Based on review of facility and resident records and interview with staff it was determined the facility failed to thoroughly investigate and report the investigation findings to the Office of Health Care Quality (OHCQ). This was evident for 2 (#433, #28) of 43 residents reviewed for Abuse.
The findings include:
1) On 5/24/2021 at 9:00 AM complaint MD00158325 was reviewed. This complaint alleged that Resident #433 was assaulted by another resident. Review of Resident #433's medical record revealed that on 8/4/2020 Resident #433 was punched on the side of the head by another resident in the hallway but sustained no injuries. At 9:40 AM the Administrator provided the facility's investigation into the incident on 8/4/2020. The facility's investigation included the Comprehensive & Extended Care Facilities Self-Report Form, Resident #433's face sheet, Resident #433's Brief Interview for Mental Status (BIMS) Assessment and a statement from the Social Services Director at that time which said the Social Service Department also conducted a safe survey which consisted of asking qualitative questions from neighboring residents and staff members in regards to what occurred and inquired how the facility can assist with preventative measures. No documentation of the other resident's responses was included in the investigation.
On 5/25/2021 at 10:05 AM the investigation was discussed with the Administrator who stated that the resident was not injured. The Administrator was informed at this time that a thorough investigation should have been completed to ensure the safety of the other residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the ...
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Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (#53,430, 431, 432 ) of 5 residents reviewed for hospitalization.
The findings include:
1) Review of the medical record for Resident #53 on 5/20/21 revealed that on 2/12/21 and 3/9/21 Resident #53 was transferred to an acute care facility due to a change in mental status. There was no evidence found in the medical record that written notification was made to the responsible party regarding the reason for the transfer and the location of the transfer.
During the interview with (staff # 3) on 5/20/21, he stated the resident and or resident representative is made aware verbally and documented in the medical record.
2. A review of Resident #430's clinical record on 5/26/21 revealed that the resident on 1/10/21 was sent to the hospital. There was no mention of the resident or the Responsible Party (RP) receiving, in writing, the reason(s) for being sent to the hospital.
3. A review of Resident #431's clinical record on 5/26/21 revealed that the resident on 1/18/21 was sent to the hospital. There was no mention of the resident or the Responsible Party (RP) receiving, in writing, the reason(s) for being sent to the hospital.
4. A review of Resident #432's clinical record on 5/26/21 revealed that the resident on 7/13/20 was sent to the hospital. There was no mention of the resident or the Responsible Party (RP) receiving, in writing, the reason(s) for being sent to the hospital.
This surveyor interviewed the Assistant Director of Nursing, ADON, (Staff #3) on 5/26/21 at 11:15 AM. He said they do not keep copies of written notices of discharges and transfers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) The facility staff failed to ensure the (MDS) assessments were accurately coded for (#39).
Review of Resident #39's medical ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) The facility staff failed to ensure the (MDS) assessments were accurately coded for (#39).
Review of Resident #39's medical record on 5/20/2021 at 11:40 AM revealed a quarterly assessment MDS from 9/20/2021 which documented in Section I, Active Diagnoses, that the resident had no Multi-drug Resistant Organism (MDRO) infections. Further review of Resident #39's medical record revealed an order for Contact precautions every shift for MDRO of unknown organism with KPC gene starting 8/22/2019 and ending 10/22/2019 when the resident was discharged .
4) The facility staff failed to ensure the (MDS) assessments were accurately coded for Resident #116.
Review of Resident #116's medical record on 5/26/2021 at 9:35 AM revealed orders for Humalog Solution 100 UNIT/ML, inject 8 units subcutaneously three times a day for DM (diabetes mellitus) as well as Humalog solution cartridge 100 UNIT/ML, inject as per sliding scale .subcutaneously before meals for Diabetes. Further review of Resident #116's Quarterly MDS assessment dated [DATE] revealed the facility had coded No for Diabetes under Section I - Active Diagnoses.
The Administrator and Director of Nursing were made aware of these findings on 5/28/2021 during the exit conference.
2) The facility failed to ensure that MDS Assessments accurately reflected Resident # 94 statuses.
The surveyor reviewed Resident #94's medical record on 5/20/21 at 11:30 AM. The review revealed that Resident #94 had a Quarterly MDS assessment coded with an Assessment Reference Date (ARD) of 4/21/21. The quarterly assessment coded 'yes' for question I2000 - pneumonia. However, the surveyor did not note that Resident #94 had an active diagnosis of pneumonia or had been treated for pneumonia in the seven day lookback from the ARD.
The surveyor interviewed the MDS Coordinators (Staff #43 and #44) on 5/20/21 at 1:31 PM. During the interview, the MDS Coordinators stated they would investigate the coding of 'yes' for question I2000 on Resident #94's 4/21/21 quarterly MDS Assessment. The MDS Coordinators stated on 5/20/21 at 1:53 PM that the coding was in error and that a correction had been completed. The corrected MDS assessment was provided to the survey team on 5/21/21.
Based on medical record review and staff interview it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment (#4, #94, #39, #116 ). This was true for four of 56 residents reviewed during the annual survey.
The findings include:
1) The facility staff failed to accurately document a residents' medication status on a quarterly MDS for Resident (#4).
The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.
A review of Resident # 4's medical record on 5/19/21 at 10 AM revealed that a quarterly MDS was completed on 2/16/21. The MDS coded the resident under Section N0410 (medications received) as not receiving an anticoagulant in the last 7 days. However, a review of the physician orders on 5/19/21 at 10:15 AM revealed a physician order dated 9/16/20 to administer Heparin Sodium Solution 5000 units/ml (milliliter) subcutaneously (under the skin) three times a day for DVT (Deep vein thrombosis). A review of the medication administration record for February 2021 revealed the resident received the medication for the entire month of February.
The MDS Coordinator (staff # 43) was interviewed on 5/20/21 at 10:34 AM and she confirmed that the MDS was coded incorrectly. After surveyor intervention, the MDS was corrected.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview, it was determined the facility failed to have a system in place to complete an interim care plan and to provide a written summary of the interim pla...
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Based on medical record review and staff interview, it was determined the facility failed to have a system in place to complete an interim care plan and to provide a written summary of the interim plan of care to the resident or responsible party. This was found to be evident for 1 out of 16 residents (Resident #4) reviewed for care planning during the annual survey.
The findings include:
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
A review of Resident #4's medical record on 5/19/21 at 10:15 AM revealed Resident #4 was admitted to the facility in September 2018 for rehabilitation and with a diagnosis that included impaired mobility. Further review of the medical record and care plans failed to reveal a care plan for Heparin and/or documentation that a copy of the baseline care plan was provided to Resident #4 or Resident #4's responsible party within 48 hours after admission.
An interview with the facility (staff #3) on 5/20/21 at 11:00 AM confirmed the findings. All findings were discussed throughout the survey and during the exit on 5/28/21.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
2) The facility failed to have a comprehensive care plan in place for Resident # 98 who wears hearing aids.
A review of Resident # 98 medical records on 5/19/21 at 11:54 AM indicated that the residen...
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2) The facility failed to have a comprehensive care plan in place for Resident # 98 who wears hearing aids.
A review of Resident # 98 medical records on 5/19/21 at 11:54 AM indicated that the resident has a history of hearing loss. Resident # 98 wears hearing aids. There was no care plan in the record available for hearing aids.
Based on a medical record review and staff interview, it was determined that facility staff failed to initiate a care plan for a resident receiving anticoagulant therapy. This was evident for two residents out of 56 selected for review during the annual survey, residents (#4, 98).
The findings include:
A Care Plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
1) The facility failed to initiate a care plan for a resident (#4) receiving Heparin for Deep venous Thrombosis.
A review of the medical records on 5/18/21 at 11:00 AM, revealed that Resident # 4 was admitted to the facility in September 2020 for long-term care and with a diagnosis that included impaired immobility.
A review of Resident # 4's medical record on 5/20/21 at 10 AM revealed a physician order dated 9/16/20 to administer Heparin Sodium Solution 5000 units/ml (milliliter) subcutaneously (under the skin) three times a day for DVT (Deep vein thrombosis) starting 9/17/20. Heparin injection is an anticoagulant. It is used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels. Further review of the medical record revealed the resident had been receiving Heparin since September 17, 2020, and a care plan was never initiated for Heparin.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
2) The failed to protect Resident # #113, who was dependent on staff for turning and positioning, from falling out of bed during care.
Minimum Data Set (MDS) is a standardized, primary screening and ...
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2) The failed to protect Resident # #113, who was dependent on staff for turning and positioning, from falling out of bed during care.
Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities.
During an interview on 05/19/21 09:35 AM, Resident #113 stated that, in January 2021, an agency nurse (could not recall name) rolled the resident over to his/her side while undressing him/her. The nurse left the bedside leaving the resident on his/her side and the resident fell off the bed. Resident stated he/she did not sustain an injury.
On 05/19/2021 at 10:22 AM, review of the resident's quarterly MDS record, dated 02/07/2021, assessed that the resident required one physical assist for bed mobility.
05/27/21 08:21 AM review of the fall incident report, dated 1/15/2021, revealed documentation that Resident #113 slid off of the bed after being turned on his/her side while receiving personal care. Resident assessed head to toe, no injuries found.
During an interview conducted on 05/28/21 at 9:24 AM, the Director of Nursing (DON) identified the GNA as Staff # 42 and stated the Geriatric Nursing assistant (GNA) no longer worked at the facility. The DON further stated an ADL (activities of daily living) in-service was not conducted since the resident's fall and he/she would conduct an in-service for ADLs today (05/28/21) for all nursing staff.
Based on observation and interview with residents and facility staff, it was determined that the facility failed to 1) provide sufficient supervision of residents' smoking as evidenced by failing to follow their smoking policy and failing to complete smoking assessments accurately and 2) failed to protect a resident, who was dependent on staff for turning and positioning, from falling out of bed during care. This was evident of 2 (Resident #116, #113)) of 3 residents reviewed for smoking.
The findings include:
1) The facility failed to 1) provide sufficient supervision of residents' smoking as evidenced by failing to follow their smoking policy and failing to complete smoking assessments accurately
During the initial tour of the facility that took place on 5/18/21, the surveyor made an observation of Resident #116's room at 11:07 AM. During the observation, the surveyor noted that Resident #116 had a cigarette lighter on his/her windowsill. When the surveyor asked if s/he keeps his/her own smoking supplies, Resident #116 said, yes. The resident also stated that s/he smokes multiple times per day.
The surveyor reviewed the list of smokers provided by the facility to the survey team on 5/18/21. The list included Resident #116, identifying him/her as an independent smoker.
The surveyor reviewed Resident #116's medical record on 5/25/21 at 2:08 PM. The review revealed three smoking assessments that had been completed for Resident #116 on 10/31/20, 2/2/21, and 5/2/21. All three assessments answered the question, Does Resident utilize tobacco with 'no.' Because the assessments were completed in a manner that indicated Resident #116 did not utilize tobacco, all of the follow up questions designed to assess smoking safety did not appear. None of the assessments could be used to determine if Resident #116 was a safe smoker.
The facility provided the survey team with a copy of their smoking policy on 5/26/21 at 11:00 AM. The policy stated, an interdisciplinary safe smoking evaluation will be performed on all residents who currently smoke at the facility to determine their level of independence/safety. This evaluation determines the level of support that may be necessary for ensuring each resident's safety while smoking. In a separate section, the smoking policy stated, All residents' smoking paraphernalia must be turned in to a management staff and will not be allowed to be in the possession of the resident.
The surveyor observed a scheduled smoking time on 5/26/21 at 9:05 AM and interviewed Activity Staff ( #8). During the interview, the Activity Staff stated that Resident #116 was a regular smoker and well known to her. Staff (#8) showed the surveyor the smoking list which matched the smoking list that had been provided to the survey team at the start of the survey and included Resident #116.
After being asked to provide the 'Safe smoking evaluation' for Resident #116 that was referenced in the facility's smoking policy, the facility provided the surveyor with a 'smoking safety evaluation' for Resident #116 that was dated 5/26/21. The smoking assessment indicated that Resident #116 did utilize tobacco and all of the follow up questions had been completed. The assessment indicated that the resident as not an at-risk smoker.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on reviews of staff competencies conducted on 5/24/21 at 1:14 PM, the facility failed to provide competency training services for 4 out of 5 staff members.
The findings include:
On 5/24/21 at 1:...
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Based on reviews of staff competencies conducted on 5/24/21 at 1:14 PM, the facility failed to provide competency training services for 4 out of 5 staff members.
The findings include:
On 5/24/21 at 1:14 PM a review of 5 staff personnel records were reviewed. This included staff records for staff # 16, 17, 18, 19, and 20. New Hire education was provided to all new staff hired after 3/2020, however there were no competencies or skills checklist in the files. The Administrator was notified of this on May 24, 2001, at approximately 1pm. Staff # 17 was the only staff person who had a skills competency in her record. The Administrator stated that the previous facility sold the building on 3/2020 and took with them all training provided to staff and all background checks. The Administrator stated that she no longer has access to their files.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on medical record review and interviews, it was determined the Nurse Practitioner and Resident #4's primary physician failed to develop a comprehensive plan to manage Heparin therapy, including ...
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Based on medical record review and interviews, it was determined the Nurse Practitioner and Resident #4's primary physician failed to develop a comprehensive plan to manage Heparin therapy, including monitoring for increased risk of bleeding and making dosage adjustments in one (Resident #4) of 16 residents reviewed during the annual survey.
The findings included:
Heparin injection is a blood-thinning medication used to treat and prevent blood clots. Heparin has a risk of increased bleeding and is monitored by a blood test called a PTT (Partial thromboplastin time). PTT is a blood test that measures the time it takes your blood to clot. A PTT test can be used to check for bleeding problems. The therapeutic PTT range for heparin is 60 to 100 seconds, with lower intensity dosing in the range of 60-80. Elevated levels indicate an increased risk of bleeding.
According to the EMR(electronic medical record), Resident #4 was admitted to the facility in September 2020, for Long Term Care with the diagnosis that included severe head trauma, craniectomy, diabetes, impaired immobility hemiparesis (complete paralysis of half of the body), aphasia (a condition characterized by either partial or total loss of the ability to communicate verbally or using written words due to brain injury), aphagia (refusal or inability to swallow) resident admitted with a gastrostomy tube (receives nutrients and fluids through a tube directly into the stomach).
A review of resident (#4's) medical record on 5/20/21 at 11 AM revealed a physician order dated 9/16/20 to administer Heparin injection subcutaneous three times a day for DVT (Deep Venous Thrombosis).
A review of the medical record revealed the Physician (staff#25) documented he saw the resident on 11/10/2020,12/3/2020, 12/18/20,2/2/21,4/30/21 and the NP (Nurse Practitioner) (staff #27) documented he saw the resident on 3/8/21, 4/6/21, 5/20/21, however, the Heparin was not mentioned in the progress notes.
Further review of the medical record revealed that the physician (staff #25) and the Nurse Practitioner (staff #27) continued to sign the monthly orders that included heparin despite no plan to monitor for the risk of bleeding. A review of the Medication Administration Record revealed that the resident received heparin 5000units/ml of heparin from 9/17/20 through the present.
A continued review of the medical record revealed no plan was developed by the Physician and/or the Nurse Practitioner for the nursing staff on monitoring for signs and symptoms of bleeding. A review of the nurses' notes revealed no documentation concerning monitoring for signs and symptoms of bleeding.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
3) The facility to respond to the medication regimen review in a timely manner for Resident #8.
According to Centers of Medicare and Medicaid Services (CMS) a Medication Regimen Review (MRR) is a revi...
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3) The facility to respond to the medication regimen review in a timely manner for Resident #8.
According to Centers of Medicare and Medicaid Services (CMS) a Medication Regimen Review (MRR) is a review of all medications the patient/resident is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.
On 05/28/21 at 09:29 AM review of Resident # 8 Medication Regimen Review (MRR) dated 10/27/2020 stated This resident is receiving the antipsychotic agent, Risperdal, but lacks an allowable diagnosis to support its use. The physician note on the MRR signed on 11/04/2020 stated current DX (diagnosis): Dementia with behavior add a diagnosis of atypical psychosis.
On 05/28/2021 at 09:32 AM review of the Medication Administration Record (MAR) for 11/2020 and 12/2020 showed physician order: Risperdal Tablet 1 MG (risperidone)
Give 1 tablet by mouth two times a day for Dementia with behavior. The diagnosis atypical psychosis was not added.
On 05/28/21 at 09:35 AM review of Resident # 8 Medication Regimen Review (MRR) dated 12/27/2020 stated This resident is receiving the antipsychotic agent, Risperdal, but lacks an allowable diagnosis to support its use. The physician note on the MRR signed on 02/02/2021 stated please have MDS add F29 psychosis.
On 05/28/2021 at 09:42 AM review of the Medication Administration Record (MAR) for 02/2021 showed physician order: Risperdal Tablet 1 MG (risperidone). Give 1 tablet by mouth two times a day for Psychosis F29: Start Date 02/03/2021.
During the interview conducted on 05/28/2021 at 11:32 AM, the Director of Nursing (DON) confirmed the diagnosis psychosis was added to the medication record on 02/03/2021 for Risperdal.
2) The facility failed to ensure that documentation of residents' showers was accurate.
The surveyor interviewed Resident #97 on 5/19/21 at 9:05 AM. During the interview, Resident #97 stated that s/he was supposed to get a shower yesterday (Tuesday, 5/18/21) but that s/he didn't receive it. S/he stated that s/he often does not receive showers on his/her shower days.
The surveyor reviewed Resident #97's medical record on 5/25/21 at 10:00 AM. During the review, an order was found dated 9/16/20 that stated, Shower days: Wednesday and Saturday, evening shift. The order was discontinued on 5/12/21. Another order was found dated 5/13/21 that stated, Shower days: Monday and Thursday, evening shift. Concurrent review of the treatment administration record (TAR) for the month of May, 2021, revealed that the first order was documented as 'done' on Saturday, 5/1/21; Wednesday, 5/5/21; and Saturday, 5/8/21. The second order was documented as 'done' on Thursday, 5/13/21; Monday, 5/17/21; Thursday, 5/20/21; and Monday, 5/24/21.
On 5/25/21 at 10:30 AM, the surveyor reviewed the point-of-care (POC) documentation completed by geriatric nursing assistants (GNAs) about bathing assistance provided to Resident #97 for the period of 4/27/21 to 5/26/21. The document allows GNAs to answer the question, How did you bath the resident? with the options, 'shower,' 'tub bath,' 'bed/towel bath,' 'resident not available,' 'resident refused,' or 'not applicable.' An answer was usually documented once per shift. During that time, the GNA documentation noted that a shower had been provided only three times: on 5/7/21 (Friday) at 9:17 PM, on 5/16/21 (Sunday) at 10:34 PM, and on 5/22/21 (Saturday) at 7:00 PM. A tub bath was documented on 5/25/21 (Tuesday) at 10:16 PM. The resident was documented as having refused on 5/8/21 (Saturday) at 6:16 PM. None of the dates when a shower or tub bath was documented as having been provided correlated with when the resident was due to receive a shower based on the physician's order and TAR documentation. The GNA's POC documentation of refusal on 5/8/21 correlated with one of the resident's scheduled shower days, but the other six shower days cannot be reconciled with the GNA documentation. The surveyor also reviewed the resident's progress notes from that period and did not find any documentation regarding changes to the resident's shower schedule or refusals of showers.
The surveyor interviewed GNA #61 on 5/26/21 at 11:28 AM. During the interview, GNA #61 stated that GNAs document in the POC screen whenever a shower is done. She stated her practice is to document a shower as soon as a shower is finished. She also stated that there is an indicator in the POC interface that shows when it is a resident's day to receive a shower.
The surveyor conducted a follow up interview with Resident #97 on 5/26/21 at 1:06 PM. During the interview, Resident #97 stated that s/he had only received about 4 showers in the previous 30 days. S/he also stated that the showers did not necessarily happen on his/her assigned shower days.
The surveyor interviewed the Assistant Director of Nursing (ADON) on 5/27/21 at 10:30 AM. The ADON provided a paper copy of the GNA's POC bathing documentation for 5/14/21 through 5/27/21. During the interview, the ADON stated that Resident #97 may receive a shower whenever s/he wants, citing the example that Resident #97 had received a shower the previous evening shift (5/26/21) despite it not being one of his/her assigned shower days. However, review of the paper copy of the GNA's POC bathing documentation that the ADON supplied revealed that no shower was documented as having been given on 5/26/21.
Based on medical record review and staff interview it was determined the facility staff failed to; 1) accurately reflect what was in Resident's #4 medical record; 2.) ensure that documentation of Residents' #97'showers was accurate. 3.) respond to Resident #8's medication regimen review in a timely manner.
The findings include:
The facility documentation in the resident's progress notes, did not accurately reflect what was in Resident #4's medical records.
1a. Review of Resident #4 medical record on 5/20/21 at 11 AM, revealed two (NP) Nurse Practitioner (staff#27) progress notes dated 4/6/21 and 5/20/21. Both Nurse Practitioner progress notes documented the resident was receiving hemoglobin A1C every three months and Humalog per sliding scale. Further review of the medical record failed to reveal an order to obtain resident (#4's) hemoglobin A1C every three months, however, the medical record revealed a physician order dated 2/3/21 to discontinue the Humalog per sliding scale per pharmacy recommendation.
Interview with the Nurse Practitioner on 5/20/19 at 1:30 PM he stated, the progress notes are incorrect, clearly no labs are being done.
1b. Review of Resident #4's medical record on 5/22/21 at 1 PM revealed a Podiatrist (staff # 45) progress note dated 5/6/21, which revealed the resident requested to be seen by the Podiatrist. The patient is seen for debridement of the painful toenail. The chart was reviewed. She was in a wheelchair. She mentioned that she was planning on seeing a Dermatologist for her skin condition.
Further review of Resident #4's medical record revealed, the resident was not seen by a Podiatrist on 5/6/21, the resident is also nonverbal and bedridden. During the interview with the Charge Nurse (staff #16) stated there is a podiatry list for each of the podiatrist visits and that the resident was not seen on 5/6/21 by the Podiatrist.
During an interview with the Podiatrist on 5/23/21, he stated that he documented on the wrong residents 'medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to ensure that residents outside of their rooms wore masks and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to ensure that residents outside of their rooms wore masks and that hand sanitizer dispensers were available and kept from going empty. Failure to apply resident masks was evident for 1 of 9 days the survey took place. Failure to keep hand sanitizer readily accessible at the check-in station was evident for 2 of 9 days the survey took place. Failure to keep hand sanitizer dispensers filled was evident for 3 of 13 sampled hallway dispensers and 5 of 20 sampled room dispensers.
The findings include:
During an initial tour of the facility that took place on 5/18/21 and beginning at 8:00 AM, the survey team observed two residents who were not wearing masks while in the hallways outside their rooms. Staff who were present in the hallways at that time did not make an attempt to assist either resident in applying a mask.
Also, during the initial tour of the facility, the survey team sampled hand sanitizer dispensers to determine if any were empty. The observation revealed that 3 of 13 sampled hand sanitizer dispensers in the hallways were empty (outside rooms [ROOM NUMBER]) and 5 of 20 sampled hand sanitizer dispensers in resident rooms were empty (in rooms 46, 45, 47, 22, and 20).
The survey team noted that hand sanitizer was not readily available at the check-in station on 2 of the 9 days that the survey took place (5/20/21 and 5/26/21). On those days, a visitor or staff member had to walk past the check-in station and the receptionist's desk to reach the nearest hand sanitizer dispenser. On the other days, a household pump-style dispenser was placed on the sill of the receptionist's window beside the check-in station.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation and interview with laundry staff and the Director of housekeeping and laundry, the facility failed to replace, fix, or have another system in place for 1 out of 2 washing machines...
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Based on observation and interview with laundry staff and the Director of housekeeping and laundry, the facility failed to replace, fix, or have another system in place for 1 out of 2 washing machines that were not in working order. This has affected all residents who have their laundry done by the facility.
The findings include:
During interviews with the residents held between 5/18/21 and 5/20/21 and at the Residents Council Meeting held on 5/25/21 at 1 PM, residents had complained about not having their laundry done and wanted to know the laundry schedule. On 5/24/21 at 11:45 AM the surveyor spoke with staff (#'s 34 and 35) who informed the surveyor that there was a laundry schedule but right now it is not in effect due to a broken washing machine. Staff # 35 said the washing machine has been broken since April 2021 and that the Director (staff 37) is aware. Staff # 37 said, this issue is creating a problem because they are trying to keep up with the linen for everyday use and when linen is not in the machine they try to do some resident's clothing. Staff # 34 stated that there was no outside company coming in and providing additional help or laundry service.
On 5/24/21 at 1:30 PM an interview was held with the Director of Housekeeping and Laundry, staff # 37, in the conference room. Staff # 37 stated he was hired in April 2021 and the washing machine was broken when he arrived. Staff # 37 stated he placed a work order and a industrial laundry equipment vendor came in and checked out the washing machine on 4/ 28/21. The vendor stated it would cost more to fix machine then it would to replace machine. Staff 37 said he reported this to his supervisor and is still waiting for a response on how they will move forward. The result of having only one machine working, is not all linen and personal clothing are being washed for quick turn around service.
Oct 2018
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on medication cart observations and staff interviews it was determined that facility staff failed to ensure that the medical record was kept in a confidential manner. This was evident in 1 out o...
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Based on medication cart observations and staff interviews it was determined that facility staff failed to ensure that the medical record was kept in a confidential manner. This was evident in 1 out of 8 medication carts with Informed Consent /Declination Forms involving Resident's #48 and Resident #363.
The finding includes:
On 8/8/18 at 10:28 A.M. on the third floor long term care unit, the surveyor observed on top of a standing unattended medication cart for Team#1, on the 1st floor west wing, the nursing shift to shift report dated 07/11/2018. The document was not kept in a confidential manner for residents in rooms; 29A, 29B, 30A, 10B, 31A, 32A, 32B, 33A, 33B, 34A, 35A, 35B, 36A, 36B, 37A, 37B, 38A,38B, 39A, 40A, 41B, 42A, 42B, 43A, 44A, 45A, 45B, 46A, 48A, 48B,49A, 50A,52B, 53, 54A and 54B.
The nursing shift to shift document is used by the facilities nursing staff for assigned nursing task preformed during the nurses shift on assigned residents. The surveyor was able to view the listed resident's names, room numbers, vital signs, medications, lab results, new medical orders (with nursing medication and treatment comments) visible for the public to view for all residents who were assigned to the nurse located on the 1st floor west nursing wing.
On the same date and time on the same nursing medication cart, the surveyor observed the Informed Consent/Declination Forms, which is a legal document and apart of each resident's medical record. It is used by the facility, as an acknowledgement copy of the Vaccine Information Statement, for various vaccines offered to the resident. Each resident has the right to receive or refuse any or all facility offered vaccines.
The surveyor was able to read Resident #48's and #363's medical choices to agree to receive the vaccination freely. Residents #48 and #363 signatures, with attending physician signatures and assigned room numbers were visible for any public viewing. The information was placed, on top of an unattended nurses' team 1 medication cart on the 1st floor west nursing wing.
On 10/16/18 at 11:00 A.M. during a staff interview with staff member #1 the surveyor was informed that he/she just stepped away while giving care to another resident and we know to keep all resident's medical records in a confidential manner.
On 10/16/18 at 11:20 A.M. during an interview with staff member #2, the 1st floor west nursing wing unit manager did observe and verified the documentation, of the nursing shift report, with signed Informed Consent/Declination Forms involving Resident's #48 and resident #363, was on top of an unattended team 1 medication cart for public viewing. He/She informed to the surveyor, this is not our practices the facilities have policy for keeping all resident's medical records are to be kept in a confidential manner according to the Health Insurance Portability and Accountability Act (HIPAA) guidelines and the facilities policies and practices.
On 10/16/18 at 2:25 P.M. during an interview with the Director of Nursing (DON), the surveyor was informed that all resident's medical records are to be kept in a confidential manner per facility policies and nursing practices.
The Administrator and Director of Nursing was informed of privacy concerns prior to the facility survey exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation and staff interview it was determined the facility failed to ensure a staff restroom was kept locked or was included in the resident call system. This was evident for 1 of 3 staff...
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Based on observation and staff interview it was determined the facility failed to ensure a staff restroom was kept locked or was included in the resident call system. This was evident for 1 of 3 staff restrooms observed during the survey.
The findings include:
On 10/22/18 at 12:10 PM the restroom door across from the therapy room was found open. Observation of the inside of the restroom revealed there was not a device connected to the resident call system for a resident to call staff if needed. Although the door is equipped with a lock that requires a code to unlock the door, when employees leave the door open there is a potential for a resident to go in, shut the door, and be unable to contact staff in case of a fall. The door was also found open by surveyors on at 1:45 PM and 2:25 PM. On 10 /23/18 at 10:06 AM the door was found open again. The Administrator was then made aware.
On 10/24/18 at 9:30 AM, the staff restroom door for the restroom closest to the front door of the facility was found open. Observation of the inside of the restroom revealed there was no device connecting to the resident call system. The restroom is equipped with a lock that requires a key for entry when the door is closed.
The facility is responsible to ensure restrooms that are not kept locked are equipped with a device connecting to the resident communication system so that residents who access the restroom can call for staff assistance if needed.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 22% annual turnover. Excellent stability, 26 points below Maryland's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 3 life-threatening violation(s), $129,636 in fines. Review inspection reports carefully.
- • 79 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $129,636 in fines. Extremely high, among the most fined facilities in Maryland. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is White Oak Rehabilitation And Nursing Center's CMS Rating?
CMS assigns WHITE OAK REHABILITATION AND NURSING CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is White Oak Rehabilitation And Nursing Center Staffed?
CMS rates WHITE OAK REHABILITATION AND NURSING CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 22%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at White Oak Rehabilitation And Nursing Center?
State health inspectors documented 79 deficiencies at WHITE OAK REHABILITATION AND NURSING CENTER during 2018 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 75 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates White Oak Rehabilitation And Nursing Center?
WHITE OAK REHABILITATION AND NURSING CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LIFEWORKS REHAB, a chain that manages multiple nursing homes. With 160 certified beds and approximately 156 residents (about 98% occupancy), it is a mid-sized facility located in HYATTSVILLE, Maryland.
How Does White Oak Rehabilitation And Nursing Center Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, WHITE OAK REHABILITATION AND NURSING CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (22%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting White Oak Rehabilitation And Nursing Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can 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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is White Oak Rehabilitation And Nursing Center Safe?
Based on CMS inspection data, WHITE OAK REHABILITATION AND NURSING CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Maryland. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at White Oak Rehabilitation And Nursing Center Stick Around?
Staff at WHITE OAK REHABILITATION AND NURSING CENTER tend to stick around. With a turnover rate of 22%, the facility is 23 percentage points below the Maryland average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was White Oak Rehabilitation And Nursing Center Ever Fined?
WHITE OAK REHABILITATION AND NURSING CENTER has been fined $129,636 across 2 penalty actions. This is 3.8x the Maryland average of $34,375. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is White Oak Rehabilitation And Nursing Center on Any Federal Watch List?
WHITE OAK REHABILITATION AND NURSING CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.