OAKWOOD SNF LLC
For profit - Limited Liability company
130 Beds
HILL VALLEY HEALTHCARE
Data: November 2025
Trust Grade
58/100
#77 of 219 in MD
Photo by Oakwood Care Center
Photo by Baby Snaps
Photo by Baby Snaps
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Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Oakwood SNF LLC in Middle River, Maryland has a Trust Grade of C, which means it is average and situated in the middle of the pack for nursing homes. It ranks #77 out of 219 in the state, putting it in the top half, and #15 out of 43 in Baltimore County, indicating that only a few local options are better. The facility is improving, with issues decreasing from 25 in 2019 to 13 in 2024. Staffing is rated 3 out of 5 stars, with a turnover rate of 40%, which is on par with the state average, suggesting some stability but room for improvement. However, there are concerning aspects as well, such as less RN coverage than 85% of state facilities and $13,270 in fines, which is average compared to other facilities. Specific incidents raise red flags: in one case, a staff member physically struck a resident during care, which is a serious concern of abuse. In another incident, a resident sustained a broken toe due to improper handling of an oxygen tank, illustrating potential neglect. While the facility has strengths like a good quality measures rating of 5 out of 5 stars, these serious findings highlight important weaknesses that families should consider when researching care options.
- Trust Score
- C
- In Maryland
- #77/219
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 40% turnover. Near Maryland's 48% average. Typical for the industry.
- Penalties ✓ Good
- $13,270 in fines. Lower than most Maryland facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 34 minutes of Registered Nurse (RN) attention daily — about average for Maryland. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 60 deficiencies on record. Higher than average. Multiple issues found across inspections.
58/100
Top 35%
Needs review
25 → 13 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2019: 25 issues
2024: 13 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Maryland average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 40%
Near Maryland avg (46%)
Typical for the industry
Federal Fines: $13,270
Below median ($33,413)
Minor penalties assessed
Chain: HILL VALLEY HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 60 deficiencies on record
2 actual harm
Oct 2024
13 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and a review of the facility investigation of intake #MD00...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and a review of the facility investigation of intake #MD00207612, it was determined that the facility staff failed to ensure residents were free from abuse. This was evident for 1 (#97) out of 6 residents reviewed for abuse. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Actual Harm Past Non-compliance (PNC).
The findings include:
This surveyor started an investigation into intake #MD00207612 on 10/2/24. It was revealed that on 7/12/24 at 8:30 AM, Geriatric Nursing Assistant (GNA) #8 was providing AM care to Resident #97 but the resident was resisting her. She asked GNA #9 for assistance. GNA #9 entered the room and held the resident's arms while GNA #8 began changing the resident. The resident got an arm free and hit GNA #9. GNA #9 responded by punching the resident 2-4 times in the face. GNA #8 ran out and got the Unit Manager. The roommate, Resident #31, witnessed the incident.
Further review revealed that Resident #97 had a facial injury just below the left eye as a result. Staff evaluated the resident after the incident. Resident #97 was evaluated as stable and safe. Resident #97 was also evaluated for psychosocial distress. The resident's responsible party was told on 7/12/24 at 8:30 AM. On 7/17/24, a facility-wide abuse interview/audit was conducted. GNA #9 was terminated and reported to the Maryland Board of Nursing (MBON). The statements of the two GNA's were reviewed on 10/7/24.
GNA #8's statement to the police: I was attending to [Resident #97's room number]. As I was putting on [his/her] clothes. [He/She] started to kick and scream. I then stop[ped] doing [him/her] and went to ask [name of GNA #9] to help me get [him/her] changed and dress. The patient still began to kick and fight. [Name of GNA #9] was holding [him/her] down. [Name of GNA #9) then strike [him/her] in the face. The patient started to yell. I looked at the patient's face and [his/her] eye started to bleed. I went to report to [name of unit manager] immediately.
GNA #9's statement was: At about 8 AM this morning another GNA asked me to assist her to dress the resident. I immediately moved to assist [him/her] as [he/she] started kicking and punching myself and [GNA #8] and I told [him/her] to stop while [he/she] continue to kick us and punch us then I hold [his/her] hand to prevent [him/her] from hurting us and asked [GNA #8] to put on [his/her] pants and shirt while we get [him/her] up as the resident keep on yelling in the process [his/her] nails cut [his/her] face.
This surveyor interviewed GNA #8 on 10/7/24 at 11:40 AM. She said that she had the resident that day. She stated she was in the resident ' s room and declared that [he/she] is a fighter. She said she asked [name of GNA #9] to help her. She said he held the resident down by both hands while she put the resident ' s pants on. She stated that GNA #9 hit the resident in the eye twice. The resident ' s roommate yelled you didn ' t have to hit [him/her]. She saw that the resident had a cut just below the eye, left the room, and told the Unit Manager immediately.
This surveyor interviewed the former roommate on 10/07/2024 at 1:28 PM. Resident #31 said the male aide held the resident down while the female changed the resident's pants, he held the resident's hands down across the chest, at some point the resident got free and started hitting the male aide. The male aide punched the resident four times [Roommate demonstrated the punching by punching the air four times]. The female aide let go and she said, I don ' t want any part of this. She left the room and talked to the Unit Manager.
This surveyor interviewed the Regional Director of Clinical Operations on 10/8/24 at 1:15 PM. Informed him the survey team reviewed the intake, reviewed the facility's investigation, conducted interviews, and determined that the resident was harmed.
The Administrator was interviewed on 10/9/24 at 1:29 PM. He said as soon as he arrived at 8 AM the nurse came to him and said you need to handle this. He said they suspended the GNA after they got a statement. He added that he instituted a mass facility-wide questionnaire for all the residents.
This surveyor interviewed the Regional Director of Clinical Operations and the Administrator on 10/11/24 at 8:00 AM. Explained that the abuse had been substantiated and that the resident was harmed. Both said they agreed that there was abuse and confirmed that an investigation was conducted. The investigation included a whole house audit of interviewable residents. They confirmed the alleged perpetrator was terminated and they educated the staff. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Actual Harm Past Non-compliance (PNC).
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 F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review, and an investigation into Intake #MD00205003, it was determined that the facility staff failed to ensure residents right to determine who speaks for t...
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Based on staff interview, clinical record review, and an investigation into Intake #MD00205003, it was determined that the facility staff failed to ensure residents right to determine who speaks for them is respected. This was evident for 1 (#128) out 44 residents in the survey sample.
The findings include:
A review of Resident #128's clinical record revealed the resident was admitted to the facility with the assistance of a granddaughter. The facility was informed that the resident had a Medical Power of Attorney form that was signed on 3/15/24 appointing the granddaughter as the Health Care Agent. The granddaughter got a second signature on 3/18/24. The facility as of 3/20/24 was still contacting the resident's son. Social services wrote a late note on 3/21/24 at 09:13 AM detailing the recent family history of the resident and the note makes it clear that the resident wants support from the granddaughter not the son.
This surveyor interviewed the Regional Director of Clinical Services prior to the survey team's exit from the facility and we discussed the importance of ensuring that the proper family contact is respected.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on record review, review of complaint intake MD 00209581 and staff interview, it was determined that the facility failed to implement the grievance process as evidenced by the failure to initiat...
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Based on record review, review of complaint intake MD 00209581 and staff interview, it was determined that the facility failed to implement the grievance process as evidenced by the failure to initiate grievances and to resolve complaints. Additionally, the facility staff failed to ensure the residents' right to voice grievances with respect to care/ treatments and the concerns of staffs' behaviors regarding their facility stay. This was evident for 1 (Resident# 144) out of 20 residents reviewed for facility complaint reviews during an annual survey.
The findings include:
Record review, on 10/11/24 at 10:55 AM, revealed that Resident #144 filed a complaint to the Office of Health Care Quality (OHCQ) with MD 00209581 and emailed the Administrator at the same time, on 9/9/24, about staff concerns during the weekend. The resident indicated that a meeting was scheduled for 9/10/24 and he/she did meet with the Administrator about the grievances. However, there was no action taken and the resident was discharged on 9/13/2024.
During the interview, on 10/11/24 at 02:00 PM, the Administrator stated that he received an email complaint about the staff delaying a smoking session and staff were argumentative loudly towards Resident #144. The Administrator confirmed that he did not enter a grievance after the meeting nor had a corrective plan.
Record review, on 10/11/24 at 2:45 PM, of the facility's Grievances/Complaints, Recording and Investigation Policy revealed that it clearly stated All grievances and complaints filed with the facility staff will be investigated and corrective actions will be taken to resolve the grievances. The Administrator was the Grievance Officer/Designee.
During interview, on 10/11/24 at 3:58 PM, the Regional Director of Clinical Operations (RDCO) was informed that it was a concern that the facility staff failed to implement the grievance process. The RDCO expected that all facility staff need to initiate the grievances immediately and follow through the Grievances/ Complaints process timely based on the facility's policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, it was determined the facility staff failed to review and revise the interd...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions to meet the needs of the residents. This was evident for 2 (Residents #32 and #91) of 44 residents selected for investigation during the survey process.
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.
Resident #32 was admitted on [DATE] with diagnoses including Acquired Absence of Left Leg Below Knee, Hemiplegia and Hemiparesis following Cerebral Infraction affecting Left Non-Dominant Side, Acquired Absence Right Leg above Knee.
1) On [DATE] at 07:41 AM the surveyor reviewed Resident # 32's care plan for Fall which was initiated on [DATE] with the Focus - Resident had an actual fall and remains at risk for falls relating to Deconditioning, Right AKA (Above the Knee Amputee), Left BKA (below the Knee Amputee), generalized weakness, history of cerebral infraction affecting left non-dominant side.
Goal: Resident will not sustain injury through the review date
An intervention which was initiated on [DATE] and remained active stated- Ensure that the resident is wearing appropriate footwear (non-skid socks) when ambulating or mobilizing in wheelchair
An interview with the Director of Nursing on [DATE] at 9:21AM confirmed that the intervention on the care plan for Resident #32 to wear footwear was not applicable to the resident who is a bilateral amputee.
On [DATE] at 9:00 AM a second review of Resident #32's care plan by the surveyor revealed that the intervention for footwear was discontinued on [DATE].
2) Resident 91 was admitted on [DATE] with diagnoses including Congestive heart Failure, Ischemic Cardiomyopathy, Acute Embolism and Thrombosis of Unspecified Deep Veins of Right Proximal Lower Extremity. Resident #91 Expired on [DATE]
On [DATE] at 08:21 AM the surveyor reviewed the medical records for Resident #91. The Physician's order revealed that the resident was receiving an anticoagulant medication (Apixaban) twice a day for Atrial Fibrillation/Deep Vein Thrombosis. The medication order was initiated [DATE] and discontinued on [DATE].
The care plan for Resident #91's revealed that the interventions pertaining to the anticoagulant medication continued after the medication was discontinued and remained active until Resident's# 91's expiration on [DATE]
On [DATE] at 08:12 AM the concern was brought to the attention on the DON by the surveyor. The DON confirmed the findings and stated that the staff should have revised the care plan after the medication was discontinued.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and medical record review it was determined that the facility failed to provide respiratory care and services appropriately. This was found to be evident for 2 Resident...
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Based on observation, interview and medical record review it was determined that the facility failed to provide respiratory care and services appropriately. This was found to be evident for 2 Residents (#8 and # 57) out of 3 residents that were reviewed for respiratory care and services.
The findings include:
1a) On 9/30/2024 at 11:18 AM the surveyor conducted a tour of Unit 100 and observed Resident #8 with oxygen in use and the oxygen tubing was not dated/labeled. In addition, the oxygen humidifier bottle that was attached to the oxygen delivery system did not have any water in the bottle and was dated 9/20/2024.
The surveyor interviewed the Registered Nurse (RN) #11 who observed the humidifier bottle empty and asked what the expectation was for the oxygen humidifier bottle, and RN #11 stated that she would replace the humidifier bottle.
On 10/4/24 at 10:00 AM the surveyor observed Resident #8 in bed with oxygen in place to his/her nostrils and the oxygen humidifier bottle and the oxygen tubing was dated 10/03/2024.
The surveyor conducted a record review of Resident #8's medical record at 12:10 PM on 10/4/2024. The medical record review revealed that Resident #8 had physician orders for oxygen and oxygen tubing to be changed every 7 days. In addition, the surveyor reviewed the facility oxygen administration policy which indicated that oxygen tubing is to be dated/labeled.
1b) On 10/04/2024 at 10:10 AM the surveyor observed Resident #57 with oxygen in use in the hallway on Unit 100 with the oxygen emergency tank in the holder on the back of the wheelchair. The surveyor observed that Resident #57's oxygen tubing that was connected to the emergency oxygen tank was not dated.
A chart review was conducted by the surveyor at 11:55 AM on 10/4/2024 and the review revealed that Resident #57 had physician orders for oxygen usage and oxygen tubing to be dated and changed every 7 days. In addition, the surveyor reviewed the facility oxygen administration policy which indicated that oxygen tubing is to be dated/labeled.
The surveyor conveyed to the Regional Nurse Consultant at 1:15 PM on 10/4/2024 of these concerns with oxygen usage.
CONCERN
(D)
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, interviews and medical record review it was determined that the facility failed to store medications appropriately. This was found to be evident in 1 (Resident #8) out of 1 resi...
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Based on observations, interviews and medical record review it was determined that the facility failed to store medications appropriately. This was found to be evident in 1 (Resident #8) out of 1 resident for medication storage.
The findings include:
During the initial tour of Nursing Unit 100 at 11:18 AM on 9/30/2024 the surveyor observed two respiratory medication inhalers at Resident #8's bedside. The surveyor notified Registered Nurse (RN) #11 of Resident #8 with medications at the bedside and RN #11 observed the two respiratory inhalers at the bedside and stated that one of them was Albuterol and that Resident #8 had a locked drawer.
The surveyor conducted a record review of Resident #8's medical record on 10/4/2024 at 07:44 AM and the review of the medical record revealed that there was not an order for medications/inhalers at the bedside. A self-administration medication assessment was completed by the nursing staff on 10/2/2024 for Resident #8.
On 10/1/2024 at 08:45 AM the surveyor observed Resident #8 with five tablets in a medication cup on the meal tray on the resident's overbed table. The surveyor notified the Certified Medication Aide (CMA) #12 and the CMA observed the five medications in the medication cup on the meal tray on the Resident #8's overbed table.
In addition, the surveyor interviewed the Certified Medication Aide (CMA) #12 and asked the CMA what these four medications were in the medication cup. The CMA stated that the five tablets were: Metoprolol, Mucinex, Zoloft, Aspirin, and Hydroxyzine. The surveyor asked the CMA what the expectation was for medication administration and medications left at the bedside, and the CMA stated, I should have stayed at the bedside while the Resident took his/her medications, but I have an hour to pass medications to all the Residents and how can I get these medications out to all these Residents within the timeframe.
At 10:49 AM on 10/01/2024 the surveyor conveyed to the Director of Nursing (DON) the medications that were observed at Resident #8's bedside, and the interview with the Certified Medication Aide (CMA) #12. The DON stated that she would address and provide re-education on medication administration to the Certified Medication Aide (CMA) #12.
On 10/4/2024 at 7:44 AM the surveyor reviewed Resident #8's medical record specifically the physician orders and the medication administration records and confirmed that Resident #8 had an order for these five medications (Metoprolol, Mucinex, Zoloft, Aspirin, and Hydroxyzine) and that these five medications were documented as administered by the Certified Medication Aide (CMA) #12.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
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 food products were properly ...
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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 food products were properly labeled and disposed of when they are past their expiration dates. This was observed on two tours of the kitchen.
The findings include:
On 9/30/24 at 8:10 AM a tour of the kitchen revealed there were several items that were either past an expiration date or their labeling was incomplete. The walk-in cooler had a container of mustard with a label indicating it was opened on 7/4 and to use by 8/4. The year was not present, but it appears to have been past the use by date. There were two containers of ricotta cheese that had expiration dates of 9/27/24. One 1-gallon container of coleslaw dressing that had a label that both a use by date and expiration date of 8/12. A second container of coleslaw dressing that was not labelled. One container of teriyaki with a use by date of 7/30. There were 4 boxes of sun cups that had a warning on the box to serve within 10 days but there was no label to indicate when they were thawed. Several containers of dressing in the cooler had black mold like growth on them.
Interviewed the Dietary Manager on 10/2/24 at 10:02 AM showed him the containers of salad dressing with labels that now show the year. Also have some kind of mold like growth on the outside containers of salad dressing and mustard. Showed him the container of Ricotta cheese and asked what does X [date] mean and he said it was an expiration date. He said he would take care of all the items in question.
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 clinical record review and staff interview it was determined that the facility staff failed to ensure clinical records were maintained in an accurate manner. This was evident for 1 (#4) out o...
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Based on clinical record review and staff interview it was determined that the facility staff failed to ensure clinical records were maintained in an accurate manner. This was evident for 1 (#4) out of 44 residents in the survey sample.
The findings include:
The Activity Director (Staff #25) was interviewed on 10/7/24 at 9:22 AM. The team asked her where to find Activity logs documenting participation. She said they switched to putting Activities information into the computer. This surveyor requested Activity logs for Resident #4.
Activity logs were brought to the survey team on 10/7/24 at 12:15 PM. This surveyor reviewed the activity logs on 10/7/24 at 12:45 PM and activity staff documented that the resident was participating in activities on 7/11/24, 7/15/24, 7/17/24, and 7/19/24. Further review of the clinical records revealed the resident was in the hospital from 7/10 to 7/22/24.
This surveyor interviewed the Administrator and Regional Director of Clinical Services on 10/11/24 at 12:13 PM. The Surveyor showed them the activity logs. They confirmed that there are activities listed on the logs. They then acknowledged that staff documented providing activities while the resident was in the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, it was determined that the facility failed to provide a safe, sanitary environment to pre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, it was determined that the facility failed to provide a safe, sanitary environment to prevent the development and transmission of disease and infection. This was evidenced by: 1) Staff failing to perform hand hygiene before entering the room of a resident with enhanced barrier precautions 2) Failure to keep contaminated pillows separate and away from clean pillows in the laundry room
The findings include:
Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).
1) On 10/3/24 at 8:20AM during rounds, on the unit with rooms 500-514, the surveyor observed Enhanced Barrier Precautions (EBP) signage over the beds of 514b, 512b, 509a, 508b, 506a, 505b, 504a. The signage which was issued by the Center for Disease Control had instructions which included Everyone Must Clean their hands, including before entering and when leaving the room.
While standing in the hallway of the unit thirty-two minutes later at 8.52 AM, the surveyor observed Staff# 4 enter one of the rooms with EBP, Room# 506a without performing hand hygiene, then at 8:56 AM Staff# 5 also entered room [ROOM NUMBER]a without performing hand hygiene. Hand Sanitizer dispensers were mounted on the walls in the hallway outside the rooms. No Personal Protective Equipment (disposable gowns, gloves and masks) storage carts were observed on the unit or outside the residents' rooms.
On 10/3/ 24 at 11:10 AM the surveyor interviewed Staff#1 in the presence of the DON.
How are the staff aware of EBP? We educate our staff on the placement of the signage and what it means. Signages are placed over the residents' beds in their rooms and green stickers are placed on their names on the wall outside their rooms to indicate they are on EBP. We do not put the signs outside on the residents' doors because we want to maintain a homelike environment and these signs could be up for a long time. Staff are educated to perform hand hygiene before entering and when leaving the room of a resident with EBP. The surveyor asked where the Personal Protective Equipment supplies (PPE) were kept for use on the unit. Staff#1 stated that the PPE supplies were kept in carts in the hallways.
The Surveyor notified Staff#1 that on 10/3/24 at 8:52 AM and 8:56 AM two GNAs on the unit were observed entering room [ROOM NUMBER]a without performing hand hygiene. Also, no PPE carts were observed in the hallway or on the unit with rooms 500-514.
On 10/4/24 at 9.00AM surveyor observed a cart in the hallway with PPE supplies on the unit with rooms 500-514
2) On 10/07/24 at 08:48AM the surveyor observed several pillows on a 3-tier rack in the laundry room. Some of the pillows were individually placed in clear plastic bags while others were sitting on the rack uncovered.
The surveyor inquired about the pillows from Staff#21, Director of Housekeeping. Staff #21 stated that when the pillows are cleaned, they are placed in plastic bags and put on the rack. The clean pillows were the ones covered in plastic bags while the uncovered pillows were the ones that needed to be cleaned. The surveyor asked whether it was the facility's practice to have clean and contaminated pillows together on the same rack. Staff#21's response was I guess and did not indicate to the surveyor, the infection control process for the cleaning of pillows.
On 10/08/24 at 08:10 AM the surveyor revisited the laundry room and observed several pillows on the 3-tier rack individually covered in clear plastic bags. The surveyor did not observe any pillow without a clear plastic cover on the rack.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observations, and interviews, it was determined that the facility failed to keep a sanitary environment. This was found evident on 1 of 3 floors observed in the laundry room area.
The finding...
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Based on observations, and interviews, it was determined that the facility failed to keep a sanitary environment. This was found evident on 1 of 3 floors observed in the laundry room area.
The findings include:
On 10/07/24 at 08:48AM the surveyor did a walk through the laundry room. Staff #22 and Housekeeping Director, Staff #21 were present. The surveyor observed the floor tiles in the room with the washing machines were visually dirty and sticky with a brown colored substance. On the floor in front of the washing machines were two large, rusty drain pit covers. Surrounding the drain pit covers were an accumulation of dirt. Chemicals for the washing machines were in buckets attached to hoses sitting on a platform covered with thick powder like white substance. The thick white substance was also scattered on the floor next to the platform. In an interview regarding the condition of the room Staff #22 agreed that the room needed cleaning.
On 10/08/24 at 08:10 AM the surveyor did a second observation of the laundry room with the Maintenance Director and the Administrator. The room was in the same condition as the surveyor observed on 10/07/24 at 08:48AM. The surveyor reviewed the findings of the dirty floor and rusty drain covers with the Administrator and Maintenance Director. The Administrator commented, maybe we could use a power wash for cleaning, it is an old building.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and facility staff interview, it was determined that the facility failed to have a safe/clean/comfortable/h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and facility staff interview, it was determined that the facility failed to have a safe/clean/comfortable/homelike environment. This was found to be evident in 6 out of 8 Resident rooms observed by the surveyors during the tours of the facility.
The findings include:
1. During the tour of the facility on 9/30/2024 at 10:45 AM the surveyor observed the following items in need of repair: the sink faucet in room [ROOM NUMBER] was missing a handle for the warm water, the cove basing in room [ROOM NUMBER] was not secure to the wall underneath the sink, one of the closets in room [ROOM NUMBER] was missing a drawer, and the walls marred in rooms 100, 112 and 114.
At 9:20 AM on 10/7/2024 the surveyor toured nursing unit 100 with the Nursing Home Administrator (NHA) and the Maintenance Director. The NHA and the Maintenance Director observed room [ROOM NUMBER] and room [ROOM NUMBER] with the surveyor and acknowledged that these two areas required repair for the missing drawer and the unsecured cove base.
During the observation on 10/7/2024 at 9:20 AM, the surveyor interviewed the Nursing Home Administrator (NHA) and the Maintenance Director and asked if they were aware of these two items that needed repair and what the expectation was for repair of those items. The NHA and the Maintenance Director stated that they were unaware of these two items that needed repair and that these items would be fixed. The Nursing Home Administrator (NHA) stated that the facility uses the TELS platform which is a computer-based system used by all facility staff for documentation of items that needed repair.
In a follow-up interview with the Maintenance Director on 10/7/2024 at 9:45 AM, the surveyor addressed the marred walls observed in the Resident rooms. The Maintenance Director stated that he was aware of the marred walls and had a plan in place for repair of these marred walls in the Resident rooms.
At 11:00 AM on 10/16/2024 the surveyor toured room [ROOM NUMBER] with the Director of Nursing. The Director of Nursing observed the handle for the warm water missing from the faucet and acknowledged that this faucet needed to be repaired. The Director of Nursing stated that she would have this documented in TELS for repair to be done by Maintenance.
2. During tours of the facility this surveyor observed several environmental issues.
On 9/30/24 at 9:30 AM observation of room [ROOM NUMBER] revealed that the baseboard molding was coming off of the wall opposite the residents' beds and the drawer face on the bottom of the armoire was off.
On 9/30/24 at 10:30 AM observation of room [ROOM NUMBER] revealed the floor around bed B was sticky.
On 10/2/24 at 10:00 AM observation of room [ROOM NUMBER] revealed the floor around bed B was still sticky.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 10/1/24 at 02:36 PM a review of the clinical record for Resident #32 revealed that the resident was transferred to the hos...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 10/1/24 at 02:36 PM a review of the clinical record for Resident #32 revealed that the resident was transferred to the hospital on [DATE] for Hypoxia and returned to the facility on 1/7/23.
There was no evidence in the clinical record to show that the facility staff provided written notification to the Ombudsman for Resident #32's transfer to the hospital
On 10/4/24 at 11:37AM the Director of Nursing and the Regional Director of Clinical Operations were interviewed by the surveyor and made aware of the findings. No evidence of the notification to the Ombudsman was provided to the team prior to the survey exit.
Based on staff interviews and medical record review it was determined that the facility failed to provide
notification to the Ombudsman of Residents that transferred to the hospital and discharged from the facility. This was found to be evident in 9 out of 9 Residents (#4, #8, #24, #32, #33, #41, #60, #105 and #118) reviewed for hospitalizations.
The findings include:
1. During an interview with Resident #8 on 10/01/2024 at 08:57 AM, the Resident stated to the surveyor that he/she was hospitalized at Greater Baltimore Medical Center in April of this year.
The surveyor reviewed Resident #8's medical record on 10/7/24 at 08:10 AM and the medical record review revealed that Resident #8 was hospitalized on [DATE].
The surveyor interviewed the Nursing Home Administrator (NHA) at 01:13 PM on 10/7/2024 and requested documentation of notification to the Ombudsman when a Resident is transferred to the hospital. The NHA stated that notification to the Ombudsman has not been completed up until a few months ago. The surveyor requested this documentation from the Nursing Home Administrator (NHA).
The surveyor interviewed Resident #33 on 10/1/2024 at 09:58 AM. Resident #33 stated to the surveyor that he/she had been in the hospital for a fall.
A medical record review was conducted by the surveyor on 10/8/2024 at 10:20 AM and that review revealed that Resident #33 had been hospitalized [DATE], 7/27/2024 and 9/6/2024.
Further review of the medical record on 10/8/2024 revealed that there was no notification of documentation that the Ombudsman was notified of these transfers of Resident #33 to the hospital.
During an interview with Resident #41 on 10/1/2024 at 10:25 AM the Resident stated that he/she was hospitalized for a fall.
The surveyor conducted a chart review on 10/1/2024 at 08:30 AM and the chart review revealed that Resident #41 was hospitalized on [DATE], 8/5/2024 and 9/9/2024. Further review of Resident #41's medical record revealed that there was no notification that the facility had notified the Ombudsman of the transfers to the hospital for Resident #41.
At 7:58 AM on 10/8/2024 the surveyor reviewed a binder of documentation received from the Nursing Home Administrator (NHA) for Ombudsman notification of transfers from August 2024 to October 2024. This documentation in the binder included individual emails from the facility Social Services Director to the Ombudsman for Resident discharges and transfers for the months of August 2024 to October of 2024. In addition, there was an Admission/Discharge To/From Report from the facility computer documentation system for 8/1/2024 to 9/30/2024 with a time stamp of 10/7/2024 at 14:08 PM.
In a follow-up interview with the Nursing Home Administrator (NHA) at 9:05 AM on 10/8/2024 the surveyor confirmed with the NHA that this was the complete documentation of facility notification to the Ombudsman. The surveyor conveyed to the NHA that there was no documentation that the Ombudsman was notified of Resident #8,
#33 and #41 transfers to the hospital.
3. On 10/08/24 at 09:39 AM, a review of Resident #60's clinical record revealed that Resident #60 was transferred to the hospital for further evaluation of his/her medical needs on the following dates: 12/16/23, 1/18/24, 2/16/24, and 3/12/24. Further review of Resident #60's clinical record revealed no documentation that the local ombudsman was notified of the hospital transfers in writing.
On 10/08/24 at 12:35 PM, an interview conducted with the Nursing Home Administrator (NHA) revealed that the facility just started sending transfer and discharge notices to the Ombudsman a few months ago via email. The NHA further stated that transfer notices were not provided to the Ombudsman for Resident #60's hospital transfers on 12/16/23, 1/18/24, 2/16/24, and 3/12/24.
On 10/08/24 at 11:53 AM, a review of Resident #118's clinical record revealed that Resident #118 was discharged from the facility on 7/14/2024. Further review of Resident #118's clinical record revealed no documentation that the local ombudsman was notified of the resident's discharge in writing.
On 10/08/24 at 12:35 PM, an interview conducted with the NHA revealed that the facility just started sending transfer and discharge notices to the Ombudsman a few months ago via email. The NHA further stated that a discharge notice was not provided to the Ombudsman for Resident #118's discharge on [DATE].
2. A review of Resident #4's clinical record on 9/30/24 revealed the resident was in the hospital from [DATE] to 7/22/24. Further review revealed that the Ombudsman was not notified.
A review of Resident #24's clinical record on 9/30/24 revealed the resident was in the hospital from [DATE] to 8/2/24. Further review revealed that the Ombudsman was not notified.
A review of Resident #105's clinical record on 9/30/24 revealed the resident was in the hospital 8/17 to 8/19/24 and 9/19 to 9/20/24. The Ombudsman was not informed about either trip to the hospital.
10/07/24 at 01:20 PM the Administrator was interviewed on 10/7/24 at 1:20 PM. He stated that they have not been telling the Ombudsman of the Centers for Medicare/Medicaid Services (CMS) requirement that the Ombudsman be notified monthly.
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to ensure tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to ensure that MDS (Minimum Data Set) assessments were coded accurately for Residents. This was found to be evident for 5 Residents (#41, #77, #119, #133 and #118) out of 5 Residents reviewed for accuracy of MDS assessments.
The findings include:
1) The surveyor observed Resident #41 sitting on the side of her bed on 10/1/2024 at 10:16 AM with a Foley catheter in use. Resident #41 stated to the surveyor that he/she has a catheter.
The MDS (Minimum Data Set) is a health status screening and assessment tool used for all residents of Long-Term Care Nursing Facilities. The 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.
A record review of Resident #41's medical record was completed by the surveyor at 8:05 AM on 10/4/2024. The medical record review revealed that the admission MDS dated [DATE] Section H0300 Urinary Incontinence indicated that Resident #41 was Frequently incontinent, and Not rated, resident had a catheter was not coded. Further review of the medical record for Resident #41 revealed that the Quarterly MDS dated [DATE] Section H0300 Urinary Incontinence indicated that Resident #41 was Occasionally incontinent, and Not rated, resident had a catheter was not coded. Review of Resident #41's care plan indicated that resident has a catheter for urinary retention. Review of Resident #41's physician orders revealed that resident had an order for Indwelling Foley catheter for obstructive uropathy.
2) On 10/9/2024 at 8:20 AM the surveyor conducted a record review of Resident #77's medical record. The chart review revealed that Resident #77 had redness to the sacrum (the large, triangular bone that forms the base of the spine and the back wall of the pelvis) on the admission Evaluation completed 9/8/2024. Resident #77's care plan indicated that resident had actual impairment to skin integrity related to sacral redness. Review of the physician orders revealed that there was an order dated 9/9/2024 for Apply foam dressing to sacrum for protection every day shift for wound care. Review of the progress notes - Skin Observation Weekly dated 9/9/2024 to 10/1/2024 indicated Weekly skin observation completed. No skin concerns noted. Further review of the medical record revealed that the Medicare admission MDS dated [DATE] Section M0100 Determination of Pressure Ulcer/Injury Risk indicated that Resident has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device. The Licensed Practical Nurse (LPN) MDS Coordinator #23 completed a modification to existing record for the Medicare admission MDS dated [DATE] on 10/14/2024 at 8:41 AM Section M0100 and did not code that Resident has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device.
3) The surveyor completed a closed record review for Resident #119 on 10/11/2024 at 9:02 AM. The closed record review revealed as documented in the progress notes that Resident #119 was discharged to custody of the County Police Department in stable condition on 7/26/2024. Further review of the medical record revealed that the Discharge Return not Anticipated MDS dated [DATE] Section A2105 Discharge Status indicated that Resident #119 was discharged Home/Community, and Not listed was not coded. The LPN MDS Coordinator #23 completed a modification to existing record for the Discharge MDS dated [DATE] on 10/14/2024 at 8:33 AM Section A2105 and did not code Home/Community but coded Not listed.
The surveyor conducted an interview on 10/11/24 at 10:06 AM with the LPN MDS Coordinator and the Director of Nursing (DON) with the Regional Director of Clinical Operations present. The surveyor conveyed that the MDS for Residents #41, #77 and #119 were not coded accurately. The LPN MDS Coordinator #23 and the Director of Nursing (DON) acknowledged that the MDS' were not coded accurately.
4) On 10/16/2024 at 8:15 AM the surveyor reviewed a closed medical record for complaint MD#00194358 for Resident #133 who discharged from the facility on 7/7/2023. During the medical record review, the surveyor identified that Resident #133 had a care plan for risk for falls related to history of stroke. Further review of Resident #133 revealed that the Resident had a fall on 6/19/2023 as indicated on the SBAR/INTERACT Communication form which is an assessment tool documented by nursing for Resident change in condition. The surveyor reviewed the Discharge Return Not Anticipated MDS assessment dated [DATE] and Section J1800 was coded that Resident #133 did not have any falls.
The surveyor interviewed the Director of Nursing (DON) at 11:30 AM on 10/16/2024 and conveyed to DON that Resident #133 had a fall on 6/19/2023, and that the Discharge Return Not Anticipated MDS dated [DATE] was coded that Resident did not have any falls. The DON acknowledged that the Resident did have a fall on 6/19/2023 and the MDS was not coded accurately.
On 10/18/2024 at 11:00 AM, the surveyor conducted a follow-up review of Resident #133's MDS section of the medical record. This follow-up review revealed that there was a Modification of the Discharge Return Not Anticipated MDS dated [DATE]. This modification was completed on 10/17/2024 at 7:11 AM by the LPN MDS Coordinator #23 for Section J1800 and J1900 which indicated that the resident had a fall with injury.
The surveyor conducted a follow-up interview with the Director of Nursing (DON) on 10/21/2024 at 9:15 AM and conveyed to the DON that there was a Modification to the Discharge MDS dated [DATE] for Resident #133. The Director of Nursing (DON) acknowledged that the modification was completed at 7:11 am on 10/17/2024 by the LPN MDS Coordinator #23 for Section J1800 and J1900 related to a fall with injury.
5) 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.
On 10/08/24 at 11:32 AM, a review of Resident #118's clinical record revealed that a discharge MDS was completed on 7/14/2024. The resident was coded under MDS Section A2105 (Discharge Status) as discharged to short term general hospital. However, a review of progress notes on 10/08/24 at 11:48 AM revealed a discharge note dated 7/14/24 written by RN #11 at 2:08 PM which stated Resident #118 was discharged to a shelter.
On 10/08/24 at 1:20 PM, the surveyor requested documents from the facility related to Resident #118's discharge status which included the Discharge MDS dated [DATE] Section A and the discharge progress note dated 7/14/24.
On 10/17/24 at 3:32 PM, a subsequent review of Resident #118's clinical record was conducted. The review revealed that on 10/08/2024 at 2:43 PM, LPN MDS Coordinator #23 modified the existing record of the Discharge MDS dated [DATE] under Section A2105 (discharge status) to reflect that the resident was discharged home.
On 10/17/24 at 4:37 PM, an interview was conducted with the VP of Clinical Services, Director of Nursing and Regional Risk Nurse #18 at which time the surveyor discussed the concerns regarding the identified MDS code inaccuracy and the record modification.
Oct 2019
25 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on record review and staff interview it was determined that the facility failed to keep a resident safe by mishandling an oxygen tank which resulted in harm. This was evident for 1 (#318) of 5 r...
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Based on record review and staff interview it was determined that the facility failed to keep a resident safe by mishandling an oxygen tank which resulted in harm. This was evident for 1 (#318) of 5 residents reviewed for accidents.
The findings include:
On 10/28/19 at 1:18 PM, review investigation notes of for a facility reported incident (include MD#) revealed that on 9/26/18 at 12:20 PM, Resident #318 was taken to the nurses' station to get his/her wheelchair weighed. Geriatric Nursing Assistant (GNA) #33 stood the resident up out of the wheelchair and asked Licensed Practical Nurse (LPN) #34 and Certified Registered Nurse Practitioner (CRNP) #31 to stand with the resident for support. GNA #33 removed the oxygen tank from the back of the resident's wheelchair and sat it on the floor failing to secure the oxygen tank. As GNA #33 was placing the wheelchair behind Resident #318, so the resident could sit back down, the oxygen tank fell on Resident #318's left toe and caused a laceration. Resident #318 was sent to the hospital for an evaluation. Later that day at 11:30 AM, LPN #34 called for an update and was informed the resident had a broken left great toe.
Review of the hospital emergency room visit notes on 11/1/19 at 3:50 PM, revealed that the admitting physician noted that Resident #318 had a broken toe and a laceration as a result of an oxygen tank being dropped on his/her left toe.
An interview with the Assistant Director of Nurses (ADON) on 10/28/19 at 3:25 PM, revealed that she was unaware of the details of the incident. The ADON reported she was the nurse educator and the facility did not currently have education for handling of oxygen tanks. She stated that it was listed on the new hire check list for the preceptor to sign off, however she was unable to state what the employee or preceptor completed in order to mark it. LPN #34 was no longer employed at the facility and an attempt was made to reach GNA #33 by telephone, however the attempt was unsuccessful.
On 10/28/19 at 4:22 PM, Administrator and Director of Nursing were made aware of the concerns with the incident and both reported they were not at the facility at the time of the incident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility staff failed to, in the presence of a resident - to - resident altercation, provide immediate intervention to ensure the safet...
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Based on interview and record review, it was determined that the facility staff failed to, in the presence of a resident - to - resident altercation, provide immediate intervention to ensure the safety and wellbeing of the resident. This was evident for 1 (#39) of 7 residents reviewed for abuse.
The findings include:
During an interview with Resident #39 on 10/21/19 at 11:04 AM, the resident reported that his/her roommate (Resident #100) was calling his/her mother names and talked about her. Resident #39 stated, I have told social services many times about this and that I wanted a room change or I would bust him/her (the roommate) in the mouth. Resident reported they (facility staff) kept telling me that I have to be on a wait list and I am not sure why. Resident stated this issue had been going on since being moved to the room in 12/2018.
An interview with Licensed Practical Nurse (LPN) #35 revealed that the roommate Resident #100 was abusive to staff and frequently called them names, but not aware of issue with the roommates.
During an interview with Social Services Director (SSD) #1 on 10/24/19 at 3:16 PM, she reported that when a resident had a complaint a Concern Form was completed. She stated that Resident #39 had completed one with Staff #24 regarding a room change, but she was not aware of the details. She stated that she had one concern form for this resident.
On 10/24/19 at 3:30 PM, an interview with the Administrator revealed the facility had a bed capacity of 130 residents with dually certified rehabilitation beds, and the current the census was 112. He was unable to provide a reason that a male resident who requested a room change could not be moved at this time. Discussed concerns with Administrator and he acknowledged them.
A subsequent interview with Resident #39, with the Administrator present, on 10/25/19 at 12:27 PM, revealed the resident reported the same complaint to both Social Service staff (#1 and #24) 3-4 times, regarding his roommate had called his/her mother names. Resident #39 stated he/she was told they were on a wait list for the room change.
An interview with Staff #24 on 10/28/19 at 11:48 PM, she stated that Resident #24 had reported to her on 10/16/19, that he/she wanted a room change because the roommate was cursing at them. I reported this to the SSD #1 the same day. Staff #24 stated resident had not reported this issue to her before that date.
A record review on 10/25/19 at 12:03 PM, revealed nursing progress note dated 9/13/19, 10/5/19, and 10/24/19 that Resident #39 is alert and oriented to person, place, and time. Review of Social Services notes and assessments revealed no documentation that Resident #39 had a psychology consultation or counseling for the roommate screaming and cursing at him/her. Further review, revealed no documentation of an assessment or further investigation of the concern form date 10/16/19 had occurred. Review of the current care plan revealed no documentation regarding a roommate with behavioral issues.
The investigation report attached to the concern form documented the response to Resident #39 request to change rooms was that he/she was informed that he/she would be placed on a wait list and was signed by the Administrator and SSD #1. A statement provided by SSD #1 on 10/25/19, documented she was aware that the resident was being cursed at by his/her roommate, however did not indicate that this situation was recognized as Resident - to - Resident abuse.
A record review for the roommate Resident #100 on 10/29/19 at 1:35 PM, revealed a care plan initiated on 9/5/19 that documented Resident cursing and screaming at roommate (Resident #39) and staff member with a goal that the resident will cooperate with care. The intervention did not indicate an intervention for cursing and screaming at his/her roommate. Review of the physician progress notes for 12/5/18 - 10/2/19, revealed the clinician staff #25 had no indication that this resident had behaviors.
On 10/28/19 at 12:19 PM, reviewed concerns with Director of Nursing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined that the facility failed to report allegation of abuse to the Office of Health Care Quality. This was evident for 1 (#39) of 7 Residents reviewed...
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Based on interview and record review it was determined that the facility failed to report allegation of abuse to the Office of Health Care Quality. This was evident for 1 (#39) of 7 Residents reviewed for abuse.
The findings include:
During an interview with Resident #39 on 10/21/19 at 11:04 AM, the resident reported that his/her roommate (Resident #100) was calling his/her mother names and talking about her. The resident reported this has been going on since he was moved into the room and that facility staff were aware.
On 10/24/19 at 3:16 PM, during an interview with Director of Social Work (DSS) Staff #1 stated she was aware of Resident #39's request to change rooms and provided the concern form dated 10/16/19.
An interview with Staff #24 on 10/28/19 at 11:48 PM, revealed she was informed on 10/16/19, by Resident #39 that he/she wanted a room change because the roommate (Resident #100) was cursing at him/her. She gave the concern form to DSS Staff #1 and reported what the resident had said to her the same day. Staff #24 and #1 failed to report this as abuse.
The Administrator was made aware of and acknowledge concerns on 10/25/19 at 12:27 PM.
A record review for roommate (Resident #100) on 10/29/19 at 1:35 PM, revealed a care plan with the last revision date of 9/5/19, which stated, resident cursing and screaming at roommate and staff member. However, facility staff failed to report this resident - to - resident abuse.
The Director of Nursing was made aware of the concerns on 10/28/19 at 12:19 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that the facility failed to initiate an investigation of an alleged violation of abuse was reported to staff. This was evident for 1 (#39) of 7 r...
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Based on record review and interview it was determined that the facility failed to initiate an investigation of an alleged violation of abuse was reported to staff. This was evident for 1 (#39) of 7 residents reviewed for abuse.
The findings include:
A record review of the roommate (Resident #100) on 10/29/19 at 1:35 PM, revealed a care plan that was revised on 9/5/19, documented, Resident (#100) cursing and screaming at roommate (Resident #39) and staff member. However, the interventions did not include how to address the resident - to - resident altercation.
A record review on 10/25/19 at 12:03 PM, for Resident #39 revealed the resident had filed a concern form with Staff #24 on 10/16/19, requesting a room change.
There was no evidence that staff recognized the abuse and initiated an investigation. Furthermore, no action was taken to prevent further incidence of abuse until surveyor intervened on 10/24/19.
An interview with the Administrator on 10/24/19 at 3:30 PM, revealed he was not aware of the reason for the room change requested by Resident #39.
An interview with Staff #24 on 10/28/19 at 11:48 AM, revealed she was told by Resident 39 that his/her roommate was cursing at him and failed to recognized this was abuse.
The administrator was made aware of these concerns on 10/28/19 at 1:00 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined that the facility failed to complete a Minimum Data Set (MDS) assessment within 14 days of the Assessment reference date (ARD). Thi...
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Based on medical record review and staff interview it was determined that the facility failed to complete a Minimum Data Set (MDS) assessment within 14 days of the Assessment reference date (ARD). This was identified for 1 (#7) of 2 residents reviewed for pressure ulcers.
The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.
The findings include.
Review of Resident #7's medical record on 10/23/19 revealed that an annual MDS assessment with an ARD of 10/3/2019 was in progress, with the name of the MDS assessor. An interview was conducted with the MDS Assessor (staff #11) at 2:45 PM on 10/23/19, she had indicated that she knows that the assessment is greater that 14 days after the assessment reference date. The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days).
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 the medical records, and resident and staff interviews it was determined the facility failed to perform appropriate revisions to the care plan interventions as resident care needs b...
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Based on review of the medical records, and resident and staff interviews it was determined the facility failed to perform appropriate revisions to the care plan interventions as resident care needs became apparent or changed over time as evidenced by failure to update interventions on an incontinence plan of care. This was evident for 1 (#69) of 2 residents reviewed for sensory (vision) concerns.
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
The findings include:
1) An Initial interview was conducted with resident #69 on 10/21/19. Resident #69 indicated that s/he does not get toileted and does not utilize a bed pan. Resident #69 indicated that a disposable bed mat is utilized as resident requested for bowel movements. The disposable bed pad is discarded, and s/he is cleaned up after each evacuation. Resident #69 indicated that s/he was continent of bowel and urine. Resident #69 could express his/her needs as warranted.
Resident #69's medical record was reviewed on 10/24/19. A quarterly Minimum Data set (MDS) assessment with an assessment reference date of 9/6/19 indicates resident #69 is continent of urinary function and has occasional bowel incontinence (1 bowel movement).
The medical record documents a plan of care with a focus area indicating that resident #69 is incontinent of bowel and bladder as revised on 9/6/19. The care area was not revised to reflect the most recent assessment that resident is continent of urine. There were three interventions written for this focused care area with a goal that Resident #69 will not have skin complications. The interventions were documented as 1) Incontinence care q2 hours and prn (as needed) as resident allows. Date Initiated: 10/5/16 2) Toilet upon rising, mealtimes, bedtimes and prn. Date initiated 2/22/17 and 3) Moisture barrier as ordered see current TAR. Date initiated 2/22/17. Additionally, the resident had an order to be toileted upon rising, at meals, bedtime, and as needed, and a 2nd order for toileting every 2 hours and PRN every shift with staff signing off both orders on a treatment administrative record per shift that this is being performed.
At 2:14 PM on 10/24/19 discussion with the GNA (staff #30) confirmed that the Resident #69 does not utilize the toilet as the resident will utilize a disposable bed pad for bowel movements. The Unit manager (staff # 2) was interviewed at 2:45 PM on 10/24/19. She indicated that she has a role in reviewing and revising plans of care and it was discussed that resident #69's plan of care was not person centered to reflect this resident individualized care needs related to bowel evacuations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of a complaint, medical record, observation, and interview it was determined that the facility failed to provide care and treatment in accordance with professional standards as evidenc...
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Based on review of a complaint, medical record, observation, and interview it was determined that the facility failed to provide care and treatment in accordance with professional standards as evidenced by: 1)failure to ensure medications were ordered and administered as indicated; 2) failure to complete a thorough physical assessment after a fall 3) failure to provide activity of daily living (ADL) care as needed 4) failed to render care in accordance with the resident's care plan and failed to apply prescribed/ ordered treatments. This was found to be evident for 1 (#39) of 3 residents reviewed for 5 day hospice respite admissions, and for 1 (#7) of 2 residents reviewed for pressure ulcers.
The findings include:
1) On 10/24/19 review of Resident #319's medical record revealed the resident had been admitted to the facility in May 2019 for a five day hospice respite stay. The resident's diagnosis included but was not limited to chronic pain, dementia with behavioral disturbances, anxiety, major depressive disorder and agitation.
Review of MD00142554 revealed concerns that that the resident did not receive the correct medications.
On 10/24/19 at 11:05 AM, the unit manager (UM) #36, for the unit the resident had been on in May, reported that a short term hospice respite stay admission is treated as a normal new admission and that the resident is admitted with a list of medications from hospice. She went on to report that the nurse would call the physician or the nurse practitioner (NP) to verify the medication.
On 10/28/19 at 12:37 PM, Register Nurse (RN) #16 reported that for residents admitted for short term hospice respite bring a medication list with them and that the list goes into the medical record.
On 10/24/19, review of the paper documentation in the resident's medical record for the May 2019 admission revealed 17 pages of documents from the hospice. Printed at the top of each page was: May/23/2019 5:28:41 PM [name of hospice and fax number]. Review of the hospice paperwork revealed a list of Medications of which there was a notation that the order for Haldol [an antipsychotic medication] 2 mg (milligrams) give every four hours as needed for agitation had been discontinued on 5/20/19; and Oxycodone 5 mg every four hours as needed for pain was discontinued on 5/16/19.
When the surveyor compared the list of medications found in the 5/23/19 hospice paperwork with the medication orders that had been put into the electronic health record on 5/24/19 several discrepancies were noted in regard to pain and psychotropic medications.
a) Hospice paperwork included acetaminophen 500 mg take 1000 mg three times a day for pain. No order for acetaminophen was found for the May admission.
Review of the Nurse Practitioner note, dated 5/28/19, revealed the following, Medication List: See Medication Administration Record (MAR) .Pain - denied pain at this time, no signs/symptoms of pain or discomfort noted. Is on acetaminophen p.o. [by mouth] as needed and morphine solution sublingually as needed as per hospice care medications. We will continue with the current regimen .
Further review of the medical record, including the MAR for May 2019, failed to reveal documentation of an order for acetaminophen to be given as needed.
On 10/24/19 at 11:07 AM, NP #31 reported that for hospice respite admissions he confirms the medications and for the most part keeps the medications the same, although if a medication is not needed he will not order it. In regard to Resident #319, the NP reported the acetaminophen three times a day was not ordered because the resident did not need it and he didn't want the resident to get 1000mg three times a day.
Acetaminophen 1000mg three times a day (3 grams total) is the maximum recommended dose per day. Review of the April MAR revealed the resident had orders for and received Acetaminophen 1000mg three times a day during the April admission.
Review of the nursing note dated 5/29/19 at 9:00 AM revealed the resident had a change in condition and was unable to swallow, was listless and responsive only to tactile stimuli. The resident was breathing fast so liquid morphine was administered under the resident's tongue. Further review of the medical record revealed that at 11:03 AM the resident was continuing to decline and began coughing when staff attempted to administer liquid Tylenol.
Acetaminophen is available in a suppository form.
On 10/24/19 at 3:54 PM surveyor reviewed with DON the concern that acetaminophen had been administered by nursing staff without an order on 5/29 and that the administration was in a liquid form when the resident had been assessed as not being able to swallow.
b) The hospice paperwork did not include morphine in the list of medications. Review of the medical record revealed an order, dated 5/24/19, for Morphine Sulfate (Concentrate) Solution 20 mg/ml (milligrams/milliliter). Give 5 mg by mouth every 8 hours for chronic pain.
There was also an order in effect from 5/24 thru 5/29 for Morphine 0.25ml (5 mg) every 2 hours as needed for pain or shortness of breath but review of the MAR failed to reveal documentation that the morphine had been administered based on this order.
Review of the Plan of Care Notes found in the hospice paperwork revealed the following note written by the nurse case manager on 5/14/19: discontinued on morphine last week.
Review of the 5/24/19 NP note revealed the following: Pain-managed on morphine as part of hospice medications. We will continue with the current regimen. This note failed to address what the current regimen consisted of.
Further review of the medical record failed to reveal documentation that the morphine, or any other medication ordered to treat pain, was administered to the resident on 5/24 or 5/25. Review of the MAR revealed the morphine was administered as ordered starting on 5/26 at 8:00 AM thru 5/28 8:00. According to the MAR the morphine was not administered when due on 5/28 at 4:00 PM or on 5/29 at 12:00 AM (midnight) due to the resident sleeping.
The DON confirmed on 10/28/19 at 5:38 PM that there was no documentation of administration of the morphine prior to 5/26/19.
Review of the NP note, dated 5/28/19, revealed the following, Medication List: See Medication Administration Record (MAR) .Pain - denied pain at this time, no signs/symptoms of pain or discomfort noted. Is on . morphine solution sublingually as needed as per hospice care medications. We will continue with the current regimen . This note failed to address the fact that on 5/28/19 the resident was receiving regularly scheduled morphine every 8 hours.
c) Hospice paperwork stated that the Oxycodone 5 mg every 4 hours had been discontinued on 5/20/19. On 5/24/19 Oxycodone 5 mg every 4 hours as needed for pain was ordered. Review of the MAR and the nursing notes failed to reveal documentation that the resident received any Oxycodone during the May admission, although 4 doses had been removed from the resident's supply. (Cross reference to F761.)
On 10/24/19 at 12:01 PM surveyor reviewed with the Director of Nursing concerns that morphine had been ordered as a regularly scheduled medication on 5/24 but was not administered until 5/26 and that according to the hospice notes the resident had been receiving acetaminophen for chronic pain three times a day prior to admission but the facility failed to administer any pain medication for the first two days of admission.
d) Hospice paperwork included sertraline (Zoloft - an antidepressant) 125 mg to be given daily. Review of the Nurse Practitioner's (NP #31) Progress Note for 5/24/19 revealed the following Plan: 4. Depression - is on sertraline. We will continue with the same regimen. (Cross reference to F842.)
Further review of the medical record failed to reveal documentation of an order for or the administration of sertraline during the May admission.
e) Hospice paperwork included Seroquel (an antipsychotic) 25 mg daily and 50 mg to be given nightly. The facility order was for Seroquel 25 mg two times a day.
f) Hospice paperwork included Haldol (an antipsychotic) 2 mg every 8 hours for agitation. Review of the electronic health record orders revealed two separate orders for regularly scheduled Haldol concentrate 2 mg/ml. One order read: Give 0.5ml by mouth every 8 hours for agitation [0.5ml would provide 1 mg of the Haldol]; the other order read: Give 1 milligram by mouth every 8 hours for agitation. (Cross reference to F756.)
Review of the MAR for these two Haldol orders revealed both doses of Haldol were administered on 7 occasions prior to the second of the orders being discontinued on 5/28/19 at 12:13 PM.
On 10/28/19 at 3:11 PM nurse #16, who entered both the Haldol orders into the electronic health record was unable to recall what the order was supposed to be. The nurse was unable to verbalize what the process should be for entering liquid medication orders. Surveyor reviewed the concern that based on these orders it is difficult to determine if 1 mg or 2 mg had been administered every 8 hours.
On 10/28/19 at 3:15 PM the Assistant Director of Nursing (ADON) was asked about the expectation for how orders for liquid medication should be entered, ie should it state how many mg to be given or how many ml of liquid. The ADON reported that she didn't believe they had anything set as long as the correct dosage was given. After reviewing the two Haldol orders her assessment was that 2 mg were administered every 8 hours. Surveyor then reviewed the concern with the ADON that the nurses and the pharmacist had failed to request clarification for these duplicate orders.
g) Hospice paperwork did not include a Zyprexa (olanzapine - an antipsychotic) on the medication list. Review of the medical record revealed an order on 5/24/19 for Zyprexa 5 mg at bedtime for agitation. On 5/28 the indication for the medication was changed to dementia with behavioral disturbances but review of the MAR revealed the Zyprexa was not administered on 5/28 due to the resident being asleep. The Zyprexa had been administered as ordered 5/24/19 thru 5/27/19.
Further review of the nursing notes and the NPs notes failed to reveal any documentation explaining why the resident had been started on the Zyprexa upon admission to the facility on 5/24/19.
Review of the physician note for a visit on 5/29/19 revealed reference to the fact that the resident is on routine Zyprexa, haloperidol and Seroquel but failed to address why the Zyprexa had been started upon admission.
Nurse #16 acknowledged on 10/28/19 at 12:37 PM that he put the Zyprexa order into the electronic health record (EHR) on 5/24/19. When asked about the discrepancy between the orders in the EHR and paperwork from the hospice agency, the nurse #16 reported that the hospice nurse will come in and write recommendations. He then referenced the area of the paper chart for hand written orders. Review of the paper chart order section, with the nurse, failed to reveal any orders written by a hospice nurse, or any orders for the Zyprexa. Nurse #16 stated: I didn't make up that medication and again indicated there should be a paper order for the Zyprexa.
On 10/24/19 at 11:12 AM, NP #31 was interviewed in regard to hospice respite admissions and Resident #319. The NP denied having ordered the Zyprexa, stating that the nurse may have called the on-call medical provider. He went on to state that he does not increase or decrease the psychotropic medications. NP also reported that he would not have changed the Haldol order either.
Further review of the electronic health record revealed documentation that NP #31 was the provider who ordered the Zyprexa on 5/24/19.
On 10/24/19 at 12:01 PM, surveyor reviewed with the Director of Nursing (DON) the above referenced medication discrepancies between the hospice documentation medication list verses what had actually been ordered upon admission in May, specifically in regard to different dosage of Seroquel, no order for the antidepressant, and a new order for the antipsychotic Zyprexa.
On 10/24/19 at 3:58 PM, the DON reported that she had requested Hospice to send over their information for the resident and indicated that the Zyprexa would be included in this documentation.
On 10/28/19 at 1:05 PM, the Administrator reported that there was no additional information regarding Resident #319 at this time.
As of time of exit on 10/28/19 at 7:00 PM, no additional documentation or information had been provided regarding Resident #319's medication, including no information as to why a third antipsychotic medication had been ordered upon admission in 5/2019. (Cross refer F757.)
2) On 10/24/19 review of Resident #319's medical record revealed a nurse's progress note with an effective date of 5/24/19 at 7:04 PM which revealed that the nurse had been called into the room where the resident had been found on laying on the floor beside the bed. The corresponding SBAR [Situation Background Assessment Recommendation note] with the same date and time revealed documentation of a set of vitals [blood pressure, pulse, respirations and temperature] that were from a previous admission the month prior.
Further review of the medical record failed to reveal documentation that nursing staff had obtained a set of vitals after the fall.
Further review of the SBAR note revealed the following: .patient is on pain management around the clock. Review of the orders revealed an order, dated 5/24/19, for morphine sulfate 5 mg to be administered every 8 hours for chronic pain, however review of the Medication Administration Record failed to reveal administration of the morphine prior to 5/26/19.
On 10/24/19 at 11:56 AM the Director of Nursing (DON) confirmed that vitals should be taken after a fall. Surveyor then reviewed the concern that no vital signs had been assessed after the fall and that the resident was not receiving pain medication around the clock as indicated in the 5/24/19 SBAR note.
3) Review of MD00142554 revealed concerns regarding care Resident #319 received while at the facility. These included concerns regarding not being fed or hydrated properly.
Review of the baseline care plan, established 5/24/19, revealed the resident required one person physical assist for eating.
Review of the documentation completed by the Geriatric Nursing Assistants (GNA) revealed that when assistance with eating was provided the resident was totally dependent on staff. Further review of the GNA documentation failed to reveal documentation that assistance was provided with eating for three of the five evenings the resident was in the facility in May.
On 10/24/19 surveyor reviewed the concern with the DON regarding a concern being expressed that the resident had not been fed or hydrated adequately during the stay and the failure to have any documentation that assistance was provided for on three of the five evening the resident was in the facility. This concern was again addressed at time of exit on 10/28/19.
4) Review of Resident #7's medical record on 10/23/19 documented that the resident was prescribed on 9/3/19 to have Ted Stockings as tolerated bilateral lower extremities on in am off at bed time and was prescribed on 9/12/19 to have Derma legs as tolerated as resident allows to Bilateral Lower extremities at all times remove for hygiene every shift. (Ted Stockings are a specialized compression hosiery designed to help prevent the occurrence of, and guard against further progression of, venous disorders such as edema). Derma legs/ DermaSaver skin protectors protect fragile skin from damage caused by friction, rubbing, abrasion and pressure that can lead to skin breakdowns, lacerations, irritation, erosions, tears, splits and superficial bruising.
On 10/24/19 at 8:53 AM resident was observed to receive a wound treatment with a dressing change to an area on the right lower leg. The [NAME] stockings and derma legs were not put on the resident after the wound treatment. Resident was observed to not have on ted stockings or derma legs as prescribed throughout the shift. Review of the treatment record at 2:45 PM revealed that both treatment orders were signed off as done/performed. There was not a progress note to indicate any reason for not applying the stockings and derma legs as prescribed. The unit manager was informed of the concern at 2:50 PM. While in resident #7's room she confirmed that neither treatment was on the resident. When asked she was unable to find the derma legs.
Resident #7 was noted to not be wearing his/her eyeglasses all shift. When asked with the unit manager in the room, the resident was unaware of the whereabouts of eyeglasses. The Unit manager had found the glasses in the top of resident's drawer of the nightstand.
Resident #7 care plan documents interventions as follows: Teds as ordered see current TAR (treatment administrative record), derma legs as tolerated as resident allows to BLE at all times, remove for hygiene, and eyeglasses as tolerated while awake.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview it was determined that the facility failed to follow a physician's order for oxygen administration for a resident. This was evident for 1 (#39)...
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Based on observation, record review, and staff interview it was determined that the facility failed to follow a physician's order for oxygen administration for a resident. This was evident for 1 (#39) of 2 residents reviewed for respiratory care.
The findings include:
During the initial pool process on 10/21/19 at 11:07 AM, an observation of Resident #39 revealed they were wearing a nasal cannula (delivers oxygen through the nose) and the oxygen (O2) level was set between 1 and 1.5 liters per minute.
A second observation was made on 10/24/19 at 10:49 AM, revealed the resident was wearing a nasal cannula and the O2 level was set between 1 and 1.5 liters per minute.
On 10/24/19 at 12:54 PM, a record review of the physician's order summary for 10/2019, revealed that Resident #39 had an order for O2 3L via nasal cannula continuous for SOB dated 1/29/19. The resident was receiving less than half the amount that was ordered.
During an interview with Licensed Practical Nurse (LPN) #35, she confirmed with surveyor that the O2 was set at 1.5 liters per minute. She stated she was not sure what the O2 rate should be and did not think he/she was on continuous O2. Reviewed the orders with LPN #35 and confirmed that the resident was to be on 3 liters per minute of O2 and it was to be continuous. LPN #35 stated she would adjust the O2 and clarify the order with the physician. She was unable to provide a reason the O2 level was incorrect.
On 10/24/19 at 2:06 PM, the Director of Nursing was made aware of the concern.
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 a physician and a certified registered nurse practitioner (CRNP) failed to write, sign and date medical visit progress notes in res...
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Based on medical record review and staff interview it was determined a physician and a certified registered nurse practitioner (CRNP) failed to write, sign and date medical visit progress notes in resident medical records the day the resident was seen. This was evident for 2 (#83, #119) of 8 residents reviewed for hospitalization.
The findings include:
1) A review of the medical record for Resident #83 on 10/25/19 revealed multiple occasions when the resident's attending physician failed to document in the resident's medical record on the day of the visit. A physician progress notes with a date of service (DOS) of 8/2/19 was documented as electronically signed on 8/9/19 and faxed to the facility on 8/12/19. Physician note with a DOS of 8/23/19 was faxed to the facility on 8/26/19. Physician note with a DOS of 9/11/19 was faxed to the facility on 9/15/19.
2) Resident of resident #119 closed record on 10/28/19 revealed that this resident was discharged from the facility on 8/14/19. The medical record was absent of a discharge summary. The Medical records director (staff #7) was informed of the missing documentation on 10/28/19 at 12:29 PM. The medical records director returned with a discharge summary with a DOS of 8/14/19 by a CRNP (staff #31). (A CRNP is an advanced practice nurse who performs the functions of a physician.) The CRNP note documented as electronically signed on 8/18/19. Upon questioning the medical records director revealed that the that the CRNP was on vacation in August and based on the discovery of missing documentation she had asked the CRNP if he had the missing Discharge Summary
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
**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 assure that residents are seen ...
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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 assure that residents are seen by a physician at least every 30 days for the first 90 days after a resident's admission. This was evident for 1 (#83) of 8 residents reviewed for hospitalization.
The findings include.
Resident #83 was admitted to the facility on [DATE]. Review of Resident #83's medical record on 10/24/19 revealed that the last physician progress note had a Date of service as 9/11/19.
The medical records director (staff #7) was interviewed on 10/24/19 at 11:10 AM. She had indicated that the resident's attending physician did not have any outstanding progress notes. On 10/25/19 at 11:14 AM the VP of clinical services was informed of the late physician's progress note/visitation. The Nursing home administrator confirmed at 1:30 PM the lack of any additional notes from resident #83's attending physician. As of 10/25/19 the physician visit for Resident #83 was two weeks overdue.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on medical record review it was determined that the facility failed to ensure the pharmacist identified medication order irregularities during the monthly pharmacy review. This was found to be e...
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Based on medical record review it was determined that the facility failed to ensure the pharmacist identified medication order irregularities during the monthly pharmacy review. This was found to be evident for one out of three (Resident #319) resident's reviewed for 5 day hospice respite admission.
The findings include:
On 10/24/19 review of Resident #319's medical record revealed two seperate orders for Haldol concentrate 2 mg/ml both of which were put into the electronic health record on 5/24/19 at 1:22 PM. One order read: Give 0.5ml by mouth every 8 hours for agitation [0.5ml would provide 1 mg of the Haldol]; the other order read: Give 1 milligram by mouth every 8 hours for agitation. Both orders were for 1 mg every 8 hours but written in slightly different format.
Review of the MAR for these two Haldol orders revealed both doses of Haldol were administered on 7 occassions prior to the second of the orders being discontinued on 5/28 at 12:13 PM.
On 5/25, 5/26 and 5/28 the doses due at 8:00 AM were coded as 9 which indicates other /see progress notes. No corresponding progress notes addressing the Haldol were found for these dates/time.
On 5/24/19 an order for Haldol concentrate give 1 ml every 4 hours as needed for agitation was put in the electonic health record at 1:48 PM then discontinued at 2:20 PM. No other orders for as needed Haldol were found until 5/28/19 at 3:23 PM.
Further review of the medical record revealed the pharmacist had completed a medication review on 5/26/19. The pharmacist made the following recommendation: Please evaluate Haloperidol [Haldol] PRN [as needed] agitation. Suggest d/c [discontinue]. At the time of the pharmacist review the resident did not have a current prn order for Haldol. The pharmacist failed to identify and address the duplicate orders for the regularly scheduled Haldol.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
2) On 10/28/19 at 11:34 AM, review of Resident #19's October 2019 MAR (medication administration record) revealed had 2 orders for narcotic medication to be given by mouth as needed for pain with no c...
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2) On 10/28/19 at 11:34 AM, review of Resident #19's October 2019 MAR (medication administration record) revealed had 2 orders for narcotic medication to be given by mouth as needed for pain with no clear indication as to which medication to give first. The resident had an order Oxycodone (narcotic) 0.5 MG (milligram) tablet give 0.5 tablet every 4 hours as needed for pain and an order for Morphine Sulfate (concentrate) Solution 20 MG/ML (milliliter) give 0.5 MG by mouth every 6 hours as needed for pain/resp. Also, the morphine order should have been clarified with the physician as the morphine dose of 0.5 MG (0.025 ML) was not a recommended adult dose per the FDA (Federal Drug Administration) and the dose, 0.025 ML (0.5 MG), would not be accurately measurable in its current form.
On 10/28/19 at 3:47 PM, during an interview, when asked how you would know which medication, the Oxycodone or the Morphine, to give if the resident was having pain, Staff #15 (RN) indicated he/she would not know which one to give and confirmed the orders did not have clear parameters to identify which one to give first. The Director of Nurses was made aware of these findings on 10/28/19 at 3:59 PM.
Based on medical record review and interview it was determined that the facility ensure the residents' medication regimen was free from unnecessary medication by 1) the ordering of an antipsychotic medication to a resident upon admission in the absence of documentation of the need for the medication and 2) failing to assure medication orders had adequate parameters to indicate when to administer as needed medications for pain. This was evident for 1 (#319) of 3 residents reviewed for hospice respite admission and 1 (#19) of 8 residents reviewed for hospitalization.
The findings include:
1) On 10/24/19 review of Resident #319's medical record revealed the resident had been admitted to the facility in May 2019 for a five day hospice respite stay. The resident's diagnosis included but was not limited to heart disease, chronic pain, dementia with behavioral disturbances, anxiety, major depressive disorder and agitation.
Review of MD00142554 revealed concerns that that the Resident #319 did not receive the correct medications.
On 10/28/19 at 12:37 PM Nurse #16 reported that for residents admitted for short term hospice respite bring a medication list with them and that the list goes into the medical record.
On 10/24/19 review of the paper documentation in the resident's medical record for the May 2019 admission revealed 17 pages of documents from the hospice. Printed at the top of each page was: May/23/2019 5:28:41 PM [name of hospice and fax number].
Review of the medical record revealed an order on 5/24/19 for Zyprexa (olazapine - an antipsychotic) 5 mg at bedtime for agitation. On 5/28 the indication for the medication was changed to dementia with behavioral disturbances but review of the MAR revealed the Zyprexa was not administered on 5/28 due to the resident being asleep. The Zyprexa had been administered as ordered 5/24 thru 5/27.
The resident was also receiving two other antipsychotic medications: Seroquel 25 mg two times a day for psychosis and Haldol 1 mg every 8 hours for agitation.
When the surveyor compared the list of medications found in the 5/23/19 hospice paperwork with the medication orders that had been put into the electronic health record on 5/24/19 it was noted that the Hospice paperwork did not include Zyprexa on the medication list.
Further review of the nursing notes and the NPs notes failed to reveal any documentation explaining why the resident had been started on the Zyprexa upon admission to the facility on 5/24/19.
Review of the physician note for a visit on 5/29/19 revealed reference to the fact that the resident is on routine Zyprexa, haloperidol and Seroquel but failed to address why the Zyprexa had been started upon admission.
Nurse #16 acknowledged on 10/28/19 at 12:37 PM that he put the Zyprexa order into the electronic health record (EHR) on 5/24/19. When asked about the discrepency between the orders in the EHR and paperwork from the hospice agency, Nurse #16 reported that the hospice nurse will come in and write recommendations. He then referenced the area of the paperchart for hand written orders. Review of the paperchart order section, with the nurse, failed to reveal any orders written by a hospice nurse, or any orders for the Zyprexa. Nurse #16 stated: I didn't make up that medication and again indicated there should be a paper order for the Zyprexa.
On 10/24/19 at 11:12 AM the NP #31 was interviewed in regard to hospice respite admissions and Resident #319. The NP denied having ordered the Zyprexa, stating that the nurse may have called the on-call medical provider. He went on to state that he does not increase or decrease the psychotropic medications.
Further review of the electronic health record revealed documentation that NP #31 was the provider who ordered the Zyprexa on 5/24/19.
On 10/24/19 at 12:01 PM surveyor reviewed with the Director of Nursing (DON) the concern that no documentation could be found in the hospice paperwork to indicate that the resident should of had an order for Zyprexa.
On 10/24/19 at 3:58 PM the DON reported that she had requested Hospice to send over their information for the resident and indicated that the Zyprexa would be included in this documentation.
On 10/28/19 at 1:05 PM the Administrator reported that there was no additional information regarding Resident #319 at this time.
As of time of exit on 10/28/19 at 7:00 PM no additional documentation or information had been provided as to why a third antipsychotic medication had been ordered upon admission in May.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, medical record review and interview it was determined that the facility failed to ensure a medication error rate of less than 5% as evidenced by 2 errors observed during the medi...
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Based on observation, medical record review and interview it was determined that the facility failed to ensure a medication error rate of less than 5% as evidenced by 2 errors observed during the medication observation of 32 opportunities for errors resulting in a medication error rate of 6.25. This was found to be evident for two (Resident #425 and #426) out of four residents observed during the medication administration observation.
The findings include:
1) On 10/23/19 at 8:37 AM surveyor observed licensed practical nurse (LPN) #5 prepare and administer medications for Resident #425. The nurse reported that an antibiotic was due but was not available on the medication cart at this time. The nurse informed the resident about the antibiotic and the resident stated that it was finished on the 22nd. The nurse informed the resident that she had checked the computer and that the medication was due to end on the 23rd.
After administering the other medications the nurse was observed obtaining Cefadroxil [an antibiotic] 500 mg capsule from the medication room. At approximately 9:15 AM surveyor observed the nurse administer Cefadroxil 500 mg to the resident.
On 10/23/19 at 10:38 AM review of the medical record revealed that the Cefadroxil was ordered on 10/8/19 to be given every 12 hours until 10/23/19 23:59 [11:59 PM] x 14 days. Every 12 hours for 14 days would result in a total of 28 doses. Review of the medication administration record (MAR) revealed the antibiotic was administered as ordered starting on 10/9/19 at 9:00 AM and the 28th dose was administered on 10/22 at 9:00 PM.
2) On 10/23/19 at 9:00 AM surveyor observed nurse #5 prepare and administer medications for Resident #426. After the regularly scheduled medications had been administered the resident reported having some pain. The nurse was then observed preparing and administered two 500 mg acetaminophen tablets. Nurse confirmed that she was administering two tablets at this time.
On 10/23/19 at 10:51 AM review of the medical record revealed an order for Tylenol Extra Strength Tablet 500 mg (acetaminophen) give 1 tablet by mouth every 4 hours as needed for PAIN do not exceed 3 gm in 24 hours. Review of the MAR revealed the nurse had documented the administration of one tablet at 9:04 AM.
On 10/23/19 at 1:00 PM surveyor reviewed with the Director of Nursing the observed antibiotic and pain medication errors and the concern that the error rate was above 5%.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on review of medical record and interview it was determined that the facility failed to ensure that narcotic medication that was removed from the resident's supply was administered to the reside...
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Based on review of medical record and interview it was determined that the facility failed to ensure that narcotic medication that was removed from the resident's supply was administered to the resident. This was found to be evident for one (Resident #319) out of 3 residents reviewed for 5 day hospice respite admission.
The findings include:
On 10/24/19 review of Resident #319's medical record revealed that on 5/24/19 Oxycodone 5 mg tablet every 4 hours as needed for pain was ordered. Review of the MAR and the nursing notes failed to reveal documentation that the resident received any Oxycodone during the May admission.
On 10/28/19 review of the narcotic control sheet for the Oxycodone 5 mg tablets revealed a total of 4 doses of the medication had been removed from the resident's supply on 5/29/19. One dose at 8:00 AM, one dose at 12 noon, and two additional doses after the 12 noon dose were removed with a notation of wasted.
Review of the nursing note dated 5/29/19 at 9:00 AM revealed the resident had a change in condition and was unable to swallow, was listless and responsive only to tactile stimuli. The resident was breathing fast so liquid morphine was administered under the resident's tongue.
Further review of the medical record revealed that at 11:03 AM the resident was continuing to decline and began coughing when staff attempted to administer liquid Tylenol. A note at 12:06 PM revealed that the resident had left the facility in an ambulance.
No documentation was found in the progress notes that the resident required or received the Oxycodone 5 mg tablets 5/29/19.
On 10/28/19 at 4:56 PM surveyor reviewed with Director of Nursing (DON) the concern that 4 oxycodone had been removed from the resident's supply but that there was no documentation that the medication had been administered to the resident.
On 10/28/19 at 5:38 PM DON confirmed that there was no documentation that the oxycodone had been administered to the resident.
2) Further review of the medical record revealed an order, dated 5/24/19, for Morphine Sulfate (Concentrate) Solution 20 mg/ml Give 5 mg by mouth every 8 hours for chronic pain.
Review of the MAR revealed the morphine was administered as ordered starting on 5/26 at 8:00 AM thru 5/28 8:00. According to the MAR the morphine was not administered when due on 5/28 at 4:00 PM or at midnight due to the resident sleeping.
Review of the controlled drug administration record for the morphine revealed a total of 10 doses of morphine had been removed from the residents supply. Review of the MAR documentation revealed only 8 doses had been administered to the resident. On 5/28/19 doses were removed at 12:00 AM; 6:00 AM and 8:00 AM. No documentation was found that the dose removed at 6:00 AM was administered to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews and observations of the kitchen with the testing of a food tray it was determined that the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews and observations of the kitchen with the testing of a food tray it was determined that the facility failed to serve food at a preferable temperature. This was identified on the unit that is the last to be served food.
The findings include.
Initial observations of the kitchen tray line food service on 10/21/19 at 7:40 AM revealed that there were not any plates in the plate warmer. The plate warmer was on and heat was felt. There were approximately 2 dozen plates sitting in the bottom plastic plate insulator behind the person that initiates the tray line. The plates were not handled appropriately to maintain heat prior to plating of the breakfast items.
Interview of resident #105 on 10/21/19 at 11:12 AM, stated that this is the last unit to get food cart and sometime the people in charge of getting the food out take their time and the food comes cold or lukewarm. Interview of resident #46 on 10/21/19 at 12:57 PM indicated when s/he eats in the room the food is cold.
During lunch time tray line food service in the kitchen on 10/23/19 a test tray was requested to be placed on the cart designated for the 500 hall. Menu items on the test tray included Bar-b-cue beef, baked beans, [NAME] slaw and Pineapple crisp. A drink was declined for the test tray. The cart was followed out of the kitchen and arrived on the 500 hall at 12:43 PM. Observations of the cart remained until the last resident on the unit was served a tray. At 12:59 with the Dietary manager present the BBQ beef was temped to only reach 120 degrees Fahrenheit, the baked beans were temped to 116 and the [NAME] slaw was temped to be 60 degrees Fahrenheit. The food service manager confirmed the temperatures record with her own digital thermometer. The hot food was lukewarm, and the cold food was warm. The test tray had confirmed the residents concern of food not being served at preferable temperatures. The surveyor had tasted the food and informed the Dietary manager had this been served in a restaurant it would have been sent back due to the cold temperature of the entrée and warm temperature of the [NAME] slaw.
On 10/24/19 interview with the facility's dietitian revealed that she had audited a lunch time test tray on 9/6/19. Per the facility's Room Test tray evaluation, acceptable delivery temperature for hot entrée/vegetable item is 135 to 160 degrees F. For cold items acceptable delivery temperature is listed as 40 to 55 degrees F.
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** 3) On 10/21/10 at 9:10 AM, observation of room [ROOM NUMBER] revealed there was a large scrape across the width of the lower doo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 10/21/10 at 9:10 AM, observation of room [ROOM NUMBER] revealed there was a large scrape across the width of the lower door and paint was missing and there were TV cables hanging loosely from the wall behind the TV. The baseboard in the room was dirty and there was a gap in the baseboard near the bathroom door that was soiled with dark debris. Observation of room [ROOM NUMBER]'s shared bathroom revealed the base board was dirty in the right front corner wall across from the toilet and the baseboard was dirty in the right front corner of the shower. There was base board was missing in the left corner of shower and, in front of the shower, the floor tile was missing in 2 areas, an area about 1 x 1 diameter and an area about 1 x 2 area.
Observation of room [ROOM NUMBER] on 10/21/19 at 9:51 AM revealed there was paint was peeling in corner of the wall near the window, the walls around the room had a chair rail made of wide width, wood board that was unfinished and unpainted and the privacy curtain next to bed A was soiled. Next to the window wall, near the foot of bed B was a chair that had a pillow on the seat with a dirty pillowcase that had brown and red colored spots on it. At that time, an observation of room [ROOM NUMBER]'s shared bathroom revealed the bathroom baseboard on the right side and in front of the toilet was very dirty. The base of the commode was dirty. The shower floor had black/brown colored stains around the drain, and, to the left of the drain, there were 2 areas of brown matter. There was a dent in the wall between the shower and the door frame. The interior bathroom door's left, lower frame had scrapes with paint missing.
On 10/21/19 at 10:25 AM, observation of room [ROOM NUMBER] revealed that porcelain was chipped along the front of the sink and rusty metal was exposed. The right window wall had a wide width, wood board chair rail that was unfinished and unpainted. Behind B bed, the chair rail had scraped areas with unfinished wood exposed, 4 areas where the nail was popping through and 3 areas that were splintered. The wall under the sink had a dented hole in the left side of the wall. The left door of the wardrobe had a brown/black streak across three quarters width of the door. The lower wardrobe door had an approximate 3-inch area of laminate missing. There was a black cord hanging down loosely from the TV on the wall mounted stand next to A bed. Observation of room [ROOM NUMBER]'s shared bathroom revealed the floor around the base and right side of the commode was soiled a brown color and the base board in the bathroom was dirty, the base board was peeling away from the wall on the right side of the toilet, and the toilet seat was loose.
Observation of room [ROOM NUMBER] on 10/21/19 at 12:21 PM revealed the chair rail around the room was a wide width wood board that was unfinished and unpainted.
Based on surveyor observation and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair including the grounds. This was evident throughout the survey 1) the outside grounds; 2) on 3(200, 300, and 500) of 4 hallways; and 3) in 4 (506, 509, 505, 502) of 6 resident rooms.
The findings include:
1) A tour of the grounds was conducted with the maintenance director on 10/25/19 at 10:10 AM. Exiting through the back doors of the facility, the grounds were not noted to be clean, neat, and attractive. There was an extensive collection of unused possessions that included mattresses, beds, bed parts, Geri chairs, air conditioning units, a large horizontal freezer, a shower stretcher, Hoyer lifts and/or other manufacture lifts, at least 5 wheelchairs, wheelchair parts and numerous walkers in the back of the facility. The maintenance director provided explanations for some of the accumulated concerns with an indication that the unused freezer had been there for at least two months. The accumulated items could be seen from some of the resident rooms that were adjacent to the backside of the building.
2) The following environmental concerns were observed during the survey and a tour was conducted with the maintenance director and the nursing home administrator on 10/28/19 at 3 PM:
The door to room [ROOM NUMBER] was noted to have separating veneer with rough edges to the door perimeter.
The bathroom/toilet room between rooms [ROOM NUMBERS] was noted to have dirty stained floor around the toilet with a very prevalent foul odor in the room. Both doorways into the room were marred/marked up at least two feet up from the floor. The damage most likely caused by wheelchairs. Black marring noted on the walls in the toilet room.
The wall behind the B-bed in room [ROOM NUMBER] was noted to be damaged with gouges behind the head of the bed.
In room [ROOM NUMBER] the outside wall with the window was noted to be deteriorating with cove molding separated from the wall. On the floor tile along the wall on both sides of the heater was cracked and deteriorating
In room [ROOM NUMBER], the wall behind the A bed was noted to have black streaks on the wall approximately two feet in length. Behind the door there was dark staining on the floor and the cove molding. Per the maintenance director the noted staining was from ineffective cleaning methods.
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 5 (#74, #105, #19, #70, #69) of 8 residents reviewed for hospitalization.
The findings include:
1) On 10/22/19 at 1:53 PM, a review of Resident #74's medical record revealed the resident was transferred to an acute care facility on 8/1/19. On 8/1/19 at 11:30 AM, in a progress note, the nurse documented a change in Resident #74's medical condition, 911 was called and Resident #74 was transported to the hospital emergency room for evaluation. Continued review of the medical record failed to reveal documentation the Resident #105 and/or the resident's representative was notified in writing of the transfer along with the reason why the resident was transferred to the hospital. The Director of Nurses (DON) was made aware of these findings on 10/23/19 at 3:00 PM.
2) On 10/24/19 at 10:48 AM, a review of Resident #105's medical record revealed documentation that Resident #105 was transferred to an acute care facility on 8/28/19. On 8/28/19 at 1:00 PM, in an SBAR (Situation, Background, Assessment, Recommendation; used to facilitate communication) progress note, the nurse documented that following an oncology radiation appointment, Resident #105 returned to the facility. The facility later received a call from his/her physician who directed Resident #105 be sent to the hospital emergency room for evaluation, indicating the resident had abnormal lab values and Resident #105 was sent to the hospital. Continued review of the medical record failed to reveal documentation the Resident #105 and/or the resident's representative was notified in writing of the transfer along with the reason why the resident was transferred to the hospital. The Director of Nurses (DON), the Administrator and the Corporate Registered Nurse were made aware of these findings on 10/24/19 at 6:15 PM.
3) On 10/28/19 at 11:34 AM, review of Resident #19's medical record revealed documentation that Resident #19 was transferred to an acute care facility on 7/6/19. On 7/6/19 at 5:50 AM, in a SBAR progress note, the nurse indicated Resident #19 was transferred to the emergency department following a fall. Continued review of the medical record failed to reveal documentation the Resident #19 and/or the resident's representative was notified in writing of the transfer along with the reason why the resident was transferred to the hospital. The DON was made aware of these findings on 10/28/19 at 3:59 PM
4) On 10/28/19 at 1:02 PM, review of Resident #70's medical record revealed documentation that Resident #70 was transferred to an acute care facility on 8/6/19. On 8/6/19 in a SBAR progress note, the nurse documented Resident #70 was sent to the hospital via 911 and indicated the resident had had a change in condition. Continued review of the medical record failed to reveal documentation the Resident #19 and/or the resident's representative was notified in writing of the transfer along with the reason why the resident was transferred to the hospital.
5) Review of the medical record for Resident #69 on 10/21/19 documented that the resident was transferred to an acute care facility on 7/9/19, 8/6/19, and again on 8/15/19. Resident #69's thin record was received upon request. There was not any documentation found in the medical record that the resident was given written notice of the transfers for the three hospital admissions. Interview of the nursing home administrator on 10/25/19 at 8 AM revealed that prior to September evidence of the written documentation would not be found in the record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected multiple residents
5) On 10/22/19 at 1:53 PM, a review of Resident #74's medical record revealed the resident was transferred to an acute care facility on 8/1/19. On 8/1/19 at 11:30 AM, in a progress note, the nurse doc...
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5) On 10/22/19 at 1:53 PM, a review of Resident #74's medical record revealed the resident was transferred to an acute care facility on 8/1/19. On 8/1/19 at 11:30 AM, in a progress note, the nurse documented a change in Resident #74's medical condition, 911 was called and Resident #74 was transported to the hospital emergency room for evaluation. Continued review of Resident #105's medical record failed to reveal documentation that Resident #105 had received an explanation of why he/she was going to the emergency room and the potential response of the resident's understanding. The Director of Nurses (DON) was made aware of these findings on 10/23/19 at 3:00 PM.
6) On 10/24/19 at 10:48 AM, a review of Resident #105's medical record revealed documentation that Resident #105 was transferred to an acute care facility on 8/28/19. On 8/28/19 at 1:00 PM, in an SBAR (Situation, Background, Assessment, Recommendation; used to facilitate communication) progress note, the nurse documented that following an oncology radiation appointment, Resident #105 returned to the facility. The facility later received a call from his/her physician who directed Resident #105 be sent to the hospital emergency room for evaluation, indicating the resident had abnormal lab values and Resident #105 was sent to the hospital. Continued review of Resident #105's medical record failed to reveal documentation that Resident #19 had received an explanation of why he/she was going to the emergency room and the potential response of the resident's understanding. The DON, the Administrator and the Corporate Registered Nurse were made aware of these findings on 10/24/19 at 6:15 PM.
7) On 10/28/19 at 11:34 AM, review of Resident #19's medical record revealed documentation that Resident #19 was transferred to an acute care facility on 7/6/19. On 7/6/19 at 5:50 AM, in a SBAR progress note, the nurse indicated that Resident #19 was transferred to the emergency department following a fall. Continued review of Resident #19's medical record failed to reveal documentation that Resident #19 had received an explanation of why he/she was going to the emergency room and the potential response of the resident's understanding. The DON was made aware of these findings on 10/28/19 at 3:59 PM
8) On 10/28/19 at 1:02 PM, review of Resident #70's medical record revealed documentation that Resident #70 was transferred to an acute care facility on 8/6/19. On 8/6/19 in a SBAR progress note, the nurse documented Resident #70 was sent to the hospital via 911 and indicated the resident had had a change in condition. Continued review of Resident #70's medical record failed to reveal documentation that Resident #19 had received an explanation of why he/she was going to the emergency room and the potential response of the resident's understanding.
Based on medical record review and staff interview it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 8 (#69, #111, #83, #119, #74, #105, #19, and #70 ) of 8 residents reviewed for hospitalization.
The findings include:
1)Review of the medical record for resident #69 on 10/22/19 documented that on 7/9/19 resident #69 was having difficulty breathing, was evaluated and transferred out to an acute care facility at 8:15 PM
2) Review of the medical record for resident #111 on 10/22/19 documented that on 9/21/19 at 3:12 PM the resident was found on the floor and sent to the emergency room.
3) Review of the medical record for resident #83 on 10/25/19 documented that on 9/9/19 at 11:45 AM resident #83 had complained of chest pain. The nursing progress note was simply written as Resident went to ER (emergency room) with right hearing aid in his ear.
4) Review of the medical record for Resident #119 on 10/29/19/19 documented that on 7/29/19 at 5:28 PM that Resident #119 fell and was to be transferred to the emergency room.
There was no written documentation found in the medical records that Resident #69, Resident #83, Resident #111, and Resident #119 were oriented and prepared for the transfer in a manner that each resident could understand and there was no documentation of the resident's understanding of the transfer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview it was determined the facility staff failed to give the written bed hold policy to the resident or resident representative upon transfer/discharge of...
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Based on medical record review and staff interview it was determined the facility staff failed to give the written bed hold policy to the resident or resident representative upon transfer/discharge of a resident to an acute care facility. This was evident for 4 (#74, #105, #19, #70) of 8 residents reviewed for hospitalization.
The findings include:
1) On 10/22/19 at 1:53 PM, a review of Resident #74's medical record revealed the resident was transferred to an acute care facility on 8/1/19. On 8/1/19 at 11:30 AM, in a progress note, the nurse documented a change in Resident #74's medical condition, 911 was called and Resident #74 was transported to the hospital emergency room for evaluation. Continued review of the medical record failed to reveal documentation that the resident and/or the resident's representative was given the written bed hold policy upon the resident's transfer to the hospital. The Director of Nurses (DON) was made aware of these findings on 10/23/19 at 3:00 PM
2) On 10/24/19 at 10:48 AM, a review of Resident #105's medical record revealed documentation that Resident #105 was transferred to an acute care facility on 8/28/19. On 8/28/19 at 1:00 PM, in an SBAR (Situation, Background, Assessment, Recommendation; used to facilitate communication) progress note, the nurse documented that following an oncology radiation appointment, Resident #105 returned to the facility. The facility later received a call from his/her physician who directed Resident #105 be sent to the hospital emergency room for evaluation, indicating the resident had abnormal lab values and Resident #105 was sent to the hospital. Continued review of the medical record failed to reveal documentation that the resident and/or the resident's representative was given the written bed hold policy upon the resident's transfer to the hospital. The Director of Nurses (DON), the Administrator and the Corporate Registered Nurse were made aware of these findings on 10/24/19 at 6:15 PM.
3) On 10/28/19 at 11:34 AM, review of Resident #19's medical record revealed documentation that Resident #19 was transferred to an acute care facility on 7/6/19 following a fall. On 7/6/19 at 5:50 AM, in a SBAR progress note, the nurse indicated Resident #19 was transferred to the emergency department following a fall. Continued review of the medical record failed to reveal documentation that the resident and/or the resident's representative was given the written bed hold policy upon the resident's transfer to the hospital. The DON was made aware of these findings on 10/28/19 at 3:59 PM
4) On 10/28/19 at 1:02 PM, review of Resident #70's medical record revealed documentation that Resident #70 was transferred to an acute care facility on 8/6/19. On 8/6/19 in a SBAR progress note, the nurse documented Resident #70 was sent to the hospital via 911 and indicated the resident had had a change in condition. Continued review of the medical record failed to reveal documentation that the resident and/or the resident's representative was given the written bed hold policy upon the resident's transfer to the hospital.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
4) Several observations were made of Resident #77 on 10/22/19, 10/23/19, and 10/24/19 at varying times and resident was in the bed.
A medical record review for Resident #77 on 10/22/19 at 10:40 AM, r...
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4) Several observations were made of Resident #77 on 10/22/19, 10/23/19, and 10/24/19 at varying times and resident was in the bed.
A medical record review for Resident #77 on 10/22/19 at 10:40 AM, revealed a care plan initiated on 12/5/18, for falls related to muscle weakness, however, there was no care plan for wandering behaviors. The physicians' notes dated 9/10/19 and 10/8/19 document resident has debility.
Review of the quarterly MDS with an Assessment Reference Date of 9/12/19, revealed in section E0900 Wandering #2 was checked, behavior of this type occurred 4 to 6 days, but less than daily. Review of the progress notes dated 9/7/19 - 9/13/19, revealed no documentation of wandering behaviors.
On 10/23/19 at 3:15 PM, an interview with MDS #11 revealed that Resident #77 did not wander because he/she rarely got out of bed. She reported that was an inaccurate assessment.
An interview with Director of Social Services #1 on 10/24/19 at 1:00 PM, she confirmed that it was marked in error, but offered no rationale for the reason this happened.
The Director of Nursing confirmed that this was an error for Resident #77 during an interview on 10/28/19 at 1:00 PM. She acknowledged the concern.
2) On 10/21/19 at 11:24 AM, during an interview, Resident #105 stated that he/she had a history of urinary tract infections (UTI) and just finished taking antibiotics for a UTI last week. On 10/24/19 at 10:48 AM, a review of Resident #105's medical record revealed on 9/20/19 at 11:50 PM, in a progress note, the physician documented that he/she was seeing Resident #105 following the resident's hospitalization and readmission to the facility. The physician documented the resident was hospitalized for a change in mental status and a urinary tract infection. Review of Resident #105's 5-day MDS, with an ARD (assessment reference date) of 9/25/19 was inaccurate. Section I, Active Diagnosis, 12300. Urinary Tract Infection (within the last 30 days) was blank. The MDS failed to capture Resident #105's UTI. The MDS coordinator (Staff #11), was made aware of these findings on 10/24/19 at 4:36 PM
3) On 10/28/19 at 11:34 AM, Resident #19's medical record was reviewed and revealed documentation that Resident #19 had diagnosis that included dementia. On 6/4/19, in a progress note, the physician's assessment documentation indicated Resident #19 had unspecified dementia without behavioral disturbance. On 7/16/19 at 8:03 PM, in a readmission note, the physician's assessment documentation indicated Resident #19 had unspecified dementia without behavioral disturbance.
Review of Resident #19's significant change MDS with an ARD of 7/17/19, revealed Section I, Active Diagnoses, failed to capture Resident #19's dementia diagnoses. On 10/28/19 at 1:25 PM, during an interview, the MDS Coordinator (Staff #10) confirmed the findings.
Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#118, #105, #19, and #77) of 34 resident investigations during the survey.
The findings include:
The MDS is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.
1) A review of the medical record for Resident #118 was conducted on 10/28/19 documents that resident #118 was discharge to the community/home on 8/30/19. Review of the MDS assessment with an assessment reference date (ARD) of 8/30/19 indicated that the resident was discharged to the hospital. The MDS assessment for Discharge Status at A2100 was inaccurately coded on 9/12/19.
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) Observations of Resident #72 on 10/23/19 at 1:49 PM, 10/24/19 at 10:33 AM, and 10/25/19 at 9:57 AM, revealed there were fall mats on the right side of the bed, but none on the left side of the bed ...
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2) Observations of Resident #72 on 10/23/19 at 1:49 PM, 10/24/19 at 10:33 AM, and 10/25/19 at 9:57 AM, revealed there were fall mats on the right side of the bed, but none on the left side of the bed under the window.
A record review on 10/24/19 at 10:22 AM, revealed a care plan initiated on 5/13/19, that documented resident has a history of falls. The goal dated 5/13/19, stated the resident will remain safe and not have a major injury. The intervention stated 2 fall mats.
On 10/28/19 at 1:30 PM, an interview with the Director of Nursing revealed her expectation for this intervention was to have a fall mat on each side of the bed.
Based on resident representative and resident interview, observation, medical record review and staff interview it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident for 1 (#105) of 1 residents reviewed for urinary tract infections and 1 (#72) of 6 residents reviewed for accidents.
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) On 10/21/19 at 11:24 AM, during an interview, Resident #105 stated that he/she had a history of urinary tract infections (UTI) and just finished taking antibiotics for a UTI last week. On 10/24/19 at 10:48 AM, a review of Resident #105's medical record revealed on 9/20/19 at 11:50 PM, in a progress note, the physician documented that he/she was seeing Resident #105 following the resident's hospitalization and readmission to the facility. The physician documented the resident was hospitalized for a change in mental status and a urinary tract infection. Continued review of Resident #105's medical record failed to reveal a comprehensive, resident centered care plan with measurable goals to address Resident #105's history of urinary tract infections.
CONCERN
(E)
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 maintain complete and accurate...
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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 maintain complete and accurate medical records by: 1) failing to void MOLST (Maryland Medical Order for Life Sustaining Treatment) forms when a new MOLST has been created, 2) failing to ensure a resident's Preadmission Screening and Resident Review (PASRR) Level I ID Screen for Mental Illness and Intellectual Disability or related conditions were retained in the resident's medical record, 3) failing to accurately document a resident's refusal to wear a soft helmet, 4) allowing the Social Service Director to sign notes in the electronic medical records as a LCSW (licensed clinical social worker) in the absence of having a social work license, and 5) failing to ensure the in-house nurse practitioner's notes were available on the medical record for review and failed to ensure the practitioner's notes were accurately documented. This was evident for 6 (#70, #74, #105, #19, #320, and #319) of 32 residents reviewed during survey.
The findings include:
1) On [DATE] at 11:06 AM, review of Resident #70's paper medical record and electronic medical record (EMR) revealed the resident had 2 medical practitioner signed MOLST (documents a person's wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatments) forms. Resident #70's paper medical record contained a MOLST, signed and dated [DATE], that documented that Resident #70's health care agent elected No CPR, Option B, Palliative and Supportive Care, and documented the resident's preferences that applied to other situations other than cardiopulmonary arrest. Review of Resident #70's EMR revealed a MOLST, signed and dated [DATE], that documented that Resident #70's healthcare agent elected No CPR, Option A, Comprehensive Efforts to Prevent arrest, Option A-2, Do Not Intubate (DNI) and documented the resident's preferences that applied to other situations other than cardiopulmonary arrest. The medical practitioner failed to void Resident #70's MOLST form dated [DATE] when a new MOLST had been created.
2) On [DATE] at 1:53 PM a review of Resident #74's paper medical record and EMR revealed Resident #2 had 2 medical practitioner signed MOLST forms. Resident #74's paper medical record contained a MOLST, signed and dated [DATE], that documented the resident elected No CPR, Option A, Comprehensive Efforts to Prevent Arrest, Option A-2, Do Not Intubate (DNI) and documented the resident's preferences that applied to other situations other than cardiopulmonary arrest. Review of Resident #74's EMR revealed a MOLST, signed and dated [DATE], that documented Resident #74 elected, CPR (resuscitation) status: Attempt CPR. The medical practitioner failed to void Resident #70's MOLST form dated [DATE] when a new MOLST had been created.
On [DATE] at 2:30 PM, during an interview, when asked what the process was for voiding MOLST forms, the Director of Nurses (DON) stated that when a MOLST is voided it goes to the social worker. At that time, the DON was made aware of the above findings.
3) On [DATE] at 10:48 AM a review of Resident #105's medical record failed to reveal a completed PASRR for Resident #105. On [DATE] at 1:53 PM a review of Resident #74's medical record failed to reveal a completed PASRR for Resident #105. On [DATE] at 2:14 PM, during an interview, when asked what the process was for implementing the PASRR, the Social Service Director (Staff #1) stated that when a resident came into the facility, their PASSR was checked for accuracy and, within 7 days, a social assessment would done and a new PASSR would be completed. Staff #1 stated that the PASRR would be kept in the resident's medical record and a copy would be kept in the social workers office. At that time, Staff #1 was made aware that Resident #74 PASRR and Resident #105's PASRR's were not found in their medical records.
On [DATE] at 4:00 PM, Staff #1 provided the surveyor with a copy of a PASRR for Resident #74, that was signed as completed by Staff #1 on [DATE]. Staff #1 also provided the surveyor with a copy of a PASRR for Resident #105 that was signed as completed by Staff #1 on [DATE]. No other PASRRs for Resident #74 and Resident #105 were provided to the surveyor. The facility staff failed to retain the resident's PASRRs in the resident's medical record.
4) On [DATE] at 10:25 AM, an observation was made of Resident #19 lying in bed. At that time, Resident #19 was not wearing anything on his/her head. On [DATE] at 10:57 AM, Resident #19 was observed in bed without anything on his/her head. On [DATE] at 11:57 AM, a review of Resident #19's medical record revealed a physician's order for Resident #19 to wear a soft helmet at all times, may remove for hygiene care; every shift check placement. On [DATE], during the afternoon, intermittent observations of Resident #19 revealed the resident was not wearing a soft helmet. On [DATE] at 11:25 AM, the resident was observed out of bed, in a wheelchair, and he/she was not wearing a soft helmet. On [DATE], [DATE] and [DATE], in the morning and afternoon, during dayshift, multiple, intermittent observations were made of Resident #19 and, during each of these observations, Resident #19 was never observed wearing a soft helmet.
On [DATE] at 1:30 PM, review of Resident 19's [DATE] TAR (treatment administration record) revealed a physician's order, Wear soft helmet at all times, may remove for hygiene care; every shift check placement which was documented as done on dayshift on 10/21, 22, 23, 24 and 28, 2019 dayshift, indicating Resident #19 wore a soft helmet on dayshift on those days. The documentation was in contravention to the multiple surveyor observations of Resident #19 not wearing a soft helmet during dayshift, on those dates.
On [DATE] at 3:40 PM, during an interview, when asked if Resident #19 ever wore a soft helmet, Staff #14 (GNA) (geriatric nursing assistant) stated the resident had not worn the helmet for a while. Staff #14 stated that he/she didn't mean to be offensive, but the resident was stubborn, and won't wear it.
The Director of Nurses was made aware of these findings on [DATE] at 3:59 PM. At that time the DON indicated that Resident #19 would not always cooperate with wearing the helmet and referred to Resident #19's fall care plan with an intervention for the resident to wear the soft helmet at al times as the resident allows. The DON was made aware of the concerns related to the staff documenting Resident#19 wore a soft helmet when the resident did not and failing to follow the physician's order by failing to ensure Resident #19 wore the soft helmet at all times.
4) On [DATE] review of Resident #320's medical record revealed a note written by the Social Service Director #1 on [DATE] at 3:10 PM regarding discharge planning. This note was electronically signed by the SSD (Staff #1) with LCSW after Staff #1's name. LCSW stands for Licensed Clinical Social Worker. On [DATE] at 1:49 PM the SSD #1 had reported she was not a licensed social worker. On [DATE] the Administrator also confirmed that the SSD was not a licensed social worker.
A check with the Maryland Board of Social Work website confirmed that no license could be found for SSD #1.
5) On [DATE] review of Resident #319's medical record revealed nurse progress notes, written by Nurse #16, that referenced a nurse practitioner. These included a note written on [DATE] stating: All meds verified with CRNP.
Review of the [DATE] admission medication orders revealed the that they had been ordered by NP #31 and entered into the electronic health record by Nurse #16.
Further review of the medical record failed to reveal documentation by a nurse practitioner for the resident's May admission.
On [DATE] at 10:07 AM NP #31 reported that he usually completes two notes for the residents admitted for 5 day hospice respite. The NP reported that his notes are in a seperate electronic health record system and that the facility's medical record department does not have access to this system but if they want the notes he is able to print them. The NP then provided print out of notes for visits on 5/24 and 5/28.
Review of the NP notes for 5/24 and [DATE] both revealed the following in the Historyof Present Illness section : .is on hospice services of [name of incorrect hospice agency] and was admitted to [name of facility] on [DATE] for respite stay. Patient completed 5-day respite stay in [name of facility]. Today [s/he] is being discharged to home with continued home hospice services of [name of incorrect hospice agency].
On [DATE] at 11:12 AM the NP reported the information in the History of Present Illness was from a previous stay but that everything else in the notes was accurate.
On [DATE] at 3:54 PM surveyor reviewed the concern with the Director of Nursing regarding failure to have the NP notes in the closed record and the inaccuracies within the notes.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 4 out...
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Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 4 out of 5 personnel files reviewed.
The findings include:
A random review of GNA personnel files was conducted on 10/28/19 at 2:00 PM with the Human Resources Director.
1) Review of Staff #17's employee personnel file documented a date of hire (DOH) of 9/16/15. The Human Resources Director did not have any yearly performance evaluation for this employee. She did imply that a past years performance review could be in a stack of boxes on the floor in her office.
2) Review of Staff #18's employee personnel file documented a DOH of 5/16/18. The yearly performance review was not performed.
3) Review of Staff #20's employee personnel file documented a DOH of 5/25/15. The last yearly performance review on file was dated 7/18/17 and it was not signed by the employee.
4) Review of Staff #21's employee personnel file documented a DOH of 2/8/17. The last yearly performance review was dated 3/14/18.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on record review and staff interview it was determined that the facility staff failed to put a system in place to ensure proper infection surveillance policies and procedures were in place by; 1...
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Based on record review and staff interview it was determined that the facility staff failed to put a system in place to ensure proper infection surveillance policies and procedures were in place by; 1) reading Tuberculosis Skin Test (TST) results outside of the specified time frame and 2) failed to update Infection Prevention and Control Program Policy (IPCP) annually. This was true for 3 (#95, #368, #427) of 3 residents reviewed for infection control and for 2 of 3 policy's reviewed for infection control. These deficient practices have the potential to affect all residents, visitors and staff in the facility.
The findings include:
The TST helps determine if someone has developed a response to the bacteria that causes tuberculosis (TB). The TST consist of two separate tests (steps). Each one is performed by injecting a small amount of fluid (called tuberculin) into the skin on the lower part of the arm. A licensed nurse will look for (read) a reaction on the resident's arm within 48 to 72 hours.
1). On 10/28/19 at 9:27 AM a record review of Resident #368 revealed that the First Step TST was read in less than 35 hours, the Second Step TST was read in less than 48 hours. Resident #95 record revealed that the Second Step TST was read in less than 43 hours.
On 10/28/19 at 2:07 PM a record review of Resident #427 revealed that the First Step TST was read in less than 45 hours, the Second Step TST for the resident was read in less than 40 hours.
2). On 10/28/19 at 4:10 PM a record review revealed that the IPCP policy was last reviewed in 2016 and the Antimicrobial Policy had no date to indicate the last review.
On 10/28/19 at 4:21 PM in an interview with Infection Control Preventionist (ICP) revealed they have no process to review policies on an annual basis.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observations and staff interview it was determined that the facility failed to have an effective system in place to ensure that the posting of staff is up to date and current. The facility is...
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Based on observations and staff interview it was determined that the facility failed to have an effective system in place to ensure that the posting of staff is up to date and current. The facility is required to list the total number of staff and the actual hours worked by the staff to meet this regulatory requirement. The information should reflect staff absences on any shift due to callouts and illness. The current and accurate staffing data should be available to residents and visitors at any given time.
The findings include.
During the survey the daily posting of staffing was observed to be on display at the reception desk at the main entrance to the facility. The staffing sheet was observed each morning of the survey with the staffing data for all three shifts. On 10/25/19 at 10:10 AM a request was made to the nursing home administrator for the current weeks daily staffing sheets. He had indicated that the staff scheduler is responsible for printing the daily staffing sheets.
Interview of the staff scheduler at 2:00 PM on 10/25/19 revealed that the staffing sheets are posted one time per day. She had indicated that the staffing sheets for the weekend will be printed for the entire weekend. With further questioning she confirmed that if there was any staff call outs during the weekend it will not be reflected in the pre-printed staffing sheets. If there were fluctuations in the resident census between shifts and/or staff call out this data will not be changed in real time.
Jun 2018
22 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on a review of the facility's investigation of a facility reported incident and staff interview it was determined that the facility failed to protect a resident from abuse. (#64). This was true ...
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Based on a review of the facility's investigation of a facility reported incident and staff interview it was determined that the facility failed to protect a resident from abuse. (#64). This was true for 1 out of 44 residents selected for review during the annual survey process.
The findings include:
A review of the facility's investigation revealed that on the morning of 2/18/18 it was reported that a Staff #2 witnessed Staff #3 state to the resident that she would slap the shit out of [him/her]. Staff #3 alleged that the resident talked inappropriately to her. The nurse sent Staff #3 home. Resident was assessed for injury and none was found. Police were called. Resident could not recall what happened. Staff #3 was terminated and was reported to the Maryland Board of Nursing.
The Director of Nursing was interviewed on 6/26/18 at 10:26 AM. She confirmed the results of the facility investigation and confirmed the results of the investigation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined that the facility staff failed to ensure the local ombudsman was notified with all of the required information of a facility initia...
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Based on medical record review and staff interview it was determined that the facility staff failed to ensure the local ombudsman was notified with all of the required information of a facility initiated resident discharge or transfer (#2 & #108 ). This was true for 2 out of the 44 residents selected for review during the survey process.
The findings include:
1.Review of the medical record on 6/19/18 revealed that on 3/18/18 Resident #108 was sent to the hospital for evaluation and treatment. Resident #108 returned to the facility on 4/25/18 and further review revealed that the facility staff failed to inform the ombudsman with the required information of the transfer to the hospital. In addition, the facility failed to provide notification in writing to resident #108 or his/her responsible party.
2. Review of the medical record on 6/19/18 revealed that on 5/21/18 Resident #2 was sent to the hospital for evaluation and treatment. Resident #2 returned to the facility on 6/6/18 and further review revealed that the facility staff failed to inform the ombudsman with the required information of the transfer to the hospital. In addition, the facility failed to provide notification in writing to resident #2.
The Administrator and the Director of Social Work were made aware of the findings on 6/19/2018 at 10:50 AM. They confirmed that the facility did not provide all of the required information to the Ombudsman and did not provide notification in writing to the resident or their responsible party in these instances.
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 clinical record review and staff interview it was determined that the facility staff failed to accurately note a resident's weight loss (#117) on the Minimum Data Set (MDS). This was true for...
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Based on clinical record review and staff interview it was determined that the facility staff failed to accurately note a resident's weight loss (#117) on the Minimum Data Set (MDS). This was true for 1 out of 44 residents selected for review during the survey process.
The MDS is a federally-mandated assessment tool that helps nursing home staff gathers 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.
Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment the interdisciplinary team develops the plan of care for the resident to obtain the optimal care for the resident.
The findings include:
A review of Resident #117's clinical record revealed that the resident's weight decreased from 141 pounds on 5/31/18 to 117.6 pounds on 6/6/18. The facility dietician noted that this represented a 11.5% weight loss. A review of the resident's admission MDS completed on 6/6/18 revealed that the staff recorded on sections K300 and K310 that the resident did not have either a weight loss or weight gain.
The Dietician wrote in her notes on 6/7/18 at 12:04 PM that the resident had a . 7.6% loss x ~30 days . which would have been during the look back period.
The Director of Nursing and dietician were interviewed on 6/19/18 at 1:52 PM. The dietician explained her thought process. She questioned the initial return weight of 141 (resident had a hospitalization with an anticipated return) and did not believe the resident weighed that much therefore she answered no to the MDS question regarding a weight loss of 10% in a three month period or a 5% weight loss within a month. I pointed out that even if she ignored the weight of 141 and used the previous weight of 132.9 on 3/28/18 the weight loss question should have been answered Yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of medical record and staff interview, it was determined the facility staff failed to develop comprehensive care plans addressing diagnoses for Residents (#13). This was evident for 1 ...
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Based on review of medical record and staff interview, it was determined the facility staff failed to develop comprehensive care plans addressing diagnoses for Residents (#13). This was evident for 1 of 44 residents selected for review during the survey process.
The findings include:
A care plan is an outline of nursing care showing all the resident's needs and the ways of meeting the needs. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the individual's specific needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care.
Medical record review for Resident #13 revealed the resident was admitted to the facility with diagnoses that include, but not limited to: high blood pressure, hyperlipemia, atrial fibrillation and Congestive Heart Failure (CHF). High blood pressure is defined as high pressure (tension) in the arteries, which are the vessels that carry blood from the heart to the rest of the body; hyperlipidemia is an abnormally high concentration of fats or lipids in the blood; Atrial fibrillation is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications and Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. Further record review revealed the facility staff failed to initiate care plans to address the above diagnoses until 6/20/18 (after surveyor inquiry). Further record review revealed the facility staff documented care plan meetings on: 5/21/18, 4/14/18 and 1/18/18; however, failed to initiate care plans to address the diagnoses.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to initiate care plans addressing diagnoses for Resident #13.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined the facility staff failed to provide Resident #114 with a translator during a Med Options assessment. This was evident for 1 out of 44 r...
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Based on medical record review and interview, it was determined the facility staff failed to provide Resident #114 with a translator during a Med Options assessment. This was evident for 1 out of 44 residents selected for review during the annual survey process.
The findings include:
Medical record review for Resident #114 revealed the resident is not English speaking. Further record review revealed the facility staff assessed the resident and on 12/28/17 initiated a care plan addressing the fact the resident is not English speaking, with an intervention of: Provide translator as necessary to communicate with the resident as needed. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the resident's needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds.
Further record review revealed the resident was seen by Med Options on 6/18/18. Med Options is the Psychiatric firm to assess medications, behaviors or mood concerns related to the residents.
Review of the Med Options assessment completed on 6/18/18 revealed the following documentation completed by the Med Options staff:
thought process: unable to assess,
Insight: unable to assess,
Thought Content: unable to assess,
Judgement: unable to assess,
Language: unable to assess and with the inclusion of a note contained the following notation: patient was difficult to engage because of language barriers.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to provide Resident #114 with a translator to assist with Med Options assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident #114 with optimal assistance during breakfast. This was evident for 1 out of ...
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Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident #114 with optimal assistance during breakfast. This was evident for 1 out of 44 residents selected for review during the annual survey process.
The findings include:
Surveyor observation of Resident #114 revealed the resident out of bed on 6/19/18 at 8:45 AM. The resident had been served his/her breakfast tray. The tray was in front of the resident. Further observation revealed the facility staff failed open the carton of milk, carton of health shake, remove the plastic lid off the orange juice and failed to open and fix the cream of wheat. Observation of the resident on 6/20/18 at 8:05 AM revealed the resident was served breakfast; however, the facility staff failed to cut up the French toast, failed to supply straws for the carton of milk, carton of health shake and water pitcher. The facility staff also failed to give the coffee as noted on the meal ticket.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to provide Resident #114 with the optimal assistance with set up at breakfast.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility staff failed to ensure that call bells were within reach. This was evident for 1 out of 44 residents (Resident #43) observed during the investigative p...
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Based on observation and interview, the facility staff failed to ensure that call bells were within reach. This was evident for 1 out of 44 residents (Resident #43) observed during the investigative portion of the survey.
The findings include:
A call bell is a bedside button tethered to the wall in the resident's room, which directs signals to the nursing station; a call light usually indicates that the patient has a need or perceived need requiring attention from the nurse or geriatric nursing assistant on duty.
Surveyor observation of Resident #43 on 6/19/18 at 10:15 AM revealed the resident out of bed in the chair on the window side of the bed. Further observation revealed the call light was not within reach of the resident, the call light was noted in the middle (between the 2 beds of the resident's) of the room and on top of the resident's refrigerator (apartment sized). When questioned what the resident would do if she/he needed a nurse, the resident stated she/he would put the call light on and looked around for the call light. Once the resident noted the call light was not within reach, the resident then stated that she/he would yell for someone to come. The Director of Nursing was notified at that time the call light was not in reach for the resident.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to provide Resident #43 with his/her call light within reach.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews it was determined that facility staff failed to provide appropriat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews it was determined that facility staff failed to provide appropriate care and services for a resident who is incontinent of bowel and bladder. This was true for 1 of 44 (#108) residents reviewed during the survey process.
Findings include:
In an interview on 6/14/18 at 2:50 PM Resident #108 stated that s/he is incontinent of bowel and bladder and requires adult diapers. S/he further stated that the facility has someone come to measure all residents to ensure that they have the right size. S/he said that the facility is always running out of his/her size and the Aids have sometimes used the next smaller size which is too small and has caused skin breakdown.
6/21/18 Review of the Minimum Data Set (MDS) assessments completed on 5/23/18 and 6/5/18 revealed that resident #108 is always incontinent of bowel and bladder.
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 need to be accurate to ensure each resident receives the care they need.
Categories of MDS are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment the interdisciplinary team develops the plan of care for the resident to obtain the optimal care for the resident.
Interview with GNA #1 on 6/21/18 at 11:00 AM who works on unit 1, surveyor asked where they get incontinent supplies for residents? GNA #1 stated in the supply closet, we have all different sizes. Residents rarely have supplies of their own in their rooms. If we can't find a size, we ask the unit manager and they get them from the supply shed.
In a follow up interview with GNA #1 at 12:50 PM surveyor asked where she can find the information indicating what size garment to use for each resident? She stated that she would find that on the electronic [NAME].
On 6/21/18 at 12:35 PM review of the Paper [NAME] in the Geriatric Nursing Assistant (GNA) book on the unit provided by Unit manager was inaccurate and revealed that resident #108 is always continent of Bowel & Bladder. Review of both the electronic and paper records failed to include the size or measurement of the incontinence brief for this resident.
The facility staff failed to consistently provide Resident #108 with proper fitting adult diapers. The Director of Nursing was made aware of this concern and was unable to provide any further documentation for surveyor during the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined the facility staff failed to document the amount of a supplement consumed for Resident (#114) as ordered and failed to obtain weights as...
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Based on medical record review and interview, it was determined the facility staff failed to document the amount of a supplement consumed for Resident (#114) as ordered and failed to obtain weights as ordered for Resident (#121). This was evident for 2 of 44 residents selected for review during the annual survey process.
The findings include:
1. The facility staff failed to document the amount of supplement consumed as ordered.
Medical record review for Resident #114 revealed on 5/30/18 the physician ordered: House shake with breakfast, record percentage consumed. Health shakes are a great tasting supplement intervention for those residents at nutritional risk. Health shakes are supplements designed to provide extra nutrition, protein and calories for residents unable to eat or losing too much weight. Review of facility documentation revealed the facility staff documented the administration of the house shake to the resident from 6/1/18-6/21/18 at 8:00 AM; however, failed to document the percentage of the house shake consumed by the resident.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to document the percentage of the house shake supplement consumed for Resident #114 as ordered.
2. The facility staff failed to obtain weights on Resident #121 as ordered by the physician.
Medical record review for Resident #121 revealed the resident was admitted to the facility with the diagnosis that included, but not limited to Congestive Heart Failure (CHF). Congestive Heart Failure-Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs.
In heart failure, the main pumping chambers of the heart (the ventricles) may become stiff and not fill properly between beats. In some cases of heart failure, the heart muscle may become damaged and weakened, and the ventricles stretch (dilate) to the point that the heart can't pump blood efficiently throughout the body. An early warning sign of a flare up of CHF is a rapid weight gain (1 or 2 pounds a day for 3 days in a row). On 2/22/18 the physician ordered: weigh resident 2 times a week and notify physician of any weight gain. Further record review revealed the facility staff documented weights for the resident on: 2/22/18, 2/23/18, 2/27/18 and 3/16/18. There is no evidence the facility staff obtained weights 2 times a week as ordered by the physician.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to obtain weights 2 times a week as ordered for Resident #121.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on medical record review, staff and resident interviews it was determined that facility staff failed to provide medically -related social services to attain or maintain the highest practicable p...
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Based on medical record review, staff and resident interviews it was determined that facility staff failed to provide medically -related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of a resident (#10). This was true for 1 of 44 residents reviewed during the annual survey process.
Findings include:
Resident #10 came to speak with the survey team on 6/21/18 at 11:50 AM. Resident #10 stated that s/he has been trying to get housing for a long time and has had numerous conversations with the social worker (SW) requesting assistance. I am in the waver program; the waver people are coming to talk to me today. They said I need a state ID, so I can get a place. I asked the SW to see how I could get it and to see if she could find out how much it would cost. She said she didn't know how much it would be and never got back to me with any information. That was a while ago, so then I was talking to another resident who was able to look it up and said that it wouldn't cost me anything because I am disabled, and I am over 62. It was hard for me to figure out what I needed to get it, but I think I have everything now. The SW should be able to help with things like this, but she is completely useless.
On 6/21/18 at 1:10 PM in an interview with SW, surveyor asked what she has done to facilitate Resident #10's discharge? SW stated that she applied for the waver program, but Resident #10 has been very difficult. SW stated that Resident #10 has worked with several service coordinators but that s/he gets very angry and has fired some of them. Surveyor asked SW if she had assisted with facilitating or mediating the service coordination meetings, or assisting Resident #10 to ensure that s/he has been able to obtain or access all necessary documents needed to obtain housing? SW said no, and stated that she has talked with resident #10 a lot but he just gets angry.
In a follow up interview with Resident #10 at 1:55 PM s/he was talking with the waver program service coordinators who confirmed that they had identified that Resident #10 needed an ID card on their first visit on 4/20/18. Resident #10 stated I told the SW that I needed the ID a long time ago, but she didn't do anything about it. That the way she does everything, she is always too busy to do anything, and she never comes back.
On 6/21/18 at 1:20 PM Interview with the Director of the Business Office confirmed that on 6/20/18 resident #10 asked for her assistance with getting the necessary documents to get an ID card.
The administrator was made aware of this concern on 6/21/18 at 2:50 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined the facility staff failed to ensure a resident (#2) was free from unnecessary medications. This was evident for 1 of 44 residents select...
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Based on medical record review and interview, it was determined the facility staff failed to ensure a resident (#2) was free from unnecessary medications. This was evident for 1 of 44 residents selected for review during the survey process.
The findings include:
Medical record review for Resident # 2 on 6/19/18 at 9:23 AM revealed a Physician's order written on 6/14/18 for Humalog Kwik Pen-injector 100 UNIT/ML (Insulin); Inject 8 units subcutaneously with meals, for Diabetes Meletus, hold if before meal Accu-checks (Blood sugar levels) are less than 120.
Review of the Medication Administration Record (MAR) revealed the blood sugar level (BS) on 6/16/18 at 8:00 AM was recorded as 8; on 6/17/18 at 5:00 PM the BS was recorded as 81; on 6/18/18 at 8:00 AM the BS was recorded as 119 and on each of these occasions it was documented that 8 units of Humalog insulin was given.
In an interview on 6/19/18 at 12:23 PM the Director of Nursing (DON) provided a copy of the MAR and was immediately made aware of this concern. She confirmed that facility staff failed to ensure that Resident #2 was free from unnecessary medications by failing to ensure ordered parameters were followed. The DON immediately began an investigation and had Resident #2 evaluated by the Nurse Practitioner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined the facility staff failed to conduct AIMs testing on Residents (#25 and #114). This was evident for 2 of 44 residents selected for revie...
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Based on medical record review and interview, it was determined the facility staff failed to conduct AIMs testing on Residents (#25 and #114). This was evident for 2 of 44 residents selected for review during the annual survey process.
The findings include:
The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was designed in the 1970's to measure involuntary movements known as tardive dyskinesia (TD). TD is a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications. Tardive dyskinesia is a syndrome characterized by abnormal involuntary movements of the patient's face, mouth, trunk, or limbs, which affects 20%-30% of patients who have been treated for months or years with neuroleptic medications. Persons taking any kind of antipsychotic medication need to be monitored for movement disorders. The AIMS (Abnormal Involuntary Movement Scale) aids in the early detection of tardive dyskinesia as well as providing a method for on-going surveillance.
1. The facility staff failed to conduct an AIMS on Resident #25.
Medical record review for Resident #25 revealed on: 3/21/18 the physician in collaboration with the psychiatric consultation ordered, Seroquel 12.5 milligrams by mouth 2 times a day for mood. Seroquel is a medication is used to treat certain mental/mood conditions (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder). Seroquel is known as an anti-psychotic drug. It works by helping to restore the balance of certain natural substances (neurotransmitters) in the brain. Further record review revealed the facility staff failed to obtain a baseline AIMS on Resident #25 prior to or as early initiation of the Seroquel.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to conduct an AIMS test on Resident #25 while administering an anti-psychotic medication.
2. The facility staff failed to conduct an AIMS on Resident #114.
Medical record review for Resident #114 revealed on 1/28/18 the physician ordered: Seroquel 25 milligrams by mouth every day for psychosis. Further record review revealed the facility staff failed to obtain an AIMS test.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to conduct an AIMS test on Resident #114 while administering an anti-psychotic medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it was determined the facility staff failed to obtain laboratory blood test as ordered by the physician for Residents (#25 and #29). This was evident for 2 ...
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Based on record review and staff interview, it was determined the facility staff failed to obtain laboratory blood test as ordered by the physician for Residents (#25 and #29). This was evident for 2 of 44 residents selected for review during the survey process.
The findings include:
1. The facility staff failed to obtain laboratory blood test as ordered.
Medical record review for Resident #25 revealed on 1/18/17 the physician ordered: LFT and every 6 months in March and September. Record review revealed the facility staff failed to obtain the LFT in March 2018 as ordered. Liver Function Tests (LFT) are blood tests that check to see how well the liver is working. They check for liver damage and can help diagnose liver diseases such as hepatitis and cirrhosis. Record review revealed the facility staff failed to obtain the LFT in March 2018 as ordered.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to obtain laboratory blood test for Resident #25 as ordered by the physician.
2. The facility staff failed to obtain laboratory blood test as ordered.
Medical record review for Resident #29 revealed on 10/17/17 the physician ordered: Atorvastatin 80 milligrams by mouth every day. Lipitor (atorvastatin) is type of statin that lowers the level of cholesterol in the blood. Cholesterol is a form of fat we need. It helps make the outer membranes of our bodies' cells stable. The different kinds of cholesterol and other fats in your blood are together called lipids. Doctors measure and diagnose lipid problems with a simple blood test.
Record review revealed on 10/27/17 the Consultant Pharmacist reviewed the medical record. At that time, the pharmacist recommended the resident to have Liver Function Test and Cholesterol screen. Further record review revealed the facility staff obtained the LFT; however, failed to obtain the Cholesterol screen.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to obtain laboratory blood test for Resident #29 as recommended by the Consultant Pharmacist and as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on record review, observation and interview, it was determined the facility staff failed to provide Resident #13 with foods he/she liked. This was evident for 1 of 44 residents selected for revi...
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Based on record review, observation and interview, it was determined the facility staff failed to provide Resident #13 with foods he/she liked. This was evident for 1 of 44 residents selected for review during the annual survey process.
The findings include:
Surveyor interview with Resident #13 on 6/18/18 at 8:50 AM revealed the resident stated he/she gets food he/she does not like. The resident also stated he/she talked to dietician and the dietician is aware; however, states the kitchen staff puts food on tray he/she does not want or like. Surveyor observation of the resident's breakfast tray on 6/19/18 at 8:45 AM revealed the resident with hot cereal and review of the meal tray ticket for the resident from the kitchen revealed the resident does not like hot cereal. The resident stated that it happens all the time, food not liked is sent from the kitchen. Observation of the resident's lunch tray on 6/19/18 at 1:10 PM revealed the resident was given a cup of pears. Further review of the meal ticket revealed the resident was to have vegetables substituted with fruit. At that time, the resident stated that he/she did not like fruit either and would not eat it.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to provide Resident #13 with foods requested or liked.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview it was determined that the facility staff failed to ensure the clinical records were maintained in a complete and accurate manner (#51). This was tr...
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Based on clinical record review and staff interview it was determined that the facility staff failed to ensure the clinical records were maintained in a complete and accurate manner (#51). This was true for 1 out of the 44 residents selected for review during the survey process.
The findings include:
A review of Resident #51's clinical record revealed that the facility nursing staff failed to document that the resident has been refusing showers.
The Director of Nursing was interviewed on 6/20/18 at 11:30 AM. DON acknowledged the lack of documentation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation of unit 500 nurses' station, it was determined the facility staff failed to maintain an environment safe for residents and visitors. This was evident for 1 of 5 nurses' stations o...
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Based on observation of unit 500 nurses' station, it was determined the facility staff failed to maintain an environment safe for residents and visitors. This was evident for 1 of 5 nurses' stations observed during the annual survey process.
The findings include:
Surveyor observation of the unit 500 nurses' station on 6/20/18 at 12:50 PM revealed the treatment care was placed on the side of the desk; however, was not locked. The surveyor opened several of the draws of the cart to observe numerous tubes and jars of ointments and pastes, bandages and scissors. During that time, the unit manager appeared and locked the cart.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to maintain the unit 500 nurses' station in the safest environment for residents and visitors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected multiple residents
Based on record review, staff and resident interviews it was determined that facility staff failed to provide the proper care and services to protect a residents (#10 & #108) personal belongings. This...
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Based on record review, staff and resident interviews it was determined that facility staff failed to provide the proper care and services to protect a residents (#10 & #108) personal belongings. This is true for 2 of 44 residents reviewed during the survey process.
Findings include:
In an interview on 6/21/18 at 11:50 AM Resident #10 stated that they make us keep our cigarettes in a box at the nurse's station and they have to give them to us when we go out for a smoke break. The problem is they don't keep track of our cigarettes and lighters and we are always missing some. Ask the other people here they'll tell you it happens to them too.
Review of facility smoking log for Resident #10 revealed several errors, resident had 9 cigarettes left at the end of 4/15/18 and on 4/16/18 it was recorded that s/he used 0 and had 7 left. Again on 6/8 the log indicated that resident #10 had 13 cigarettes, used 2 and then had 7; on 6/9 s/he had 3 then 2 lines were left blank and then there were 15. On 6/10 there were 13 at 9:00 AM a blank space then at 3:30 PM there were 7 left. Throughout the log from 6/8-6/24 there were several discrepancies and several lines with nothing recorded.
In a follow up interview with Resident #10 on 6/26 s/he stated that everyone doesn't keep track, it depends on who is taking you out for the smoke break.
In an interview on 6/26/18 at 9:45 AM Resident #108 stated that there have been a lot of problems with the cigarettes. I just got a carton from my mom on 6/8 and had placed 2 packs (a total of 40 cigarettes) in my envelope at the nurse's station. After the first day 2 whole packs were gone. Some of the people write down what you use but some of them don't.
Review of the smoking log for Resident #108 from 6/8/18 -6/25/18 revealed several errors in tracking resident's cigarettes. On 6/8 Resident #108's log had 7 cigarettes at 9:00 AM. There was no documentation of 2 packs of cigarettes being placed in the envelope, there was a blank space at 1:00 PM then at 3:30 PM s/he used 3 and had 0 remaining. On 6/9 all lines were blank. On 6/10 at 9:00 AM resident used 1 ½ cigarettes and had 0 left. On 6/10 at 7:00 PM s/he had used 3 and 9 remaining. On 6/11 used 4 and had 6 remaining. Resident #108 spoke to the unit Manager about the missing cigarettes on 6/12/18, a concern form was completed however there is no evidence of an investigation and resident #108 confirmed that no one has followed up with him/her.
A note of interest, this surveyor requested to see the complete Resident smoking log on 6/26 which at that time was in the Activities Directors office. Review of the log revealed that the smoking logs for Residents #10 and #108 for the above mentioned dates had been changed. In an interview with the Director of Nursing (DON) on 6/25 at 2:10 PM she was made aware of these concerns.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
5. Medical record review for Resident #87 revealed the resident was to have showers on Monday and Thursday 7-3 shift. In an interview with Resident #87 on 6/14/18 at 9:38 AM s/he stated, I don't alway...
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5. Medical record review for Resident #87 revealed the resident was to have showers on Monday and Thursday 7-3 shift. In an interview with Resident #87 on 6/14/18 at 9:38 AM s/he stated, I don't always get my showers, I didn't get one on Monday and not yet today. Review of the Aide task sheet from 5/22/18- 6/18/18 revealed that Resident #87 did not receive a shower on Thursday 5/28, Monday 6/7 or Thursday 6/11, there was no documentation that s/he refused or was unavailable.
The Director of Nursing was made aware of this concern on 6/20/18 at 1:00 PM
3. The facility staff failed to administer showers to a resident.
Medical record review for Resident #29 revealed the resident was scheduled for showers on Wednesday and Saturday 3-11 shift. Review of the staff documentation in the Electronic Medical Record revealed the facility staff failed to document showers for the resident on: 5/23/18, 5/26/18, 5/30/18, 6/6/18, 6/9/18, 6/13/18 and 6/16/18. The facility staff documented showers for the resident on 6/2/18.
4. The facility staff failed to administer showers to a resident.
Medical record review for Resident #114 revealed the resident was due to have showers 2 times a week on the 3-11 shift. Further record review revealed the facility staff failed to document in the Electronic Medical Record the resident received showers on: 5/22/18, 5/23/18, 5/25/18-6/6/18, and 6/8/18-6/20/18. The facility staff documented the resident received showers on 5/24/18 and 6/7/18 on the 3-11 shift.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to administer 2 showers a week to Residents #29 and #114.
Based on resident interview, staff interview, and clinical record review it was determined that the facility failed to ensure residents received showers twice a week as scheduled (#5; #9; #29; #87 & #114). This was true for 5 out of 44 residents selected for review during the annual survey process.
The findings are:
1. Resident #5 was interviewed on 6/14/18 at 10:30 AM. The resident stated that he/she had only received one shower since admission. A review of the resident's clinical record revealed that the resident received a shower on 6/19/18 and refused a shower on 6/13/18. There is no mention of receiving showers on any other day. Shower sheets were provided. They listed the resident received showers on 6/5/18, 6/9/18, and 6/13/18. These dates were contradicted by the clinical record.
2. Resident #9 was interviewed on 6/15/18 at 8:40 AM. The resident stated that he/she does not get two showers every week. A review of the clinical record revealed that the resident received no showers in June. A shower schedule for June 2018 was provided but was contradicted by the clinical record.
I interviewed the resident on 06/20/18 at 01:16 PM. The resident stated that he/she received a shower yesterday and gets a bed bath every Tuesday and Thursday.
The Director of Nursing was interviewed on 6/20/18 at 1:00 PM. She acknowledged what was recorded in the clinical records.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review, observation and interview, it was determined the facility staff failed to provide care which promoted the highest practicable well-being for Residents (#13, #25, #29 and #122)....
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Based on record review, observation and interview, it was determined the facility staff failed to provide care which promoted the highest practicable well-being for Residents (#13, #25, #29 and #122). This was evident for 4 of 44 residents selected for review during the annual survey process.
The findings include:
1. The facility staff failed to maintain Resident's #13 bed in the lowest position as ordered.
Medical record review for Resident #13 revealed on 10/17/17 the physician ordered: low bed always. Surveyor observation of the resident on 6/18/18 at 12:00 PM and 6/19/18 at 10:10 AM revealed the resident in bed; however, the bed was not in the lowest position. Observation of the resident's bed revealed the bed to be approximately 4 feet off the floor. A low bed is approximately 1.5 feet off the floor.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to maintain the bed of Resident #13 in low position as ordered by the physician.
2. The facility staff failed to indicate on the Medication Administration Record (MAR) timing of an eye medication to be administered 15 minutes after other medications.
Medical record review for Resident #25 revealed on 1/6/17 the physician ordered: artificial tear 1 drop right eye every 6 hours. Artificial tears are lubricant eye drops used to treat the dryness and irritation associated with deficient tear production in dry eyes. On 1/27/17 the physician ordered: Dorzolamide HCL 2% solution, 1 drop right eye for Vitreous hemorrhage. Dorzolamide is used to treat high pressure inside the eye due to glaucoma (open angle-type) or other eye diseases (ocular hypertension). Lowering high pressure inside the eye helps to prevent blindness. This medication works by decreasing the amount of fluid within the eye. If you are using another kind of eye medication (drops or ointments), wait at least 10 minutes before applying other medications. On 11/6/17 the physician ordered: Systane Balance Solution, 1 drop 4 times a day for dry eye. Systane Balance Eye Drops help support and restore the eyes' delicate lipid (fat) layer by replenishing essential moisture to the eyes.
Per consultant pharmacist recommendation, on 11/3/17 the physician ordered: Dorzolamide HCL Solution 2%, 1 drop right eye 2 times a day for Vitreous hemorrhage and give 10 minutes apart from other eye medications. Although the physician ordered the Dorzolamide to be given at least 10 minutes apart from other eye drops, review of the Medication Administration Record revealed the Dorzolamide was transcribed to be administered 10 minutes apart from other eye drops, however, the facility staff transcribed the time of administration of the Dorzolamide and Systane both at 9:00 AM.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to indicate on the MAR the administration time of an eye medication to be at least 10 minutes separate from other eye medications for Resident #25.
3. The facility staff failed to elevate the heels of Resident #29 as ordered.
Medical record review for Resident #29 revealed on 3/23/17 the physician ordered: float heels to alleviate pressure. Heel pressure ulcers can cause significant morbidity and mortality. They should be anticipated and prevented in patients at risk for pressure ulcers. Preventing heel ulcers involves the use of simple devices such as pillows and offloading devices to protect delicate heels. Surveyor observation of the resident on 6/20/18 at 7:25 AM revealed the resident in bed; however, the facility staff failed to elevate the resident's heels as ordered.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to elevate the heels of Resident #29 as ordered by the physician.
4. The facility staff failed to obtain an EKG per the discharge summary of Resident #122.
Medical record review for Resident #122 revealed the Discharge Summary from the hospital: Please repeat EKG within 1 week to follow up on 1st degree AV Block. In first-degree heart block, the heart's electrical signals are slowed as they move from the atria to the ventricles (the heart's upper and lower chambers, respectively). This results in a longer, flatter line between the P and the R waves on the EKG (electrocardiogram). An EKG measures the heart's electrical activity. This noninvasive test can measure many aspects, from how fast the heart beats to how well its chambers conduct electrical energy. An abnormal EKG can mean many things.
The orders on the Discharge Summary are orders for the facility to follow unless contraindicated or rejected by the physician in the facility. Further record review revealed no evidence the physician in the facility disagreed with the EKG; however, the facility staff failed to obtain the EKG per the discharge summary.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to obtain an EKG on Resident #122 per discharge summary.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on medical record review, resident and staff interviews it was determined that facility staff failed to thoroughly assess residents (#10;#24; #37; #48; #115;;#171) need for and effectiveness of ...
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Based on medical record review, resident and staff interviews it was determined that facility staff failed to thoroughly assess residents (#10;#24; #37; #48; #115;;#171) need for and effectiveness of pain medications in a timely manner. This was true for 6 out of 44 residents reviewed during the anual survey process.
1. A review of Resident #48's medical record revealed diagnoses including but not limited to Malignant (Cancerous) Neuroendocrine Tumors. Further review of the medical record revealed that the nursing staff were not evaluating the effectiveness of Resident #2's pain medication in a timely manner. Review of the Medication Administration Record (MAR) revealed a Physicians order for Dilauded 4mg 2 tabs every 2 hours as needed for pain. The resident was administered Dilauded 4mg 2 tablets on 6/18 at 10:39 AM and it was evaluated as being effective 2 minutes later at 10:41 AM. Resident #48 was administered Dilauded 4mg 2 tablets on 6/18 at 5:01 PM and was not evaluated until 4 hours and 55 minutes later at 9:56 PM as being ineffective.
2. A review of Resident #10's clinical record revealed a Physicians order for Oxycodone 10mg every 4 hours as needed for pain and further review revealed that the nursing staff were not evaluating the effectiveness of the pain medication in a timely manner. The resident was administered Oxycodone 10mg on 6/17 at 6:34 PM but it was not evaluated for effectiveness until 6/18 at 10:38 AM. The resident was administered Oxycodone 10mg on 6/18 at 10:38 AM but it was not evaluated for effectiveness until 4:01 PM. The resident was administered Oxycodone 10mg on 6/18 at 4:01 PM but it was not evaluated for effectiveness until 8:15 PM. The resident was administered Oxycodone 10mg on 6/19 at 12:54 AM but it was not evaluated for effectiveness until 9:52 AM.
The Director of Nursing was interviewed on 6/26/18 at 1:55 PM and confirmed that there was no evidence that the nursing staff are consistently evaluating administered pain medication in a timely manner or that the facility staff are unable to review or maintain records of the evaluations of pain medication beyond two days.
6. The facility staff failed to thoroughly assess and administered pain medication for Resident #37 and documented no pain.
Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication.
Medical record review for Resident #37 revealed on 2/3/18 the physician ordered: Tylenol 500 milligrams by mouth, 2 times a day for pain/fever. Tylenol is a pain reliever and a fever reducer. Further record review revealed the facility staff failed to thoroughly determine with collaboration with the resident and the physician at what pain level would the Tylenol be administered for and what defined a fever.
On 2/4/18 the physician ordered: Oxycodone 10 milligrams (mgs) by mouth every 4 hours as needed for pain. Oxycodone is a strong narcotic pain-reliever like morphine, codeine, and hydrocodone. The precise mechanism of action is not known but may involve stimulation of opioid receptors in the brain. Oxycodone does not eliminate the sensation of pain but decreases discomfort by increasing the tolerance to pain. In addition to tolerance to pain, oxycodone also causes sedation and depression of respiration. It is prescribed to treat moderate to severe pain. Review of the Medication Administration Record revealed the facility staff administered the Oxycodone 10 mgs to the resident on 6/2/18 at 7:42 AM, 6/3/18 at 7:40 AM and 6/17/18 at 8:07 AM. The facility staff documented assessment of the resident's pain and documented the resident's pain level as 1 on 6/2/18, 0 on 6/3/18 and 2 on 6/17/18. On 5/21/18 at 9:30 AM the facility staff documented the administration of the Oxycodone and documented pain assessment as 0. The facility staff failed to determine at what level of pain the Oxycodone would be administered for, since Oxycodone is a strong narcotic pain medication, administration of the Oxycodone for levels of pain ranging from 0-2 would not be expected.
Record review revealed the facility staff documented administration of Tylenol from 6/1/18-6/3/18, 6/6/18, 6/1218-6/13/18, 6/17/18 and 6/20/18 at 9:00 with no pain. On 6/3/18, 6/8/18-6/9/18, 6/11/18-6/12/18, 6/14/18 and 6/19/18 at 2100 with no documented pain.
Interview with the Director of Nursing on 6/26/18 at 2:00 PM confirmed the facility staff failed to thoroughly assess the need for pain medication for Resident #37 and documented the administration of a strong narcotic and no pain.
3. Resident #24 was interviewed on 6/14/18 at 9:33 AM. The resident stated pain is often present but treated with medication. A review of the resident's clinical record revealed that there is an absence of evidence that staff are evaluating the effectiveness of the pain medication in a timely manner or at all. For example, the resident was administered Oxycodone 10 mg on 6/19/18 at 9:09 AM but nursing staff did not evaluate the effectiveness until 1:43 PM. Further review revealed that there was no documentation of staff evaluating the effectiveness of the pain medication.
4. Resident #115 was interviewed on 6/18/18 at 9:06 AM. Resident stated pain medication is requested and administered. A review of the clinical records revealed an absence of documentation that nursing staff are evaluating the effectiveness of the pain medication. The resident was administered Oxycodone 5 mg on 6/3, 6/4, 6/9, 6/10, and 6/11 but nursing staff only documented that they evaluated the effectiveness on 6/9 and 6/10. Further review revealed that nursing waited 5 1/2 hours to evaluate the effectiveness of the pain medication on 6/9/18 and waited 3 1/2 hours on 6/10/18.
5. A review of Resident #171's clinical record revealed that the nursing staff were not evaluating the effectiveness of the pain medication in a timely manner. The resident was administered Oxycodone 5mg on 6/17 at 2:59 AM but it was not evaluated for effectiveness until 6:26 AM. The resident was administered Oxycodone 5mg on 6/17 at 6:50 AM but it was not evaluated for effectiveness until 10:53 AM. The resident was administered Oxycodone 5mg on 6/17 at 7:15 PM but it was not evaluated for effectiveness until 10:11 PM. The resident was administered Oxycodone 5mg on 6/18 at 12:20 AM but it was not evaluated for effectiveness until 2:09 AM.
The Director of Nursing was interviewed on 6/26/18. No evidence that the nursing staff are consistently evaluating administered pain medication in a timely manner or that the nursing staff are maintaining records of the evaluation of pain medication beyond two days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on resident interview it was determined that the facility dietary staff failed to provide palatable meals for its residents (#8, #9, #14, #38). This was true for 4 out of the 44 residents select...
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Based on resident interview it was determined that the facility dietary staff failed to provide palatable meals for its residents (#8, #9, #14, #38). This was true for 4 out of the 44 residents selected for review during the annual survey process.
The findings include:
1. Resident #8 was interviewed on 6/25/18 at 7:37 AM. The resident stated that the food is lousy but they are supposed to get a new food service company in two weeks.
2. Resident #9 was interviewed on 6/15/18 at 8:44 AM. The resident said food is lousy.
3. Resident #14 was interviewed on 6/25/18 at 8:50 AM. The resident said that the food is lousy, pulled pork looks like mush, and they need a better menu.
4. Resident #38 was interviewed on 6/14/18 at 2:23 PM. The resident said food is lousy.
Administrative staff were informed of the residents' complaints of poor food quality on 6/26/18 at the exit conference.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected multiple residents
Based on observation and interviews with residents from Resident Council, it was determined the facility staff failed to display the results of survey inspections in an open area. This was evident dur...
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Based on observation and interviews with residents from Resident Council, it was determined the facility staff failed to display the results of survey inspections in an open area. This was evident during observation on 6/22/18.
The findings include:
Surveyor interview with residents #24, #42, #56 and #64 during the resident council meeting on 6/22/18 at 10:00 AM revealed the residents stating they were unaware of the State inspections results and the placement of those results. Surveyor observation of the lobby at the end of the resident council meeting revealed no evidence of the State inspection results in an open and readily accessible area for residents, staff and visitors to review. The surveyor asked the receptionist where the State inspection results were, and the receptionist presented the surveyor with a black binder that was placed behind the desk of the receptionist and contained the results of the survey inspections. It is the expectation the results of survey inspections, both complaint and annual be placed in an open, easily accessible and labeled so review of any persons can be obtained without asking for the results of the survey inspections.
Interview with the Director of Nursing and Nursing Home Administrator confirmed the facility staff failed to place the results of survey inspections in a place easily accessible to any persons to be reviewed.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 40% turnover. Below Maryland's 48% average. Good staff retention means consistent care.
Concerns
- • 60 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $13,270 in fines. Above average for Maryland. Some compliance problems on record.
- • Grade C (58/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 58/100. Visit in person and ask pointed questions.
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About This Facility
What is Oakwood Snf Llc's CMS Rating?
CMS assigns OAKWOOD SNF LLC an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Maryland, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Oakwood Snf Llc Staffed?
CMS rates OAKWOOD SNF LLC's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 40%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Oakwood Snf Llc?
State health inspectors documented 60 deficiencies at OAKWOOD SNF LLC during 2018 to 2024. These included: 2 that caused actual resident harm, 56 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Oakwood Snf Llc?
OAKWOOD SNF LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by HILL VALLEY HEALTHCARE, a chain that manages multiple nursing homes. With 130 certified beds and approximately 116 residents (about 89% occupancy), it is a mid-sized facility located in MIDDLE RIVER, Maryland.
How Does Oakwood Snf Llc Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, OAKWOOD SNF LLC's overall rating (4 stars) is above the state average of 3.0, staff turnover (40%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Oakwood Snf Llc?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Oakwood Snf Llc Safe?
Based on CMS inspection data, OAKWOOD SNF LLC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Oakwood Snf Llc Stick Around?
OAKWOOD SNF LLC has a staff turnover rate of 40%, which is about average for Maryland nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Oakwood Snf Llc Ever Fined?
OAKWOOD SNF LLC has been fined $13,270 across 1 penalty action. This is below the Maryland average of $33,212. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Oakwood Snf Llc on Any Federal Watch List?
OAKWOOD SNF LLC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.