MANOKIN NURSING AND REHAB
For profit - Limited Liability company
135 Beds
KEY HEALTH MANAGEMENT
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#211 of 219 in MD
Photo by robert nock jr
Photo by robert nock jr
Photo by robert nock jr
1 / 5 photos
Last Inspection: August 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Manokin Nursing and Rehab has received a Trust Grade of F, which indicates poor performance with significant concerns. It ranks #211 out of 219 in Maryland, placing it in the bottom half of facilities statewide, and #2 out of 2 in Somerset County, meaning there is only one other local option that is better. The facility is currently improving, with issues decreasing from 51 in 2023 to 4 in 2025, but it still has serious deficiencies. Staffing is rated below average at 2 out of 5 stars, with a turnover rate of 49%, which is concerning. Additionally, the facility has incurred fines totaling $197,970, which is higher than 98% of Maryland facilities, suggesting ongoing compliance issues. Specific incidents include failing to remove expired food items and ensure proper food safety standards, which could affect all residents, and a failure to protect residents from physical abuse, putting them at risk for serious harm. Another incident involved inadequate supervision when positioning a resident in bed, which resulted in harm to that resident. While the facility has some strengths, such as a trend toward improvement, the serious issues noted should be carefully considered by families researching options.
- Trust Score
- F
- In Maryland
- #211/219
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $197,970 in fines. Lower than most Maryland facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for Maryland. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 68 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 4%
Review needed
51 → 4 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 51 issues
2025: 4 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Maryland average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 49%
Near Maryland avg (46%)
Higher turnover may affect care consistency
Federal Fines: $197,970
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: KEY HEALTH MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 68 deficiencies on record
2 life-threatening 2 actual harm
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 1 (Resident #100) of 6 residents ...
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Based on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 1 (Resident #100) of 6 residents reviewed for medical record accuracy during the recertification/complaint survey.The findings include:During a record review on 09/23/2025 at 09:20 AM of a Facility Reported Incident, it was noted that Resident #100 had an Emergency Petition (EP) transfer to the hospital for suicidal ideation on 9/9/2025. Upon further review of the record, the surveyor found a progress note dated 9/17/2025 documented as This visit was conducted with the use of an interactive audio and video telecommunication system with real-time communication between the patient and the provider. On 09/23/2025 at 9:23 AM, an interview with the unit manager, Staff #11 revealed that the resident was not in the facility on 9/17/2025 and could not explain why that progress note was written in the resident's medical record.An interview was conducted on 09/23/2025 at 10:17 AM with the medical record director, Staff # 7. When surveyor asked if the medical record entry notes are reviewed for correct dates, Staff # 7 said no, but if there was a late entry note, the note must indicate late entry and if note is written in error, it will indicate such lines drawn through the note. Staff #7 reviewed the progress note written on 9/17/2025 and could not find where a late entry annotation or a written in error indication were documented as part of the entry. The Director of Nursing (DON) was made aware of the concern on 9/23/2025 at 11:30 AM, who confirmed that the resident was not in the facility on 9/17/2025 to have a virtual visit with the physician.
Jun 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews and staff interviews, the facility failed to protect resident property and provide a safe environment by not ma...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews and staff interviews, the facility failed to protect resident property and provide a safe environment by not maintaining an inventory of resident belongings and not investigating a lost item for one Resident (R28) of three sampled residents.
The findings included:
Record review of the resident and family grievances policy facility's dated 02/06/2024, showed the following: It is the policy of the facility to support each resident's and family members' right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The policy documented the facility social worker has been designated as the Grievance Official and backup is the Administrator. The Grievance Official is responsible for overseeing the grievance process receiving and tracking grievance through to their conclusion; leading any necessary investigation by the facility, maintaining the confidentiality of all information associated with grievance; issuing written guidance decisions to the resident; and coordination with state and federal agencies as necessary in light of specific allegations.
Record review of R28's face sheet showed an admission was dated 11/08/2023; diagnoses included anxiety disorder and major depressive disorder. R28's Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating cognition was intact. The R28 care plan initiated on 11/09/2023 documented the resident having impaired visual function. The care plan directed the staff to tell the residents where they were placing the items.
Record review of Licensed Practical Nurse (LPN)27 nurse's notes dated 11/18/2023 at 10:35 AM, LPN 27 documented resident reported to his/her daughter and staff that a ring was missing. The staff searched the room, bed linens, and called the laundry. R28's daughter called the state police, and they came to take R28's statement.
Record review of R28 nurse's notes dated 11/18/2023 at 1:30 PM, (LPN)8 documented she went and asked R28 what happened to the ring and the resident stated he/she lost it. The note documented R28 then stated I swallowed it dummy.
During an interview on 06/05/2025 at 10:58 AM, Social Services Director (SSD) 9 stated that she was not employed at the facility in November of 2023 and did not remember talking with R28's Responsible Party (RP) about R28's ring missing. SSD9 stated that after reviewing R28's medical record, she could not find the inventory list completed during the resident's admission. SSD 9 stated that she reviewed the grievance log for the entire year of 2023, and she could not find the report indicating the staff searched for the ring and the resolution on R28's missing ring. SSD 9 stated the practice at the facility was upon the resident's admission, a staff member completes a resident s inventory list and when an item was reported missing, the staff member will complete the grievance, and they will search for the missing items and get back to the family with a resolution.
During the interview on 06/11/2025 at 10:52 AM, LPN 8 stated she recalled a discussion with the family back in November 2023 in reference to R28's ring missing. LPN8 reported she notified the former Social Services Director (SSD) about the report of R28's ring missing but did not recall if a grievance or a follow-up was done by the SSD. She stated she did not recall observing the resident with a ring, but she recalled R28's RP reporting to her that the resident's ring was missing.
During an interview on 06/18/2025 at 11:27 AM, the Nursing Home Administrator (NHA)1 reported that she was not employed at the facility in November of 2023 when R28's ring was reported as missing. NHA1 reported she could not find any document in R28's record indicating a follow up on the family's grievance regarding R28's missing ring. NHA1 reported that now when a resident is being admitted to the facility, the staff completes an inventory form which lists all the residents' belongings and if an item was reported missing the staff will search for it and if it cannot be found then the facility will replace the item with a comparable item.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of R35's face sheet showed an admission was dated 07/20/2022; diagnoses included Generalized anxiety disorder, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of R35's face sheet showed an admission was dated 07/20/2022; diagnoses included Generalized anxiety disorder, Alzheimer's disease, and Major depressive disorder. R35's Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 03/15 indicating cognition was severely cognitively impaired. R35 care plan initiated 07/20/20/2022 documented the resident had Activities of daily Living (ADL) self- care deficit due to Alzheimer's. The care plan directed the staff to assist the resident with bathing and grooming.
Record review of R35 nurse's notes dated 10/20/2023, revealed Licensed Practical Nurse (LPN)36 documented it was reported to her that R35 smacked GNA37 in the face and then GNA37 hit R35 back. LPN36 reported this information to the former administrator. The Medical Doctor (MD) stated he was going to see R35 the next day for assessment and readjust medications. The responsible party was contacted and notified of the R35 incident and confirmed that she would like to press charges against GNA37. R35 was assessed for pain, injury, and skin assessment. R35 denied any pain or distress at the time. R35 skin assessment contained no bruising, tears or swelling.
Record review of R35 provider note dated 10/21/2024 revealed the provider note documented R35 was seen for an acute visit as R35 struck a nursing Aide in the face yesterday. The nursing Aide then struck R35 back. The patient did not have any recollection of the events and denied experiencing any pain. R35 noted to be agitated at times. Plan of care revealed the following plan: 1. The patient seems to have suffered no significant injuries or was struck by a staff member. The facility is taking appropriate steps to address this issue.
Review of GNA 37 personnel file revealed the license was up to date, and the criminal background check was completed prior to GNA 37 employment at the facility. The report revealed GNA 37 had no history of crime.
During an interview on 06/18/2025 at 11:42 AM, the Nursing Home Administrator (NHA1) revealed she was not employed at the facility in October 2024. She reported that her expectation was for staff at the facility to protect the residents and GNA37 should not have slapped R35. She also added that the abuse training was done regularly at the facility.
During an interview on 06/19/2025 at 2:38 AM, Director of Nursing (DON) 2 stated that staff at the facility were regularly in-serviced on different types of abuse. DON 2 reported other staff members reported hearing GNA37 slapping R35. She stated GNA37 was suspended and then terminated after the outcome of the investigation. She reported that other staff members were all in serviced after the abuse incident on 10/20/2024. DON 2 all the residents who could have been potentially affected by abuse were interviewed, and they all reported they did not have concerns related to abuse at the facility.
LPN 36 was no longer employed at the facility and did not return the phone call.
GNA 37 was no longer employed at the facility and did not return the phone call.
Based on interviews, observations and record review, the facility failed to maintain an environment that was free from staff-to-resident abuse for two residents (Resident R10 and R35) of ten residents sampled for abuse. Specifically, Maintenance Assistant (MA) 39 slapped a R10 in the face and Geriatric Nurse Aide (GNA)35 hit R35 in the face. The facility census was 101.
The findings include:
Record review of the facility's abuse, neglect and exploitation policy dated 02/02/2024, and last revised on 3/25/2025 showed the following:
The facility is to provide protection for health, welfare and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means, the willful infliction of injury, unreasonable confinements, Intimidation, or punishment resulting from physical harm, pain or mental anguish, which can include staff to Resident abuse, and certain Resident to Resident altercations. Instances of abuse include all Residents, irrespective of any mental or physical condition that cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. The covered individual is anyone who is an owner, operator, employee, manager, agent, or contractor of the facility. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. The facility will designate an abuse prevention coordinator, who is responsible for reporting allegations of suspected abuse, neglect, or exploitation to the state survey agency. And other officials in accordance with state law. The facility will have written procedures. That includes immediately, but not later than two hours after the allegation is made; it should be reported to the State Survey agency.
1. Record review of R10s face sheet showed his admission date was dated 06/28/2023; diagnoses included Spinal Stenosis, Bipolar Disorder and Chronic Systolic Congestive Heart failure. Record review of R10s Care Plan initiated on 6/28/2023 documented. R10 was dependent on staff to meet emotional, intellectual, physical, and social needs due to physical limitations. R10 had chronic pain related to contractures/ decreased mobility.
Record review of R10s written statement dated 3/23/2024 revealed that on 3/22/2024, R10 documented he/she was at the nurse's station when MA 39 angrily approached using profane language and hit him/her on the back of the head and poked him/her on the shoulder.
Record review of R48s written statement dated 3/23/2024 revealed that on 3/22/2024, R48 documented he/she was at the nurses' station when he/saw saw MA 39 poking R10 on the shoulder and documented he/she could smell the breath of alcohol from MA 39's breath. R48 concluded MA 39 dropped a bottle of alcohol on the floor, where he was working at the nurse's station.
Record review of R10s progress notes dated 03/22/2024 at 09:17 PM, Licensed Practical Nurse (LPN) 10 documented a Late Entry and wrote, R10 approached him/her and called the LPN to his/her room and stated the drunk maintenance guy, Maintenance Assistant (MA) 39 slapped him/her on the back of the neck while he/she was in the Day Room and R10, stated, everybody in the day room heard it. R10 stated that he/she does not want MA 39 to lose his job.
Record review of a written statement dated 3/23/2024, the Maintenance Director (MD7) documented on 3/22/2024 that he asked MA 39 to leave the facility three times and MA 39 refused. On 3/23/2024 when MD7 reported to work in the morning, he asked MA 39 to leave the facility and MA 39 walked out.
Record review of the quarterly Minimum Data Set (MDS), a federal mandated data assessment form dated 7/28/2024, revealed R10 had a BIMS score of 15/15, which indicated the resident was cognitively intact.
Record review of the discharged MDS, a federal mandated data assessment form dated 8/11/2024, revealed R10 was discharged with no anticipated return.
During an interview on 6/13/2025 at 10:49 AM former, Licensed Practical Nurse (LPN) 10 stated, on 3/22/2024 at approximately 7:00 PM, R10 approached him and stated the MA 39 slapped him/her on the face, he went to investigate and found MA 39 drunk and disorderly, and he told the MA 39 he was calling the police. At that point according to LPN 10, MA 39 ran through the back door. LPN 10 stated the police were outside the parking lot for two hours waiting for MA 39. LPN 10 stated he notified the former Director of Nursing (DON) 4 and former Nursing Home Administrator (NHA) 3.
During an interview on 6/16/2024 at 10:01 AM, the Assistant Director of Nursing (ADON)11 stated she remembered sometime in March 2024, MA 39 came into the building while he was intoxicated and physically struck R10. ADON 11 stated that the former NHA 3 and DON 4 were made aware immediately.
During an interview with on 6/16/2025 at 11:15 AM, the Maintenance Director (MD7) revealed in March 2024, he was the transitional MD. MD7 stated on 3/22/2024 at approximately 12:00 PM he observed, MA 39 exhibited unusual behavior. According to MD 7, on the same day at approximately 1:30 PM, he found MA 39 sleeping in the storage room and smelling alcohol. MD 7 stated he spoke to MA 39 a second time at approximately 3:00 PM and directed MD 39 to go home as he was intoxicated and MA 39 refused. According to MD 7, at approximately 3:30 PM, he offered MA 39 a ride to his home since he had no transportation. MD 7 further revealed at approximately 4:30 PM he walked MA 39 out of the building and told him to go home. Later on, he was told MA 39 left the building and returned to the facility and was more intoxicated. He also learned that MA 39 hit R10 while intoxicated. MD 7 stated the next day on 3/23/2024 at approximately 7:30 AM when he reported to work, R10 told him MA 39 physically assaulted R10 and struck him/her on the head and R10 stated he/she was afraid of MA 39 and wanted someone to talk to him.
During an interview on 6/16/2024 at 11:30 AM the former DON 4 stated she remembered MA 39, a former employee, was intoxicated on duty, and he hit another resident (R10) while he was under the influence. According to the former DON 4, the resident declined to press charges.
During an interview on 6/16/2025 at 12:30 PM, the former NHA 3 revealed, on 3/22/2024, R10 stated, MA 39 hit him/her on the head while he/she was in the day room. R10 stated MA39 was drunk.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to provide adequate supervision and implement intervention to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to provide adequate supervision and implement intervention to prevent multiple falls for one Resident (R31) of 3 sampled residents who was at high risk for falls.
Findings included:
Record review of R31's face sheet showed an original admission was dated 12/13/2018; diagnoses included severe intellectual disabilities, major depressive disorder, restlessness, and agitation. R31's Minimum Data Set (MDS) dated [DATE] indicated that the resident had severely impaired cognitive skills for daily decision-making. R31's functional limitation in range of motion was impaired on both sides of upper extremity and lower extremity. The resident was dependent on staff with toileting hygiene and personal hygiene. R31 care plan initiated 04/04/2019 documented the resident was at risk and had potential for falls due to limited mobility, cognition decline due to severe Intellectual Disability (ID). The care plan directed the staff to place a bed against wall-per guardian preference, bed in lowest position when occupied, ensure proper body posture while in bed to ensure safety, floor mats beside bed when the resident is in bed and perimeter mattress applied to bed.
Review of MD00203104 and the un-witnessed fall form dated 02/18/2024, Licensed Practical Nurse (LPN)29 documented, Geriatric Nurse Aide (GNA) alerted her that R31 was on the floor when she entered to provide care. R31 was found lying in a curled-up position (Baseline position) on the floor directly next to the bed. The bed was in the lowest position. It documented R31 rolled over the edge. The report indicated R31 was unable to give a statement. The report indicated a full assessment, Vital signs were obtained, R31 was safely assisted back to bed and wound care to small laceration to above left eye. The report revealed no injury was observed at the time of the incident. Further review of the incident report revealed no intervention was put in place after the fall incident.
Review of the un-witnessed fall form dated 02/27/2024, RN (Registered Nurse)28 documented she was called to room about R31 being on the floor. When RN28 entered the room, R31 was on the floor. After the R31 assessment, the resident was assisted by two staff members to the bed. No apparent injury was noted at the time. R31 was unable to give a description. Further review of the form revealed no intervention was put in place after the R31 fall.
Record review of R31 nurse's notes dated 03/31/2024 at 9:43PM, LPN #30, documented that R31 was observed laying on his/her Right side, on the floor mat beside the bed. His/Her head was towards the foot end of the bed. R31 was assessed for injuries, and injuries were noted. R31 appeared agitated when staff put him/her back into bed and was rubbing the skin on his/her arms. As needed pain medication was given for pain R31 may have been experiencing. Neuro checks have started. R31 was assisted back in bed. Notification was made for Medical Doctor, Director of Nursing (DON) and social workers. Neuro checks were within normal limits (WNL). Further review of the incident report revealed no intervention was put in place after the fall incident.
During an interview on 06/13/2025 at 4:08 PM, Minimum Data Set Coordinator (MDSC) 30 revealed she was not employed at the facility when R31 had the falls in 2024. She reported reviewing R31's care plan completed in February 2024 and March 2024 and did not find the interventions for the falls 02/18/2024, 02/27/2024 and 03/31/2024. MDSC 30 reported that the facility has an Interdisciplinary Team (IDT) meeting in the mornings that discusses the residents' falls. MDSC 30 stated the IDT comes up with the root cause of a fall, and the care plan was updated with new interventions.
During an interview on 06/18/2025 at 11:38 AM, the Nursing Home Administrator (NHA1) revealed that she was not employed at the facility when R31 had the falls. She stated she could not find any documentation on R31's records indicating the interventions that were put in place after the falls that happened on 02/18/2024, 02/27/2024 and 03/31/2024. NHA1 stated that when R31 had the falls, the interventions should have been put in place and the care plan updated.
During an interview on 06/18/2025 at 11:40 AM, the Director of Nursing (DON)2 revealed she was not employed at the facility when R31 had fallen. She added that the interventions should have been put in place after each fall that happened on 02/18/2024, 02/27/2024 and 03/31/2024.
LPN30 was no longer employed at the facility and did not return phone calls.
LPN29 was no longer employed at the facility and did not return the phone call.
RN 28 was no longer employed at the facility and did not return the phone call.
Aug 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of the facility policies, review of medical record, as well as staff interviews, it was determined t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of the facility policies, review of medical record, as well as staff interviews, it was determined that the facility staff failed to notify a resident's physician when a resident had fallen and received an injury to the head. This was evident for 1 (Resident #1) reviewed during a complaint survey.
The findings include:
A review of facility reported incident MD00195570 on 08/17/23 revealed an allegation Resident #1 had been observed with a hematoma to the forehead and a black eye on 08/12/23.
A review of Resident #1's medical record on 08/17/23 at 9 AM revealed that Resident #1 was admitted to the facility on [DATE] for a Hospice, 5-day respite stay. Resident #1 was admitted with diagnoses that include: a history of falls, dementia, bone density and structure disorders, and hypertension.
Further review of Resident #1's medical record revealed nursing progress notes indicating that on 08/11/23 at 2:20 AM, LPN #1 observed Resident #1 fall out of his/her wheelchair onto the floor hitting his/her head. LPN #1 documented that Resident #1 was observed with a lump to the right side of his/her forehead. LPN #1 documented on a nursing, change of condition form, that Resident #1's physician was made aware by placing a note in the physician communication book on 08/11/23 at 2:30 AM. No call was placed to the physician.
Review of the facility policy, Assessing Falls and Their Causes, with a policy date of December 7, 2007, page 7, 1. After a Fall, paragraph d, on 08/17/23, revealed that the nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone.
In an interview with LPN #1 on 08/18/23 at 10:28 AM, LPN #1 stated that s/he documented Resident #1's 08/11/23 at 2:20 AM fall. LPN #1 stated s/he witnessed Resident #1's fall out of his/her wheelchair and subsequent hematoma to Resident #1's right side of his/her forehead. LPN #1 stated that he/she was not aware of how to contact a physician at night because there are no On Call procedure or phone instructions on the nursing unit. LPN #1 stated Resident #1's right forehead hematoma was observed to be small initially and was bleeding but not profusely. Resident #1 did not complain of pain. LPN #1 also stated that Resident #1's right forehead hematoma did get bigger.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of the facility policies and a medical record, as well as staff interviews, it was determined that t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of the facility policies and a medical record, as well as staff interviews, it was determined that the facility staff failed to initiate a neurological assessment when a resident fell and was observed with a head injury. This was evident for 1 (Resident #1) reviewed during a complaint survey.
The findings include:
A review of facility reported incident MD00195570 on 08/17/23 revealed an allegation Resident #1 had been observed with a hematoma to the forehead and a black eye on 08/12/23.
A review of Resident #1's medical record on 08/17/23 at 9 AM revealed that Resident #1 was admitted to the facility on [DATE] for a Hospice, 5-day respite stay. Resident #1 was admitted with diagnoses that include: a history of falls, dementia, bone density and structure disorders, and hypertension.
Further review of Resident #1's medical record revealed nursing progress notes indicating that on 08/11/23 at 2:20 AM, LPN #1 observed Resident #1 fall out of his/her wheelchair onto the floor hitting his/her head. LPN #1 also documented that Resident #1 was observed with a lump to the right side of his/her forehead. LPN #1 also documented on a nursing, change of condition form, that Resident #1's physician was made aware by placing a note in the physician communication book on 08/11/23 at 2:30 AM.
Review of the facility Neurological Assessment policy, dated 2001, on 08/17/21, revealed General Guidelines that indicated neurological assessments are indicated: C. following a fall or other accident/injury involving head trauma or, D. when indicated by resident's condition. Under Steps in the Procedure, #12. Check eye opening, verbal, and motor responses using the Glasgow Coma Scale and record the observations.
In an interview with LPN #1 on 08/18/23 at 10:28 AM, LPN #1 stated that s/he documented Resident #1's fall on 08/11/23 at 2:20 AM . LPN #1 stated s/he witnessed Resident #1's fall out of his/her wheelchair and subsequent hematoma to Resident #1's right side of his/her forehead. LPN #1 stated that /she was not aware of how to contact a physician at night because there are no On Call procedure or phone instructions on the nursing unit. LPN #1 stated Resident #1's right forehead hematoma was observed to be small initially and was bleeding but not profusely. Resident #1 did not complain of pain. LPN #1 also stated that Resident #1's right forehead hematoma did get bigger.
The next nursing documented assessment of Resident #1 did not occur until 08/11/23 at 11:29 AM which documented Resident #1 had a hematoma to the forehead and no complaints of pain.
Aug 2023
42 deficiencies
2 IJ (1 facility-wide)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
Based on clinical and administrative record reviews, and interviews, the facility failed to protect residents' right to be free from physical abuse by other residents. The facility's failure to implem...
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Based on clinical and administrative record reviews, and interviews, the facility failed to protect residents' right to be free from physical abuse by other residents. The facility's failure to implement adequate interventions for a resident (#79) to prevent recurring resident-to-resident abuse placed residents at risk for serious harm. This finding was evident for 3 of 9 residents (#62, #22, and #6) reviewed for abuse.
The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the
Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 6:08 PM on 8/7/23. On 8/7/23 8:42 PM The facility submitted an abatement plan to remove the immediacy while surveyors were onsite. The abatement plan was accepted by the OHCQ at 8:48 PM on 8/7/23.
The findings include:
On 08/02/2023 at 7:50 AM the surveyor reviewed the facility's investigation file regarding
the incident between Resident #79 and Resident #22 that occurred on 05/27/2023 and the incident that occurred on 6/21/23 between Resident #79 and Resident #62.
Review on 08/02/2023 at 8 AM of the facility reports revealed that Resident #79 was identified as the aggressor for 3 of the 20 Facility Reported Incidents reviewed during the annual survey.
Additional review of Resident #79's medical record revealed diagnoses including adjustment
disorder with mixed anxiety and depressed mood and delusional disorders.
Further review of Resident #79's medical record revealed that the resident did not have a care plan for abusive behaviors or aggression towards residents. A care plan is a document that
summarizes a person's health conditions, specific care needs and current treatments. It should
outline what needs to be done to manage the person's care needs.
Review of Resident #79's medical record on 08/02/2023 showed that on 02/17/2023, the psychiatrist recommended Resident #79 to start taking a medication for anxiety. Review of the physician orders for Resident #79 revealed that the anti-anxiety medication was not acknowledged or ordered by the physician.
Review of resident #79's Medication Administration Record on 08/07/2023 at 9:30 AM revealed that for the months of February 2023 through August 2023 there were no orders for anti anxiety medication that the psychiatrist recommended.
On 08/02/2023 review of the Facility Report for Resident #62 revealed that on 04/19/2023, Staff #26 witnessed Resident #79 hit Resident #62 on the back of his/her head with an open hand multiple times.
Review of the medical record for Resident #79 revealed a note written by Staff #4 on 4/19/2023 at 3:25 PM that documented Resident # 79 was moved from a room on a secured unit into another room on a general nursing unit.
Further review of the Facility Report Incident revealed that on 05/27/2023 Resident #22 reported to facility staff that, while Resident #79 was exiting their room, Resident #79 used his/her hand to hit him/her on the top of the head while Resident #22 was in a wheelchair.
During record review on 8/7/2023 7:30 AM Resident #79's psychiatric evaluation dated 05/31/2023 revealed that Resident #22 stated I am afraid of her (Resident #79), {Resident #79} told me to shut up all the time. Resident #22 was moved to another room for safety.
Surveyor interview on 8/7/2023 9:10 AM with Staff #17, the resident's room was changed because staff realized that Resident #79 was offended by wandering residents on the locked unit.
Review of the follow up psychiatry visit notes dated 06/02/2023 for Resident #79, revealed that the psychiatrist recommended that the resident start an anti depressant used to treat depression and generalized anxiety disorder for anxiety and aggressive behavior. Further review of the physician orders revealed that the medication was not acknowledged or ordered by the physician. Review of resident #79's Medication Administration Record on 08/07/2023 9:30 AM revealed that for the months of June 2023 through August 2023 there were no orders for the anti depressant recommended by the pharmacist.
On 08/02/2023 review of the Facility Report for Resident #6 revealed that on 06/21/2023, Resident #79 hit Resident #6 on his/her head with a remote control.
On 08/02/2023 at 1:30 PM the interim Administrator was interviewed and stated she could not provide surveyors with the facility's investigation files for the incident on 5/27/2023 regarding Resident #79 as the aggressor towards Resident #22 and for the incident on 06/21/2023 regarding Resident #79 as the aggressor towards Resident #6. The interim Administrator went on to say that she was sure the investigations were conducted but she searched for them and could not find the documentation of the investigations.
During an interview on 08/07/2023 at 9 AM, surveyors asked Licensed Practical Nurse (LPN), Staff #18, if she had knowledge of the medication recommendations from the psychiatrist, to which she answered, Yes. I told the psychiatrist that Resident #79 refuses medications. Staff #18 went on to say she also discussed Resident #79's refusal of medications with the covering Nurse Practitioner. That is why the recommended medications were not ordered.
Surveyors requested documentation of Resident #79's refusal of medications. Staff #18 stated, I usually document resident refusals in the progress notes or the medication administration record, but somehow, I missed this one. Sorry.
On 08/07/2023 at 9:20 AM Staff #18 provided surveyors with Resident #79's psychiatric notes dated 7/27/2023 which stated Resident #79 has been refusing to take medications.
There was no documented evidence that the resident was refusing to take medications nor was there a plan to implement alternate interventions if the resident refused medications.
During a phone interview on 08/07/2023 at 7:06 PM, the Psychiatrist confirmed that he recommended the antidepressant medication after one of the incidents that had occurred and the antianxiety medication after another incident had occurred. He also stated that he was told by Staff #18 that the resident refuses medications which is why he documented that in the 07/27/2023 note. The psychiatrist stated that he was in contact with facility staff on 08/07/2023 and gave the recommendation to move Resident #79 to a room, without a roommate, and to place Resident #79 on 1:1 (one resident to one staff person) observation for 24 hours a day until reevaluated.
An interview held on 08/7/2023 9:25 AM with the Social Worker Assistant, Staff #4, with Staff #17 present, revealed that Resident #79 makes his/her needs known to nursing staff. Staff #4 went on to say that Resident #79 displays aggression when surrounded by wandering residents and when being questioned about anything.
During an interview on 08/07/2023 at 5:50 PM with the Interim Nursing Home Administrator (NHA), surveyors made concerns known that the facility failed to ensure effective systems to prevent resident-to-resident abuse that occurred and that reached three different residents (#62, #22 and #6) and further, left residents at continued risk for serious harm.
Review of the facility reported incident which occurred on 4/19/2023, the facility verified the allegations of abuse and implemented a room change for Resident #79. The facility also verified the allegation of abuse that occurred on 5/27/2023 and 06/21/2023. However, after the room change on 4/19/2023, there were no other preventative measures put in place to prevent further resident to resident abuse.
These identified concerns were brought to the attention of the facility interim NHA on 08/07/2023 and an immediate jeopardy was called on 8/7/23 6:08 PM related to preventing abuse of residents.
On 08/07/2023 8:42 PM The facility submitted an abatement plan to remove the immediacy while surveyors were onsite. The abatement plan was accepted by the OHCQ
at 8:48 PM on 08/07/2023.
The plan included:
- An audit of all residents in the facility that have exhibited behaviors (date of alleged compliance 08/07/2023) their care plans updated accordingly with appropriate interventions to reduce the risk of resident to resident abuse (date of alleged compliance 08/08/2023)
- Referrals to the psychiatrist for recommendations with (date of alleged
compliance 08/08/2023) .
- Mandatory training was conducted for all staff in all departments on resident behaviors,
interventions, and implementation of new interventions when incidents occur including
resident to resident abuse (date of alleged compliance 08/09/2023).
- Also, included in the plan was all recommendations from the psychiatrist would be
reviewed during the clinical meeting to ensure that recommendations are followed up with the medical provider for implementation by alleged date of compliance 08/08/2023.
Tour of the facility on 08/09/2023 7:05 AM and of Resident #79 ' s room revealed that only one resident was assigned to the room (Resident #79) and the 1:1 sitter was present outside of the door. The Surveyor approached certified nursing assistant (CNA), Staff #45, positioned by the entrance of Resident #79 ' s room door, she stated she received a report from the 11 PM to 7 AM staff that the resident was awake throughout the night and had recently laid in the bed without any incident. Staff stated if there were any incidents, she would make sure the resident isn ' t harmed or harms others then report to the Unit Manager.
On 08/09/2023 at 9:45 AM the Surveyor received a list from the interim NHA, which included the sign-in list of all staff who received the training on resident to resident abuse and a list of all facility staff. Review of the documents revealed several staff signatures were missing from the sign-in sheet therefore the facility was not in compliance with their 8/8/23 date of completion for all staff education.
An interview was held with the interim NHA on 08/09/2023 at 11:45 AM and the interim NHA confirmed that the missing signatures were for the staff that were current employees but not scheduled to work, therefore they would be contacted by phone and if no contact could be
made, they would not be scheduled to work unless the training was completed.
On 08/11/2023 at 9 AM the interim NHA submitted a list of all scheduled staff which the surveyor verified signatures were present on the training titled, Resident to Resident
Behaviors/Documentation of Behavior/Interventions sign-in sheet dated 08/11/2023.
The team confirmed the facility implemented their abatement plan and the Immediate Jeopardy was abated on August 11, 2023.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Food Safety
(Tag F0812)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on observation and interview with facility staff, it was determined that the facility failed to remove expired food items and label opened stored food items and in a manner that maintains profes...
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Based on observation and interview with facility staff, it was determined that the facility failed to remove expired food items and label opened stored food items and in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility kitchen.
The findings include:
Surveyors conducted an initial brief tour of the kitchen on 07/24/2023 with and identified:
- Three unopened 6-lb cans of marinara sauce without an expiration date
- Five bags of unopened hot dog buns with an expiration date on 07/14/2023
- 50 Resident food trays were rusty around the trim and cracked
- 10 Blue domed plate covers, and plate holders, were cracked and missing pieces
The surveyor conducted a second tour of the kitchen including the dry storage area on 07/24/2023 at 9:27 AM with cook, Staff #6. During the tour, we observed:
- One sealed 52 ounce (oz) can of Red and [NAME] Pepper strips without an expiration date
- Elbow macaroni stored in an opened transparent plastic container without an opened date
- Egg noodles stored in an opened transparent plastic container without an opened date
- Tri colored rotini stored in a transparent plastic container without an opened date
- Spaghetti stored in a transparent plastic container without an opened date
- One 52 oz can of dry navy beans without an expiration date
- Raisins stored in unsealed transparent bag inside an open brown box with an open date of 01/05/2023
- One opened box with white shredded coconut with expiration date 01/2022
- One small bag of mini marshmallows with an expiration date of 06/29/2023
- Two 52 oz unopened cans of split peas with uncured ham uncured bacon; one with an expiration date of 08/05/2022 and one can with an expiration date of 2/18/2022
- Three 52 oz cans of Cream of Mushroom with an expiration date of 12/10/2022
- One 52 oz can of beans with uncured bacon with an expiration date of 3/16/2023
- One opened metallic colored bag of vanilla pudding filling mix with out and expiration date
- One opened 20 oz container of Welch's grape jelly, the label advises to: refrigerate after opening
- One 5-pound (lb.) bag of fudge brownie mix without an expiration date
- Two 5-lb. bags of buttermilk pancake mix with an expiration date of 3/31/2023
- Two 5-lb. bags of yellow cake mix unopened without an expiration date
- One 28 oz brown bag labelled cream soup base without an expiration date
- Four 5-lb. boxes of buttermilk biscuit mix with an expiration date of 06/22/23
- One gallon of thousand island dressing with an expiration date of 08/22/2020
- One opened gallon plastic container labelled LA Choy Sweet & Sour Sauce, open date of 01/05/2023 and label advises to refrigerate after opening
- One rusty and dented 6-lb. can pf aged cheddar cheese sauce.
During a tour of the dishwashing area of the kitchen that took place on 07/24/2023 at 9:55 AM, with the Maintenance Director, the surveyor found a broken eyewash station filled with paper trash and missing a white plastic drainpipe from under the eyewash station. The surveyor and Maintenance Director also identified a faucet with a red hose attached, leaking onto the floor near the entrance of the dishwasher room. The Maintenance Director advised the surveyor that a plumber was contracted to fix the drainpipe and leaking faucet.
A second tour of the dishwashing area of the kitchen took place on 08/03/2023 at 6:55AM with the Certified Dietary Manager (CDM). The surveyor and CDM observed the eyewash station with crumbled paper trash in it. The CDM indicated to the surveyor that he scheduled a mandatory all dietary staff meeting which includes use and maintenance of the eye wash station equipment.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility staff failed to ensure adequate superv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility staff failed to ensure adequate supervision while positioning a resident in bed during the provision of care. This deficient practice resulted in harm for Resident #212. This was evident for 1 (#212) of 14 residents reviewed for accidents.
The findings include:
On 08/08/2023, a record review was conducted which revealed that Resident #212 had diagnoses which included, but were not limited to, left femur fracture, stroke and hemiplegia affecting his/her left non-dominant side. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body.
The MDS (Minimum Data Set) is a screening tool that is utilized to ensure each resident's individual needs are identified.
A review of the MDS assessment, with an assessment reference date of 01/17/2023, identified that to turn from side to side and position body when in bed, the resident was totally dependent on staff for the activity and required 2 staff persons to physically assist.
According to facility notes dated 03/10/2023 at 12:27 PM, Resident #212 fell from bed during activities of daily living (ADL) care. Rolled to the floor, hit head on the way down. As a result, he/she sustained an injury to the right ear.
A facility incident report was obtained. The report described how Staff #29, a Geriatric Nursing Assistant (GNA) and the only witness to the fall, had been providing care without the assistance of another staff member. Per the incident report, the resident was holding onto quarter rail and pulled self over too far in bed causing [his/her] weight to shift. The GNA could not reach across the bed quickly enough to prevent the fall.
On 8/8/23 at 1:50 PM, an interview was conducted with Staff #41, a GNA. When asked how a GNA would know how much assistance a resident requires, Staff #41's answer included using the [NAME] that can be found in the resident's electronic chart.
According to the facility's training materials, the [NAME] is a quick summary of individual resident needs tells you all you need to know about the resident, how to care for them, and any items that they require.
Before providing care to Resident #212, Staff #29 would have been able to quickly find information pertaining to the resident's bed mobility in the [NAME].
After the fall, Resident #212 was sent to the Emergency Department (ED) for an evaluation. ED notes revealed that the resident suffered a laceration of the right ear that required 10 sutures.
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 F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on record review and staff interview it was determined that the facility staff failed to ensure that a resident's right to make decisions was honored. This was evident for 1 (#164) out of 68 res...
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Based on record review and staff interview it was determined that the facility staff failed to ensure that a resident's right to make decisions was honored. This was evident for 1 (#164) out of 68 residents in the survey sample.
The findings are:
An investigation into a complaint (#MD00173260) on 8/4/23 revealed that on 8/16/22 Resident #164's family member observed that the resident did not awaken when nudged and appeared unresponsive. The family member told the nursing staff who responded that the resident was normally slow to awaken and that this was normal. The family member called the daughter who was the responsible party. The daughter called the nursing station and demanded that the nurse check the resident. Vital signs were taken and were within normal limits. The resident was put on the phone to speak with the daughter. Resident #164 said he/she was fine. Daughter insisted the resident be sent out to the hospital via 911. The resident was alert and oriented x 2. The nurse informed the daughter that the resident had the right to decide whether or not to go to the hospital. The resident's advanced directive was triggered upon signature not upon a clinical condition. The resident did not give up the right to make the decision but had deferred the decision making to the daughter. The daughter called 911 and the resident was sent to the hospital for evaluation.
The Administrator, Director of Nursing, and Regional Administrator were interviewed and informed of the findings on 8/04/23 at 12:45 PM. No evidence to contradict the findings were presented prior to the exit conference.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations and interviews it was determined the facility failed to ensure that the resident's call light was within reach to allow access to assistance when needed. This was evident for 3 (...
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Based on observations and interviews it was determined the facility failed to ensure that the resident's call light was within reach to allow access to assistance when needed. This was evident for 3 (#16, #21, #15) of 3 residents observed on the Chase nursing unit during the initial tour of the facility.
The findings include:
On 11/29/23 at 8:53 AM a tour of the facility was conducted. Observation was made in Resident #16's room of the resident lying in bed. The bed was on the left side of the room against the wall. Observation was made of the call bell hanging off the wall on the other side of the nightstand and out of reach of the resident.
Observation was made of Resident #16's roommate, Resident #21, who was lying in bed. There was a soft gray call bell lying on the floor next to the bed. The surveyor watched staff go in and out of the rooms without placing the call bell within reach.
On 11/30/23 at 9:07 AM a second observation was made of Resident #16's call bell cord hanging on the wall. At that time the surveyor asked Certified Medicine Aide (CMA), Staff #26 to come in the room. The surveyor showed Staff #26 the call bell. Staff #26 stated, that should not be on the wall and proceeded to place it on Resident #16's bed. At that time Staff #26 was shown Resident #21's soft gray call bell that was on the bed next to Resident #21, who was sitting in a wheelchair. The surveyor told her about the observation the previous day. Staff #26 stated that the call bell should always be in the resident's lap because the resident cannot move his/her arms to reach the call bell. At that time Staff #26 placed the call bell in Resident #21's lap.
The surveyor walked across the room to Resident #15 and his/her call bell cord was attached to a package of wipes that was sitting on the nightstand and out of reach of the resident. Staff #26 asked Resident #15 why the call bell was there, and Resident #15 stated because that is where the aide put it. At that time Staff #26 clipped the call bell to the bed. Resident #15's roommate stated that he/she always has to ring his/her call bell because Resident #15 can't ring his/hers because it is not within reach.
The Director of Nursing was informed of the findings on 11/30/23 at 5:50 PM.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it was determined that the facility staff failed to ensure that nursing home staff fu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it was determined that the facility staff failed to ensure that nursing home staff fully informed a resident and their family of how to receive final disbursement of all monies sent to the facility in the resident's name. This was evident for 1 (#163) out of 68 residents in the survey sample.
The findings are:
An investigation into Intake #MD00192746 included a review of Resident #163's account which revealed the resident had $1,720 on [DATE]. The resident expired on [DATE]. The resident was charged $1407 on [DATE] for the cost of services for March. On [DATE] $1720 was returned to the Social Security Administration.
The family, as of [DATE], had not received the money left in the resident's account.
The Administrator was interviewed on [DATE] at 2:00 PM. He said that once the resident died the Power of Attorney (PoA) status disappeared. He said the former PoA has to write a letter to the Board of Administrators to request a check for the remaining balance. I asked if the PoA was told and he replied, I don't think so, but I'll call.
The Administrator was interviewed on [DATE] at 8:20 AM. He stated that if the resident is on Medicare, then they deduct the amount from the account. If the resident is Medicaid, then the amount is deposited and then billed. If the resident dies, then the check is returned but the resident is not billed. The Surveyor showed the statements and explained that the resident died on [DATE] but was billed for [DATE]. The money billed was not returned. The Administrator said it was probably because the billing system is automatic. The Surveyor asked if they (billing system) had been told to stop and he replied that he did not know.
Staff #21 was interviewed on [DATE] at 11:17 AM. She explained that when a resident has been discharged /died we have a letter/form that we give them when they sign out their belongings. The Surveyor asked what if they come unannounced and just walk out the front door with the belongings. She said that in that case she would send an email and/or phone call and inform them of the process. She said she has just started sending notices in [DATE]. Staff #21 said she reached out to the PoA and explained how to submit the documentation. The resident will be reimbursed for the cost of care charge as well as getting the balance in the account.
The Administrator, Director of Nursing and acting Administrator were interviewed and informed of the findings on [DATE] at 12:45 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interviews, it was determined that the facility staff failed to ensure clarity regarding whether Advance Directives had been formulated by a resident. This wa...
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Based on clinical record review and staff interviews, it was determined that the facility staff failed to ensure clarity regarding whether Advance Directives had been formulated by a resident. This was evident for 1 (#25) of 6 residents reviewed for Advance Directives during the annual survey.
The findings include:
Advance Directives are legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes.
On 07/24/2023 at 1:05 PM, a clinical record review revealed that there were no Advance Directives in Resident #25's chart (clinical record).
Contained within the chart was a document entitled Advance Directive Acknowledgement. The document had been signed on 06/11/2020. At the bottom of this document was a prompt which read: PLEASE CHECK ONE OF THE FOLLOWING STATEMENTS:. Provided were two options to check; I HAVE executed an Advance Directive or I HAVE NOT executed an Advance Directive. On Resident #25's document not only was the first option checked, but handwritten in was a third, ad-hoc option, pending, which was also checked. Having two options checked made it unclear whether the resident had formulated Advance Directives.
On 07/26/2023 at 8:04 AM, an interview with Staff #4, the Social Work Assistant (SWA), was conducted. When asked to clarify if Resident #25 had formulated Advance Directives, the SWA said she was unsure. Per the SWA, whoever handwrote in pending should have followed-up. She stated I don't think [Advance Directives] have been done. I'll do one with him today.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview it was determined that the facility nursing staff failed to ensure a resident's family was notified of a hospitalization and to ensure only an autho...
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Based on clinical record review and staff interview it was determined that the facility nursing staff failed to ensure a resident's family was notified of a hospitalization and to ensure only an authorized contact was notified. This was evident for 2 (#164 and #82) out of 68 residents in the survey sample.
The findings are:
1. An investigation of intake #MD00182928 revealed Resident #164 was having respiratory issues on 7/26/22 at 5:30 AM. Nursing called the primary physician and an order to send to the hospital was received. The Power of Attorney (PoA) was not notified and did not know the resident was sent to the hospital until the resident returned to the facility.
2. An investigation of intake #MD00191339 revealed Resident #82 had a fall without injury on 1/20/23. Nursing staff called the daughter instead of the daughter in law. The daughter is not the responsible party or an approved contact person.
The Acting Administrator was interviewed on 7/31/23 at 11:04 AM. She was informed the daughter is not an approved contact person and asked why she was called and not the daughter in law who is an approved contact person.
The Acting Administrator was interviewed on 7/31/23 at 11:23 AM. She stated that the nursing home staff call the daughter in law during the week when the resident's son is working and questioned whether it was the daughter who was called. Informed her that the son confirmed that the daughter was called.
The Acting Administrator returned on 7/31/23 at 12:05 PM and could not find out why the daughter was contacted.
The Administrator, Director of Nursing, and regional Administrator were interviewed and informed of the findings on 8/04/23 at 12:45 PM. No evidence to contradict the findings were presented prior to the exit conference.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and review of facility documentation, it was determined the facility failed to report a critical unusual occurrence that affected the health and safety of all residen...
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Based on observation, interviews, and review of facility documentation, it was determined the facility failed to report a critical unusual occurrence that affected the health and safety of all residents in the facility to the Office of Health Care Quality (OHCQ). This was evident for 3 days when the kitchen failed to have hot water to provide to the kitchen dishwasher, handwashing sinks, and the 3 compartment sink to wash pots and pans.
The findings include:
On 11/29/23 at 12:47 PM a tour of the kitchen was conducted to follow-up on concerns cited during the annual survey that ended on 8/11/23. Dietary Staff #9 was in the dishwashing area and mentioned to the surveyor that they had been having problems with hot water while washing dishes.
On 11/29/23 at 2:09 PM the surveyor returned to the kitchen to observe the dishwasher while dishes from the lunch service were being washed and sanitized. Observation of the temperature gauges on the outside of the dishwasher failed to reach the required temperature for adequate sanitation. Staff #8 was in the dishwashing area at that time and stated it was the third day with no hot water, which began on 11/27/23. Further observation of the kitchen revealed that the sinks for staff to wash their hands only had cold water.
Staff #8 was asked to see the dishwasher temperature logs. Staff #8 stated they did not keep logs. Staff #8 stated that they did not have hot water for the past 3 days and the Nursing Home Administrator (NHA) knew about it.
There was no documentation supplied to the surveyors that OHCQ was notified of the lack of hot water in the kitchen as required. The kitchen staff continued conducting food preparation and services activities in the kitchen in an unsanitary manner every day for 3 days.
On 11/29/23 at 2:50 PM surveyors called the local county health department and spoke to the sanitarian who stated he was not aware of the hot water issue in the kitchen and that the local health department had not been notified.
On 11/29/23 at 6:30 PM the NHA and Staff #5, the [NAME] President of Clinical Operations were informed of the concern.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on review of faciity records and interview, it was determined that the facility failed to conduct a thorough investigation. This was found to be evident for 2 (# 25, # 32) out of 20 facility rep...
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Based on review of faciity records and interview, it was determined that the facility failed to conduct a thorough investigation. This was found to be evident for 2 (# 25, # 32) out of 20 facility reported incidents.
The findings include:
On 07/27/23 at 8:45 AM, a record review revealed that a facility reported incident (FRI) regarding Resident #25 was received by the Office of Healthcare Quality on 04/26/2022 at 1:06 PM. In the FRI, the facility reported that per Resident #25, on 03/18/2022 Staff #46 threw a remote at him/her.
The facility's investigation was reviewed and was deemed to be missing several key components:
1.
The self-report is missing.
2.
The facility failed to obtain an interview with the alleged perpetrator, Staff #46.
3.
No other residents, including the roommate, were interviewed.
4.
There was no evidence that measures were put into place to protect the resident from further abuse while the investigation was being completed.
On 07/27/23 at 11:04 AM, a record review revealed that a FRI regarding Resident #32 was received by the Office of Health Care Quality on 07/08/2022 at 11:38 AM. According to the FRI, the resident reported that he/she had been assaulted by two unknown men.
The facility's investigation was reviewed and was deemed to be missing several key components:
1.
The self-report is missing.
2.
No other residents, including the roommate, were interviewed.
3.
2 interviewees were unidentifiable as there was no name or signature.
On 07/31/23 at 11:10 AM, when asked to locate the missing self-reports, the Interim Nursing Home Administrator admitted that she did not know where the former administration kept a lot of the self-reports and did not know why they were separated from the investigations.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview it was determined the facility failed to ensure that Minimum Data Set (MDS) assessments were complete. These concerns with incomplete assessments wer...
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Based on medical record review and staff interview it was determined the facility failed to ensure that Minimum Data Set (MDS) assessments were complete. These concerns with incomplete assessments were evident for 1 (#44) of 5 residents reviewed for an annual/admission assessment during a revisit 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 these individualized needs, and that the care is provided as planned to meet the needs of each resident.
On 11/30/23 at 10:30 AM a review of Resident #44's annual MDS with an assessment reference date (ARD) of 11/4/23 revealed the assessment was not complete for section C - Cognitive Patterns and Section D - Mood.
On 11/30/23 at 11:37 AM an interview was conducted with the MDS Coordinator who stated, our social worker does those sections of the MDS, so I do not know why they were missed. I don't see it until after the fact. It has been hit or miss. Every once in a while there are one or two that are missed. Speech Therapy has started to do them when social work can't get to them.
On 11/30/23 at 12:06 PM an interview was conducted with the Director of Social Work who stated, I have a social work assistant so it should have been done. Yes, I sometimes don't get to them.
On 11/30/23 at 5:50 PM Staff #5 was informed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident had baseline care plans created and initiated for a resident. This was evident...
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Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident had baseline care plans created and initiated for a resident. This was evident for 1 (#162) out of 68 residents in the survey sample.
The findings are:
A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is given to the resident and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive.
An investigation into intake #MD00189012 was initiated by the survey team on 8/3/23. The clinical record review revealed an absence of baseline care plans. The resident had Chronic Obstructive Pulmonary Disease, macular degeneration (affects eye site), was on an anticoagulant, and had other conditions which would have benefitted from the development of a baseline care plan.
The Administrator, Director of Nursing, and Regional Administrator were interviewed and informed of the findings on 8/04/23 at 12:45 PM. No evidence to contradict the findings were presented prior to the exit conference.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to provide incontinence care. This was evident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to provide incontinence care. This was evident for 1 (# 90) out of 8 residents reviewed for Activities of Daily Living (ADL) Care.
The findings include:
The Activities of Daily Living (ADL) care is a term used to collectively describe fundamental skills required to care for oneself, such as bathing, dressing, toileting, transferring (getting in and out of bed or chair), eating, and continence.
During a phone interview conducted on 07/27/2023 at 11:32 AM, the complainant stated the resident was left soiled for long periods of time.
On 8/7/23 at 11:51 AM, the surveyor reviewed the ADL care documentation for August 2022 through December 2022 for Resident # 90. For the month of August there was no toilet use documented for 31 out of 87 shifts and urinary continence care was documented for 30 of 87 shifts. In September, toilet use was not documented 46 out of 90 shifts and urinary continence was not documented 47 out of 90 shifts. In October 2022 there was no toilet use documented for 38 out of 93 shifts and no urinary continence documented for 31 out of 90. For November 2022, 31 out of 90 shifts had both toilet use, and urinary continence were not documented. In December 2022, 34 shifts out of 90 shifts did not have toilet use and urinary continence documented.
According to CMS, the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.
The Brief Interview for Mental Status (BIMS) is a screening tool used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. A series of standardized questions in the BIMS are scored and when added result in a total score between 0-15. The numeric value falls into one of three cognitive categories: Intact which is 13 to 15 points, Moderate which is 8 to 12 points or Severe cognitive impairment which is 0 to 7 points.
A review of Resident #90's admission 5-day MDS dated [DATE] was conducted on 08/09/23 at 3:10 PM. The MDS record revealed the resident scored a BIMS of 12, Section G - resident requires extensive one person assist for toileting and Activities of Daily Living cares.
During an interview conducted on 08/08/23 at 3:45 PM, the Administrator stated all incontinent care and toilet use is documented only under the ADL care documentation. The surveyor advised the Administrator of the missing incontinent care and toilet use for Resident #90.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, it was determined that the facility staff failed to ensure that activities were provided that met a resident's needs. This was evident for 1 (#32...
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Based on observations, interviews, and record reviews, it was determined that the facility staff failed to ensure that activities were provided that met a resident's needs. This was evident for 1 (#32) of 5 residents reviewed for activities during the annual survey.
The findings include:
On 07/24/2023 at 1:18 PM, 07/25/2023 at 10:00 AM, 07/25/2023 at 1:00 PM, and 07/27/2023 at 10:03 AM, Resident #32 was observed lying in his/her bed. The resident was not engaged in any individual activities nor were any facility staff engaging him/her in a 1:1 activity.
On 07/27/2023 at 9:27 AM, Staff #8, the Activities Director (AD), was interviewed regarding activities for Resident #32. The AD stated, the Activities Aids will do 1:1s with [him/her], devotionals, short stories, anything that meets [his/her] interest. When asked to see the logbook where the 1:1 visits were recorded, the AD picked up a binder. It was discovered that there were no 1:1 visits logged for the resident. The AD commented they should be recording 1:1 visits.
On 07/28/2023 at 10:32, an interview was conducted with Resident #32's son. The son reported that he has not observed the resident watching television, listening to the radio, or engaging in group or 1:1 activities. The son stated, the resident hasn't walked in a long time and that he would like to see [him/her] engaged in activities.
On 07/31/2023 at 9:10 AM, Resident #32's roommate was interviewed. Per the roommate, the activities team will engage Resident #32 in 1:1 activities once in a while.
On 07/31/2023, a record review revealed that according to Resident #32's care plan, due to immobility and physical limitations, the resident needs 1:1 bedside/in-room visits and activities if unable to attend out of room events.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on resident and staff interviews, observations, and medical record review, it was determined that the facility staff failed to provide a resident with a multi podus boot, as ordered. This was ev...
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Based on resident and staff interviews, observations, and medical record review, it was determined that the facility staff failed to provide a resident with a multi podus boot, as ordered. This was evident for 1 (#92) of 2 residents reviewed for positioning and mobility.
The findings include:
A Multi Podus Boot is a protective brace that corrects foot misalignments and minimizes the chance of skin breakdown.
On 07/24/2023 at 11:55 AM, Resident #92 was interviewed regarding issues with positioning and mobility. The resident stated that he/she needs a brace for the right leg. It was observed that the resident was not wearing a brace on either foot at the time.
A subsequent record review revealed that there was a physician's order for Resident #92
to wear multi podus boot at all times while in bed except for during care for positioning and pain management. The order had been active since 9/22/2022.
On 07/31/2023 at 9:15 AM, it was observed that Resident #92 was not wearing a multi podus boot. The resident stated, the doctor and nurses have mentioned it, nobody does anything. Before Christmas [Physical Therapy] took it because it felt too small. He said he would fix it.
On 07/31/2023 at 9:20 AM, Staff #7, a Registered Nurse, confirmed the physician's order. Staff #7 then checked Resident #92's room and confirmed there was not a multi podus boot in the resident's room.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it was determined that the facility staff failed to ensure that consent was obtained prior to utilizing bed rails. This was evident for 1 (#212) of 68 resid...
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Based on record review and staff interview, it was determined that the facility staff failed to ensure that consent was obtained prior to utilizing bed rails. This was evident for 1 (#212) of 68 residents reviewed during the annual survey.
The findings include:
Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths.
On 08/08/2023, at 2:50 PM, a record review was conducted which revealed that Resident #212 had diagnoses which included, but were not limited to, left femur fracture, stroke and hemiplegia affecting his/her left non-dominant side. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body.
A review of the MDS (Minimum Data set, or MDS, is a screening tool), with an assessment reference date of 01/17/2023, identified that the resident was cognitively intact.
A nurses note dated 03/10/2023 at 12:27 PM, described how Resident #212 fell from bed while receiving care from staff. The corresponding incident report described how the resident was holding onto [the] quarter rail and pulled self over too far in bed.
There was neither a physician's order in place for bed rails nor was there any documentation that the resident had been made aware of the risks and benefits of utilizing bed rails and consented to their use.
On 08/10/2023 at 10:52 AM, the finding was corroborated by the Acting Nursing Home Administrator, who stated, I was looking at the file yesterday. I'm already making a list of everyone who uses bedrails.
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 F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, it was determined that the facility failed to ensure the physician provided supervision for a resident with significant weight loss. This was found to be eviden...
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Based on interviews and record reviews, it was determined that the facility failed to ensure the physician provided supervision for a resident with significant weight loss. This was found to be evident for 1 (Resident #90) out of 1 resident's reviewed for weight loss.
The findings include:
According to the Centers of Medicare and Medicaid (CMS) a significant weight loss is a weight loss of: 5% in one month; 7.5% in 3 months; or 10% in 6 months.
During a phone interview conducted on 07/27/23 at 11:32 AM, the complainant stated the resident lost significant weight and the facility had not addressed it.
During a review of the Resident # 90 weights on 07/28/23 at 06:54 AM, the surveyor discovered that on 09/21/22 Resident # 90's weight was 185.6 pounds and on 10/07/22 it was 163 pounds which was a 12.18 % weight loss. The physician progress notes from 11/4/22, 12/30/22, 1/27/23 and 3/3/23 report no weight changes and the Certified Registered Nurse Practitioner (CRNP) notes written on 10/24/22, 12/3/22, 1/2/23 and 2/18/23 did not address the weight loss.
During an interview on 7/28/23 at 11 AM, the Administrator was informed of the concern that no weight loss or changes were addressed in Resident # 90's medical record by the physician or CRNP. The Administrator stated that although the facility Dietician documented the weight changes and implemented dietary changes the lack of physician supervision was a concern.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, it was determined that the facility failed to consistently monitor the behavior of a resident. This was found to be evident for 1 (#28) out of 1 resident review...
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Based on record reviews and interviews, it was determined that the facility failed to consistently monitor the behavior of a resident. This was found to be evident for 1 (#28) out of 1 resident reviewed for behavioral monitoring.
The findings include:
A complaint investigated on 8/21/2023 at 8:00 AM confirmed Resident #28 had been sexually inappropriate (masturbating) in a common area (dining room) on 04/04/2023.
On 8/21/23 at 08:30 AM, the surveyors reviewed medical records for Resident #28. A review of the Monitor Behavior Symptoms tool from March 23 through the end of July 23 for sexually inappropriate revealed documentation for inappropriate sexual behavior only on 4/10/2023.
Further review of the resident's progress note dated 4/4/23 at 2:28 PM, revealed a note from Social Worker (SW) # 4 that stated, I spoke with resident about the incident that happened today, and [resident] does understand [resident] shouldn't have done that, and [resident] was sorry, and [resident] will go to [resident] room for now on. I told [resident] that I talked to [resident] guardian, and [resident] said oh no please don't do that. So, I said to [resident] I have to do that when [resident] misbehaves. [Resident] said ok.
On 08/21/23 at 8:43 AM a review of the progress note dated 6/12/23 at 4:45 PM for Resident # 28's roommate revealed Resident #24 (roommate) requested and was granted a room change due to Resident #28's sexually inappropriate behavior (masturbating) in the dining room.
During an telephone interview conducted on 8/21/23 at 11:10 AM, SW #4 revealed that Resident # 28 had a history of inappropriate sexual behaviors (masturbating) in common areas and the nursing staff handled it by redirecting the resident to his/her room.
On 8/22/23 at 2:07 PM, during a telephone interview, the Nursing Home Administrator acknowledged the surveyor's concern that there was no behavior monitoring for inappropriate sexual behavior.
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 observation and staff interview it was determined that the facility staff failed to ensure that medication carts were locked and secured. This was evident for 1 of 3 nursing units.
The findi...
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Based on observation and staff interview it was determined that the facility staff failed to ensure that medication carts were locked and secured. This was evident for 1 of 3 nursing units.
The findings are:
1. This surveyor observed on 7/24/23 at 1:40 PM the medication cart parked across from the Antioch conference room was left unlocked. Two staff members walked past the cart and did not lock the medication cart. No residents were observed in the area. A third staff member, Staff #1, walked by at 1:44 PM and put her right hand behind her back and locked it.
Staff #1 was interviewed on 7/24/23 at 1:48 PM. She was informed of the observation. She confirmed that she locked the cart and verbally informed the nurse responsible.
2. This surveyor observed on 7/31/23 at 11:45 AM the medication cart parked across from the Antioch conference room was left unlocked. Staff #1 was walking up the hallway and observed the unlocked and unattended medication cart. She locked the cart and spoke with Staff #10 at 11:47 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interviews it was determined that the facility failed to provide routine dental services identified as need for a resident. This was found evident of 1 of 5 (R...
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Based on observation, record review, and interviews it was determined that the facility failed to provide routine dental services identified as need for a resident. This was found evident of 1 of 5 (Resident #91) residents reviewed for dental concern during an annual and complaint survey.
The findings include:
On 7/24/23 at 1:08 PM, the surveyor observed Resident# 91 eating at his/her bedside. Resident # 91 had both front teeth missing.
On 7/31/23 at 1:29 PM, the surveyor reviewed Resident # 91's medical record. The record revealed Resident # 91 had been admitted in May of 2022 and had a past medical history that included, paranoid schizophrenia and dementia.
Further review of the medial record revealed a care plan created on 5/10/2022 stating resident has potential for oral discomfort due to broken or carious teeth. The interventions included; Coordinate arrangement for dental care.
On 7/31/23 at 1:50 PM, the surveyor reviewed Minimum Data Set (MDS) assessments. The MDS assessment, with a date of May 16th 2022, had box D checked on the Oral/Dental Status. The description of box D stated; Obvious or likely cavity or broken natural teeth. The surveyor reviewed the following annual MDS assessment documented on May 16th 2023. Box D was still checked in the Oral/Dental status section.
On 8/1/23 at 10:16 AM, the surveyor conducted an interview with the Social Worker Assistant Staff #4. In this interview, Staff #4 stated, we discuss dental needs in the care plan meetings that are held quarterly and if a need is identified before then nursing would let social services know. She further stated the facility has a dental service come to the facility to see residents in need. The surveyor showed the initial MDS assessment from May 2022 and Staff #4 stated she was not in that meeting and was not sure if Resident # 91 was referred to the dental service. She further stated she was not shown how to offer 360 dental services.
On 8/1/23 at 10:33 AM, the surveyor reviewed the facility's policy titled; Availability of Services, Dental. Statement 1 states, Dental services are available to all residents requiring routine and emergency dental care. Statement 3 states, Social Services will be responsible for making necessary dental appointments. Statement 4 states, All requests for routine and emergency dental services should be directed to Social Services to assure that appointments can be made in a timely manner.
On 8/2/23 at 7:55 AM, the surveyor interviewed Social Worker Staff #17. Staff # 17 stated she had been asked to come to the facility in July to train the new social worker but reported that social worker had resigned and the facility was looking to hire a new social worker. She stated that she would bring the records of who was on the schedule for dental services.
On 8/2/23 at 9:33 AM, the surveyor reviewed the list given by Staff #17 of residents being seen for dental care. Resident #91 was on the 5/24/2023 list and was documented as a New Patient Exam. No records indicated that Resident #91 was seen prior to this.
On 8/2/23 at 9:44 AM, the surveyor interviewed the Nursing Home Administrator. During this interview the surveyor discussed the concerns about the delay in dental care of Resident #91.
On 8/2/23 at approximately 10 AM, the surveyor interviewed Staff #4. Staff #4 clarified that the resident was on the list to be seen in May 2023 but due to the dental services company having a call out on the date they were in the facility, Resident #91 was rescheduled and would be on the August schedule. This was over a year after Resident #91 was first identified as having a dental need.
Cross reference F850
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews it was determined that the facility failed to keep complete and accurate medical records. ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews it was determined that the facility failed to keep complete and accurate medical records. This was found evident of 2 of 68 (Resident #106 and #66) residents reviewed during a recertification and complaint survey.
The findings include:
1) On 7/31/23 at 12:39 AM, the surveyor reviewed Resident #106's medical record. There review revealed that the resident was admitted to the facility on [DATE].
On 8/1/23 at 10:40 AM, the surveyor reviewed Resident #106's physician's assessment note dated 4/25/23. This note was located in the miscellaneous section in the medical record.
Further review of this section revealed a physician's assessment note dated 3/27/23 for a person with the same first name but different last name.
On 8/1/23 at 10:54 AM, the surveyor asked the Acting Nursing Home Administrator (NHA) for clarification of the two assessment notes with different names in Resident #106's medical record. The NHA stated she would look into the issue and follow up.
On 8/2/23 at 7:50 AM, the surveyor conducted a follow up interview with the NHA. The NHA stated that the physicians upload their assessments into the medical record and the current physician who conducted the assessment was on vacation. She further stated that the assessment completed on 3/27/23 was removed from Resident #106's chart because the Resident #106 was not at the facility at this time. The NHA concluded that the 3/27/23 must have been uploaded in error.
2) On 8/1/23 at 3:22 PM, the surveyor reviewed Resident #66's medical records. The review revealed that Resident # 66 was admitted to the facility in late 2022 and had a past medical history of dementia, psychological disturbance, mood disturbance, anxiety and delusional disorders.
Further review of the medical record revealed a note written by the acting Nursing Home Administrator (NHA) on 4/18/23. The note was a follow up to Resident #66's right eye swelling. The NHA stated, Resident had been evaluated by the NP [Nurse Practitioner] earlier today. Please refer to NP progress notes. The surveyor was unable to find the NP's progress notes from the referenced note.
On 8/2/23 at 1:36 PM, the surveyor interviewed the NHA. The surveyor informed the NHA that there was no progress notes in Resident #66's chart from the NP on 4/18/23. The NHA stated that she knew she saw the resident on that day and would look for the note.
On 8/2/23 the surveyor conducted a follow-up interview. In this interview the NHA stated she could not find the progress note from the NP on 4/18/23 but provided the order for eye medication written that day by the NP. The NHA confirmed the assessment should have been documented in the medical record and was missing from the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected 1 resident
Based on staff interviews and record review, the facility failed to designate a qualified Infection Control Preventionist (IP), who had completed specialized training in infection prevention and contr...
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Based on staff interviews and record review, the facility failed to designate a qualified Infection Control Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Control and Prevention program. This was evident for 1 of 1 staff member reviewed for IP credentials.
The findings include:
On 08/02/2023 at 9:55 AM, an interview was conducted with Staff #11, the facility designated IP. Per the IP, she had been working as the IP for the past 90 days and had received her certification within 2 weeks of starting the position. A copy of her certificate was requested at the time of the interview.
On 08/03/2023 at 9:40 AM, the IP submitted records for review. A review of the records revealed that the IP had provided a copy of her transcripts for the IP course, however, there was no certificate of completion. This was brought to the attention of the Interim Nursing Home Administrator, who indicated she was already aware.
On 08/04/3023 at 9:20 AM the IP provided a copy of her certificate with a completion date of 08/03/2023. The IP explained that when she had initially taken the course it never prompted her to take the test.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, it was determined that the facility staff failed to ensure that a resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, it was determined that the facility staff failed to ensure that a resident had a functioning call system. This was evident for 1 (#6) of 68 residents reviewed during the annual survey.
The findings include:
Resident #6 had diagnoses which included, but was not limited to, dementia, anxiety, legal blindness, and syncope (fainting) and collapse.
On 07/30/2023 at 7:23 PM, an observation conducted on the [NAME] Unit revealed that Resident #6's call system was continuously signaling the nurses station that assistance was required.
A subsequent interview with Staff #9, a Registered Nurse, revealed that Resident #6's call system was malfunctioning. Staff #9 stated, I put in a maintenance request, but I guess nothing was done. Staff #9 pointed to where the call light indicator for Resident #6's room had been stuck on since 07/29/2023 at 11:59 PM. When asked how she would know if Resident #6 needed help, Staff #9 replied; [he/she] yells.
On 07/31/2023 at 8:30 AM, the Interim Nursing Home Administrator was made aware. She stated, they have bells they could give them. Relying on a resident to yell is unacceptable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on the record reviews and interviews, it was determined that the facility failed to ensure that a Geriatric Nursing Assistant (GNA) received the required 12 hours of in-service training. This wa...
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Based on the record reviews and interviews, it was determined that the facility failed to ensure that a Geriatric Nursing Assistant (GNA) received the required 12 hours of in-service training. This was found to be evident for 1 (GNA #34) out of 5 training records reviewed during the recertification survey.
The findings include:
A record review on 08/09/23 at 10:00 AM, revealed that GNA #34 had not received the required 12 hours of annual in-service training since 7/13/2018.
During an interview on 08/09/23 at 10:45 AM, the Staff Development, Staff #15, stated that she tried but could not locate additional training for GNA # 34. The Staff Development staff stated that she had not met GNA # 34 because she only worked once a month.
During an interview on 08/09/23 at 11:30 AM, the Director of Nursing (DON) was notified of the missing required 12 hours of annual in-service training for GNA # 34 and stated she would look for more training records.
On 08/09/23 at 2:33 PM, the DON confirmed that no other required training records were located for GNA # 34.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, it was determined that facility staff failed to treat each resident in a dignified manner by 1) standing over a resident while feeding the resident, and 2) pu...
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Based on observation and staff interview, it was determined that facility staff failed to treat each resident in a dignified manner by 1) standing over a resident while feeding the resident, and 2) pulling a resident down the hallway backwards. This was evident for 4 (#11, #43, #22, #14) of 30 residents observed during the serving of lunch on 1 of 3 nursing units during a revisit survey.
The findings include:
1. On 11/29/23 at 12:22 PM observation was made of Resident #11 sitting in a wheelchair in the dining area adjacent to the nurse's station in the Chase unit. The food delivery cart was next to where Resident #11 was sitting. Staff #25 was standing to feed Resident #11 while talking to 2 other staff members about something unrelated to residents or the facility. Staff #25 continued to stand and feed Resident #11 during the entire observation.
2. On 11/29/23 at 12:30 PM Resident #43 was sitting in the common area on the Chase unit during lunch in a semi-reclining geriatric chair. Staff #12 was reaching over to touch the resident's food that was sitting next to him/her. Resident #43 did not have his/her food yet. At that time Staff #12 pulled Resident #43's geriatric chair backwards and proceeded to pull the resident down the hall to his/her room.
3. On 11/29/23 at 12:38 PM on the Chase unit, Resident #22 was sitting with a food tray in front of him/her. Staff #27 was standing to feed Resident #22.
4. On 11/29/23 at 12:40 PM on the Chase unit, Staff #12 was standing to feed Resident #14.
On 11/30/23 at 10:26 AM the Director of Nursing (DON), Assistant Director of Nursing, and Staff #23 were informed of the observations. The DON stated that staff should not be standing to feed and that it was a dignity issue to wheel someone backwards down the hallway.
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 observations and interviews, it was determined that the facility failed to ensure resident rooms were maintained in a h...
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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 ensure resident rooms were maintained in a homelike environment. This was found to be evident for 2 out of 10 rooms (# 100 and # 102) observed during the tour of the Antioch Nursing Unit.
The findings include:
During the initial tour of the Antioch Nursing Unit conducted on 07/24/23 at 9:45 AM, the surveyors observed water stained ceiling tiles in resident rooms # 100 and #102. The residents who resided in those rooms confirmed that when it rained, the ceiling leaked, and the ceiling tiles would become wet and stained.
During an interview conducted on 07/24/2023 at 11:00 AM, the Maintenance Director stated that the roof leaked and needed repair. However, until the repairs are made the procedure is to replace the ceiling tiles that were water stained. The surveyor advised the Maintenance Director of the findings in resident rooms #100 and #102.
On 07/26/23 at 9:33 AM, a tour was conducted on the Antioch Nursing Unit. The tour revealed the ceiling tiles in resident room [ROOM NUMBER] had not been replaced. The residents who resided in room [ROOM NUMBER] confirmed new water stains were present on the ceiling tiles from a recent rainstorm since last observed on 07/24/23.
During an interview conducted on 08/07/23 at 10:15 AM, the residents in room [ROOM NUMBER] stated that ceiling tiles had not been replaced and the ceiling continued to leak when it rained.
During an interview on 08/07/23 at 10:40 AM, the Administrator was notified about the continued concern with the ceiling leaks, and she stated that the roof needed to be patched.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview it was determined the facility failed to ensure that Minimum Data Set (MDS) assessments were complete. These concerns with incomplete assessments wer...
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Based on medical record review and staff interview it was determined the facility failed to ensure that Minimum Data Set (MDS) assessments were complete. These concerns with incomplete assessments were evident for 5 (#15, #54, #27, #45, #38) of 12 residents reviewed for completed quarterly assessments during a revisit 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 these individualized needs, and that the care is provided as planned to meet the needs of each resident.
1) On 11/30/23 at 10:30 AM a review of Resident #15 and Resident #54's quarterly MDS with an assessment reference date (ARD) of 11/1/23 revealed the assessment was not complete for section C - Cognitive Patterns and Section D - Mood.
A review of Resident #27 quarterly MDS with an ARD of 11/6/23 revealed the assessment was not complete for section C - Cognitive Patterns and Section D - Mood.
A review of Resident #45 quarterly MDS with an ARD of 11/7/23 revealed the assessment was not complete for section C - Cognitive Patterns and Section D - Mood.
A review of Resident #38 quarterly MDS with an ARD of 11/8/23 revealed the assessment was not complete for section C - Cognitive Patterns.
On 11/30/23 at 11:37 AM an interview was conducted with the MDS Coordinator who stated, our social worker does those sections of the MDS, so I do not know why they were missed. I don't see it until after the fact. It has been hit or miss. Every once in a while there are one or two that are missed. Speech Therapy has started to do them when social work can't get to them.
On 11/30/23 at 12:06 PM an interview was conducted with the Director of Social Work who stated, I have a social work assistant so it should have been done. Yes, I sometimes don't get to them.
On 11/30/23 at 5:50 PM Staff #5 was informed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
2) During a complaint investigation on 8/21/23 at 11:05 AM the surveyors reviewed a care plan for Resident # 28 for interventions related to the resident exposing him/herself and masturbating. The sur...
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2) During a complaint investigation on 8/21/23 at 11:05 AM the surveyors reviewed a care plan for Resident # 28 for interventions related to the resident exposing him/herself and masturbating. The surveyors found that Resident # 28's care plan had no interventions to monitor for sexually inappropriate behaviors.
An interview with Social Worker, Staff # 4, on 8/21/23 at 11:10 AM revealed that Resident # 28 had a history of inappropriate sexual behaviors in common areas and the nursing staff handled it by redirecting the resident to his room.
On 8/22/23 at 2:07 PM, the Nursing Administrator acknowledged the surveyors concern that there was no care plan for inappropriate sexual behavior for Resident # 28.
Based on interviews and record review it was determined that the facility failed to develop and implement a comprehensive care plan to meet the medical needs of a resident. This was found evident for 2 out of 11 (Residents #24 and #28) residents reviewed for care planning during an annual and complaint survey.
The findings include:
1) On 7/25/23 at 1:25 PM, the surveyor reviewed Resident #24's medical record. The review revealed that Resident #24 was admitted to the facility in early March of 2023 and had a past medical history of malignant neoplasm of the bladder (bladder cancer) and artificial opening of urinary tract.
Further review of the medical record revealed Resident #24 was admitted to the facility with a urostomy. A urostomy is created in a surgical procedure and re-directs urine to an opening in the abdominal wall. The urine is collected in a bag secured to the outer abdomen.
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.
On 7/25/23 at 2:15 PM, the surveyor reviewed the care plan for Resident #24. There was no plan of care for Resident #24's urostomy.
On 7/26/23 at 8 AM, the surveyor requested a copy of Resident #24's care plan. The copy provided to the surveyor was updated on 7/25/23 by Unit Manager Staff # 1. A care plan was created on 7/25/23 for urostomy care.
On 7/26/23 at 9:09 AM, the surveyor conducted an interview with Staff #1. In this interview Staff #1 stated Resident #24 did not have a care plan meeting yesterday but she wanted to update the care plan to include Resident's #24 urostomy. Staff #1 stated, Resident #24 was admitted to the facility with the urostomy and the care plan should have been created on admission.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
2) During a phone interview conducted on 07/27/2023 at 11:32 AM, the complainant stated the facility had not held care plan meetings.
During an interview on 8/10/23 at 9:00 AM, the surveyor asked Soci...
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2) During a phone interview conducted on 07/27/2023 at 11:32 AM, the complainant stated the facility had not held care plan meetings.
During an interview on 8/10/23 at 9:00 AM, the surveyor asked Social Worker (SW) # 4 to explain the process for scheduling care plan meetings. SW # 4 stated that letters are sent to the families inviting them to attend. The meetings are rescheduled if the family requests. When asked about Resident # 90's meetings she replied that the June 2022 meeting was rescheduled for July 5th, 2022, and that she couldn't account for the meetings that she didn't have sign in sheets for. SW # 4 presented the surveyor with the sign in sheet for 7/5/22 and 2/7/23. The resident did not attend either meeting but her daughter in law attended both. There were no minutes for either meeting.
On 8/10/23 at 10 AM, the surveyor notified the Administrator of the missing documentation for care plan meetings and stated she would look for the minutes and sign in sheets from the care plan meetings from August 2022 through January 2023 for Resident # 90.
According to CMS, the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.
The Administrator informed the surveyor on 8/10/23 at 1:30 PM that she was not able to locate the care plan meeting notes for Resident # 90 for August 2022 through January 2023. The Administrator stated the facility's procedure is to hold care plan meetings coinciding with the MDS transmissions either every 30 days or quarterly.
Based on interviews and record review, it was determined the facility failed to ensure residents attended care plan meetings. This was found to be evident for 2 (Resident #24, # 90) out of 11 residents reviewed for care plan meetings.
The findings include:
1) On 7/25/23 at 1:25 PM, the surveyor reviewed Resident # 24's medical record. The review revealed that Resident #24 was admitted to the facility in early March of 2023 and was his/her own representative, responsible for making his/her own decisions.
On 7/26/23 at 8:16 AM, the surveyor conducted an interview with Social Service Assistant, Staff #4. During the interview Staff #4 stated she remembers Resident #24 had a care plan meeting in June but Resident #24 refused to attend. Staff #4 continued to state that if a Resident refuses it should be documented in the medical record. Staff #4 stated she would provide the attendance log.
On 7/26/23 at 9:32 AM, the surveyor conducted an interview with Resident #24. During this interview Resident #24 stated he/she was not asked to participate in the any of the care plan meetings.
On 7/26/23 at 11:01 AM, the surveyor reviewed the care plan attendance log for Resident #24's care plan completed in June of 2023. No documentation that the resident attended or that the resident refused was noted on the attendance log.
On 7/31/23 at approximately 3 PM, the surveyor reviewed the facility's policy titled, Care Planning-Interdisciplinary team. Number 3 in the implementation section state; The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.
On 8/1/23 at 10:10 AM, the surveyor conducted a follow-up interview with Staff #4. Staff #4 stated that she notifies residents in advance of their upcoming care plan meeting with a letter informing them of the date and time. No letter was provided for Resident #24's June 2023 care plan meeting or any documentation that the Resident #24 refused to attend the care plan meeting. Staff #4 agreed no documentation could be provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5)During a review of a complaint conducted on 8/9/2023 at 3:15 PM, the complainant stated that Resident #462 had not received a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5)During a review of a complaint conducted on 8/9/2023 at 3:15 PM, the complainant stated that Resident #462 had not received a medication Synthroid as ordered for 3 consecutive days in January 2023.
On 08/9/2023 at 03:43 PM a review of the Medication Administration Record (MAR) revealed an order for Synthroid Tablet 50 MCG (Levothyroxine Sodium) Give 1 tablet by mouth one time a day for Hypothyroid with a Start Date of 11/11/22 at 0600 AM.
Further review of the MAR for January 2023 revealed that 6 doses were not documented as given: January 2nd, 6th, 21st - 23rd and 30th.
During an interview conducted on 8/9/2023 at 4:04 PM, the Unit Manager (UM) #1 stated she had the opportunity to administer Synthroid to Resident # 462 however she was unaware of the reason the medication was not administered as ordered in January 2023.
During an interview on 8/10/2023 at 9:50 AM, the Administrator was notified of the surveyor's concern of Resident # 462's medication not administered as ordered. The Administrator stated she was unable to provide additional documentation to confirm the medication had been administered.
3) Resident #60 had a past medical history of Parkinson's, dementia, muscle wasting, and was bedbound.
On 07/24/23 at 1:30 PM, an interview was conducted with Resident #60's spouse. Per the spouse, something happened to [his/her] nose and nothing was written up. The spouse pointed to an area on the top of Resident #60's nose. The area was observed to be reddened.
On 08/03/2023 at 9:00 AM, a medical record review was conducted. In a progress note dated 7/17/2023 at 9:56 PM, Staff #42 wrote that Resident #60's spouse reported redness on top of the nose. Staff #42 applied skin protectant to the area. No physician was notified.
The next note to appear in the medical record was written 19 hours after Resident #60's spouse first reported the redness on the nose. On 07/18/2023 at 4:57 PM the author wrote that the Nurse Practitioner was called to order an X-ray to rule out a nasal fracture.
On 08/03/2023 at 10:15 AM, the Director of Nursing was interviewed. She said that Staff #42 was an agency nurse, but that the expectation would have been when she discovered or was made aware of the redness on the top of the nose, she should have called the physician.
4) On 08/01/2023 at 1:00 PM, Resident #94's medical records were reviewed. Per the nurses notes, on 8/22/2022, the resident complaint of dysuria (painful or difficult urination). 2 days later, on 08/24/2022, a urine specimen was obtained and sent to the lab to test for potential Urinary Tract Infection (UTI).
10 days after the initial complaint of dysuria, on 09/02/2022, Resident #94 was seen by his/her Attending Physician. The Attending wrote in his note resident complains of dysuria, order urinalysis/culture, try Pyridium. The previous lab results had been reported back to the facility on [DATE] and would have been available to the Attending Physician.
On 09/06/2022, at 6:25 PM, the nurses note reported that Resident #94 complained of burning when urinating and pain in bladder. UTI results from 9/1 showed +UTI with culture. Faxed to Nurse Practitioner. Awaiting new orders. The Nurse Practitioner subsequently ordered the antibiotic Augmentin for the resident.
On 08/01/2023 at 1:55 PM, the Director of Nursing (DON) was questioned regarding why the Attending Physician did not seem to know the results of the first urine specimen? The DON stated that the nurses are responsible for notifying the physician and that the results are faxed to the central fax.
It was brought to the DON's attention that from the time Resident #94 first complained of UTI symptoms to the time he/she received his/her first dose of antibiotics was 2 weeks. The DON replied I can't account for it. Usually if they are symptomatic, they will order antibiotics prophylactically until they get results of the [culture].
Based on clinical record review, staff interview, and observation it was determined that the facility staff failed to ensure quality of care was provided to residents. This was evident for 4 (#161, #162, #60, #94, and #462) out of 68 residents reviewed for Quality of Care.
The findings are:
1. Nursing failed to call physician for orders and to clarify treatment.
An investigation of intake #MD00191247 revealed the resident was admitted on [DATE]. Resident #161 was admitted on [DATE] from the hospital with an Aspen neck collar (device used to support and protect neck). The hospital discharge summary did not include orders on how to care for the collar nor were orders on collar care obtained from the primary physician. The paperwork from the hospital did include a summary of a hospital consultation with the surgeon that included a note indicating the collar was to stay on but not how to care for the skin underneath.
Further review of the medical record revealed that the nursing did not seek and/or clarify orders for collar use.
Staff #1 was interviewed on 8/3/23 at 9:11 AM. She said she remembered the resident and that the resident came in with the cervical collar. She said she recalled that there were no orders to take it off or change the brace. Nursing should have called the doctor to find out what he/she wants to be done. That is the proper procedure. Someone should have called the doctor.
The Medical Director (Staff #19) was interviewed on 8/3/23 at 3:09 PM. He did not recall being told of the collar. He said he would expect nursing staff to follow what the neurosurgeon recommended. He said he would expect nursing to clarify any unclear order or in absence of an order nursing should attempt to call the doctor.
2. Nursing failed to administer medication as ordered.
An investigation of intake #MD00189012 was initiated on 8/3/23. A review of Resident #162's clinical record revealed the resident was admitted on [DATE]. A review of the resident's Medication Administration Record (MAR) revealed the resident was ordered several medications that were ordered to be administered starting on 1/15/23 but were not administered until 1/16/23. Some of these medications were available in the pharmacy interim box meaning the nursing staff could have taken the medications from this box and administered them but nursing staff instead chose otherwise.
Medications that were ordered to be started on 1/15/23 but not administered until 1/16/23 even though they were in the interim box: Lasix 40 mg (diuretic), Eliquis 5 mg (an anticoagulant), and Carvedilol 25 mg (treats blood pressure).
Medications that were ordered to be started on 1/15/23 but not administered until 1/16/23 even though they were available as house stock (bottles of medication that are available for all to use): calcium carbonate 600 mg.
The Director of Nursing (DON) was interviewed on 8/4/23 at 9:17 AM. This surveyor showed her the MAR's and explained the concerns. She said she would check and verify via the Omnicell (pharmacy dispensing system).
The Administrator, Acting Administrator, and the Director of Nursing were interviewed on 8/4/23 at 12:45 PM. The findings were discussed and facility staff expressed an understanding of those findings.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected multiple residents
Based on medical record review and staff interview it was determined the physician progress notes were not in the resident medical records the day the resident was seen. This was evident for 5 (#41, #...
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Based on medical record review and staff interview it was determined the physician progress notes were not in the resident medical records the day the resident was seen. This was evident for 5 (#41, #17, #14, #25, #52) of 54 residents reviewed during a revisit survey.
The findings include:
On 11/30/23 at 3:00 PM Resident #41's medical record was reviewed and revealed on 11/30/23 the physician progress notes were uploaded in the medical record for dates of service (DOS) 10/23/23, 11/1/23, and (2) notes from 11/17/23.
Continued review of medical records revealed Resident #17's physician progress notes dated 11/8/23 and 11/17/23 were not uploaded into the medical record until 11/30/23.
Resident #14's physician progress note of 11/3/23 was not uploaded in the medical record until 11/30/23.
Resident #25's physician progress note of 11/3/23 was not uploaded in the medical record until 11/30/23.
Resident #52's physician progress notes dated 10/23/23 and 10/24/23 were not uploaded in the medical record until 11/30/23.
On 11/30/23 at 3:45 PM Physician #3 was interviewed and stated, both the NP (nurse practitioner) and I have been overwhelmed and I have signed a 5-foot stack of paperwork. We are trying to juggle a lot. We are behind in getting notes uploaded into the medical record and we are working on that now.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on the review of facility administrative records and interviews, it was determined that the facility failed to ensure a sufficient number of staff to meet the needs of the residents. This defici...
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Based on the review of facility administrative records and interviews, it was determined that the facility failed to ensure a sufficient number of staff to meet the needs of the residents. This deficient practice has the potential to affect all residents.
The findings include:
During a phone interview conducted on 07/27/2023 at 11:32 AM, the complainant stated the resident was left soiled for long periods of time, staff turnover was high and staff complained they don't have enough staff.
On 8/7/23 at 11:51 AM, the surveyor reviewed the Activities of Daily Living (ADL) care documentation for August 2022 through December 2022 for Resident # 90. For the month of August there was no toilet use documented for 31 out of 87 shifts and urinary continence care was documented for 30 of 87 shifts. In September, toilet use was not documented 46 out of 90 shifts and urinary continence was not documented 47 out of 90 shifts. In October 2022 there was no toilet use documented for 38 out of 93 shifts and no urinary continence documented for 31 out of 90. For November 2022, 31 out of 90 shifts had both toilet use, and urinary continence were not documented. In December 2022, 34 shifts out of 90 shifts did not have toilet use and urinary continence documented.
The Administrator was notified and said that was all the staffing information they could provide for the requested dates.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility staff failed to provide pharmaceutical s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility staff failed to provide pharmaceutical services that met the needs of the residents. This was evident for 1 (#162) out of 68 residents in the survey sample.
The findings are:
An investigation of intake #MD00189012 was initiated on 8/3/23. A review of Resident #162's clinical record revealed the resident was admitted on [DATE]. A review of the resident's Medication Administration Record (MAR) revealed the resident was ordered several medications that were ordered to be administered starting on 1/15/23 but were not administered until 1/16/23. Some of these medications were available in the pharmacy interim box meaning the nursing staff could have taken the medications from this box and administered them to the resident but nursing staff instead chose otherwise.
Medications that were ordered to be started on 1/15/23 but not administered until 1/16/23 even though they were in the interim box: Lasix 40 mg (diuretic), Eliquis 5 mg (an anticoagulant), and Carvedilol 25 mg (treats blood pressure).
Medications that were ordered to be started on 1/15/23 but not administered until 1/16/23 even though they were available as house stock (bottles of medication that are available for all to use): calcium carbonate 600 mg.
Medications that were ordered to be started on 1/15/23 but not administered until 1/16/23: Famotidine 20 mg (reduces acid in stomach), Ezetimibe 10 mg (treats high cholesterol), amlodipine 5 mg (treats blood pressure), Pramipexole Dihydrochloride 0.25 mg (treats Parkinson's), and Atorvastatin Calcium 40 mg (cardiac medication).
The pharmacy delivering the medications did not deliver all of the medications nor did it have a system in place such as an agreement with a local pharmacy to provide medications to the residents.
The Director of Nursing (DON) was interviewed on 8/4/23 at 9:17 AM. This surveyor showed her the MAR's and explained the concerns. She said she would check and verify via the Omnicell (pharmacy dispensing system).
The Administrator, Acting Administrator, and the Director of Nursing were interviewed on 8/4/23 at 12:45 PM. The findings were discussed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on recorded review and interviews it was determined that the facility failed to have monthly medication regimen reviews by a licensed pharmacist and failed to have a process in place to ensure t...
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Based on recorded review and interviews it was determined that the facility failed to have monthly medication regimen reviews by a licensed pharmacist and failed to have a process in place to ensure the medication irregularity reports were part of the resident's medical record. This was found evident of 2 of 5 (Resident # 74 & #62) residents reviewed for medication regimen review during a Medicare/Medicaid recertification and complaint survey.
The findings include:
Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the Inter Disciplinary Team (IDT), including the resident, their family, and/or resident representative.
1a) On 7/31/23 at 12:23 PM, the surveyor reviewed the medial record for Resident #74. The review revealed that Resident #74 had a past medical history of, dementia, anxiety disorder, and major depressive disorder.
On 8/1/23 at 11:16 AM, the surveyor reviewed Resident #74's paper medical record. The review revealed an irregularity report from 3/22/22. No other reports were in the paper chart. On 8/1/23 at 2:40 PM, the surveyor asked the Acting Nursing Home Administrator (NHA) for MRRs for Resident #74 and any irregularity reports if indicated.
On 8/2/23 at 8:32 AM, the surveyor was given printed MMR reports for 6/30/23 and 7/30/23 by the NHA. The NHA stated she was continuing to look for the other reports.
On 8/2/23 at 9:50 AM, the surveyor reviewed Resident #74's psychologic evaluations. The review indicated that Resident #74 continued to have psychological symptoms and recommended continuing the current medication. No reductions of medications were recommended.
On 8/2/23 at 10:06 AM, the surveyor reviewed the electronic medical record for Resident #74. This review revealed a MRR was conducted on 9/23/22, 10/19/22, 11/21/22, 12/14/22, 1/11/23, 2/15/23, 3/27/23, 4/30/23. The electronic medical record did not have the MRRs the the NHA had given from the dates of 6/30/23 an 7/30/23. Irregularity reports were indicated for the dates of, 11/21/22, 1/11/23, 2/15/23, and 4/30/23.
On 8/2/23 at 3:20 PM, the surveyor asked the NHA for the irregularity reports for Resident #74 from 11/21/22, 1/11/23, 2/15/23, 4/30/23 and the MMR from May of 2023.
On 8/2/23 at 3:45 PM the surveyor interviewed the NHA. During that interview, the NHA described the process or the medication regimen review. She stated that the pharmacist reviews the resident's medical record each month. If an irregularity is found a report gets generated and sent to the NHA, the Director of Nursing (DON), and the Unit Manager via email. The report is then printed. If the irregularity can be addressed by nursing the Unit Manager takes care of it. If the physician needs to address the irregularity then the report is placed in a binder for the physician to review at the nurses station. The NHA further stated, currently there are providers here Monday through Friday and a physician that comes in weekly and that they review the irregularity reports. The NHA reported that a new Pharmacist started in June and the NHA was aware that the May MRRs were not completed.
On 8/3/23 at 11:18 AM, the surveyor interviewed Unit Manger Staff #18. During this interview the surveyor was provided medication irregularity reports along with actions taken from the recommendations for Resident #74. She stated she found the reports in her email and printed them. The surveyor reviewed the report from 11/21/22. This report suggested a gradual dose reduction for a psychotropic medication (a medication that affects behavior, mood, thoughts or perceptions). Resident # 74's psychiatric note indicated the current regimen was affective and recommended no change; However the primary care physician did not respond to the section, Agree, Disagree or Other. There was no rationale given on the decision even though there was a space provided on the report. The surveyor noted no report from 1/11/23 was provided and reports from 2/15/23, and 4/30/23 were signed and addressed by the provider, however, were not in Resident #74's medical chart.
1b) On 7/31/23 at 12:23 PM, the surveyor reviewed Resident #62's medical record. The review revealed that Resident #62 had a past medical history of dementia, anxiety and diabetes mellitus.
On 8/02/23 7:50 AM, the surveyor asked the NHA for MMR and any irregularity reports if indicated for Resident #62.
On 8/2/23 at 8:32 AM, the surveyor was given printed MMR reports for 6/30/23 and 7/30/23 by the NHA. The NHA stated she was continuing to look for the other reports.
On 8/2/23 at 10:06 AM, the surveyor reviewed the electronic medical record for Resident #62. This review revealed a MRR was conducted on 10/19/22, 11/21/22, 12/14/22, 1/11/23, 2/15/23, 3/27/23, 4/30/23. The electronic medical record did not have the MRRs that the NHA had given from the dates of 6/30/23 and 7/30/23. No MRR for May 2023. Irregularity reports were indicated for 1/11/23.
On 8/2/23 at 3:20 PM, the surveyor asked the NHA for the irregularity reports for Resident #64 on 1/11/23 and the MMR from May of 2023.
On 8/2/23 at 3:45 PM the NHA followed up and indicated the May MRRs were not complete for Resident #62.
On 8/3/23 at 11:18 AM, the surveyor interviewed Unit Manger Staff #18. During this interview the surveyor was provided the medication irregularity report for Resident #62 from 1/11/23 along with actions taken from the recommendations. The report was not singed by the provider but the lab recommendation was ordered and completed. The report was not in Resident #62's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation of medication administration it was determined that the facility staff failed to ensure medications were administered in a safe, appropriate, and timely manner. This was evident f...
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Based on observation of medication administration it was determined that the facility staff failed to ensure medications were administered in a safe, appropriate, and timely manner. This was evident for 5 medications out of 31 administered.
The findings include:
Medication is to be administered according to the five rights of medication administration: right person, right medication, right route, right dosage, and right time.
This surveyor observed Staff #12, Staff #10, and Staff #13 administer medications. The observations took place on 7/28/23, and 8/1/23.
On 7/28/23 at 10:16 AM Staff #10 was observed administering medication to Resident #12. The resident was to be administered aspirin 81 mg (pain reliever), critical care supplement 30 cc, Omeprazole 20 mg (reduces stomach acid), Potassium Chloride 20 milliequivalents (supplement to treat low potassium levels), and Senna 8.6 mg (laxative) at 8:00 AM. Medication is to be administered within one hour of the medication time.
The Administrator, Acting Administrator, and the Director of Nursing were interviewed on 8/4/23 at 12:45 PM. Findings were discussed and facility staff expressed an understanding of those findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected multiple residents
Based on interviews and review of the facility's policies it was determined that the facility failed to have a qualified, full-time social worker employed to oversee the social service duties. This wa...
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Based on interviews and review of the facility's policies it was determined that the facility failed to have a qualified, full-time social worker employed to oversee the social service duties. This was found evident of 4 months in 2022 and 2 months in 2023.
The findings include:
On 8/1/23 at 10:16 AM, the surveyor interviewed Social Worker Assistant Staff #4. During that interview, Staff #4 explained that the social service department sets up care plan meetings after the resident has a Minimum Data Set (MDS) assessment and stated the needs of the residents are addressed at those meetings. The surveyor asked Staff #4 to explain the process for addressing an identified dental need of a resident. Staff #4 explained, if a resident was assessed to have a dental need the Social Worker would follow up with the resident. If the resident did not have an established Dentist, then the facility would offer the resident to register with a provider that services dental needs within the facility. Staff #4 stated, currently the facility uses an contracter/consultant, who offers dental, as well as other services, inside the facility. She further stated that she was not shown how to offer the contracter/consultant dental services to residents.
On 8/1/23 at 10:33 AM, the surveyor reviewed the policy for Care Planning. The policy stated an interdisciplinary team, including the social services worker responsible for the resident, should develop a comprehensive care plan for each resident after every Minimum Data Set (MDS) assessment. The surveyor next reviewed the facility's policy titled; Availability of Services, Dental. The policy stated, Social Services will be responsible for making necessary dental appointments, and all requests for routine and emergency dental services should be directed to Social Services to assure that appointments can be made in a timely manner.
On 8/2/23 at 7:55 AM, the surveyor interviewed Licensed Social Worker Staff #17. Staff #17 stated that she was currently the social worker for the facility and worked Monday through Friday, however on Thursdays she worked at another facility and was able to assist Staff #4 as needed. She stated she had been working this schedule since July 20, 2023, when the Social Worker in training resigned. Staff #17 stated there had been two social workers hired in 2023 but both no longer worked at the facility. The surveyor asked Staff #17 for a timeline of social worker coverage.
On 8/2/23 at 9:33 PM, the surveyor conducted a follow up interview with Staff #17. During the interview, Staff #17 was able to provide a timeline of social worker coverage for the facility. The Social Services Director, Staff #43, left the facility in August of 2022. Staff #4 was assisting Staff #43 in an assistant social service role. A new social worker was hired and worked from January 2023 to April 2023. The next social worker was hired early in July of 2023 and left on July 20, 2023. Staff #17 agreed there was no full-time social worker for the months of September through December 2022 and no full-time social worker from May 2023 through June 2023.
On 8/2/23 at 9:44 AM, the surveyor interviewed the Acting Nursing Home Administrator (NHA). The NHA agreed there were months without a qualified social worker on a full-time basis and multiple facility policies designated the social worker with responsibilities.
On 8/2/23 at 11:01 AM, the surveyor conducted a follow up interview with the NHA and was informed that the facility hired a new Social Worker for the facility.
Cross reference F791
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
Based on observations and facility staff interviews, the facility failed to ensure that all corridors had firmly installed handrails on each side.
The findings include:
On 07/25/2023 at 11 AM, survey...
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Based on observations and facility staff interviews, the facility failed to ensure that all corridors had firmly installed handrails on each side.
The findings include:
On 07/25/2023 at 11 AM, surveyors observed there were no handrails available on either side of the two connected corridors in the facility. The first of the connected corridors began from the outside of a unit and at the furthest end, connected to the other corridor that led to the main entrance of the facility.
On 07/31/2023 at 8:50 AM the interim Nursing Home Administrator (NHA) confirmed the absence of handrails.
On 07/31/2023 at 09:21 AM an interview with the Maintenance Director who stated that he worked at the facility for 12 years and the two connected corridors never had handrails on either side.
On 08/01/2023 at 9:10 AM the Maintenance Director confirmed that handrails were to be installed and the total distance of the connected corridors equaled two hundred thirty-six feet and six inches.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
Based on staff interview and record review, it was determined that the facility failed to ensure that the dementia training provided to staff included managing challenging behaviors. This was evident ...
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Based on staff interview and record review, it was determined that the facility failed to ensure that the dementia training provided to staff included managing challenging behaviors. This was evident for 1 of 2 staff training PowerPoint slide show presentations reviewed for content.
The findings include:
On 08/02/2023 at 10:04 AM, an interview was conducted with Staff #11, the IP/Staff Development Nurse, regarding the dementia training provided to staff. Per Staff #11, the training consisted of a PowerPoint presentation upon hire and annually thereafter. If a staff member needed additional training, Staff #11 would review a typed version of the same PowerPoint presentation with that staff member. Per Staff #11, the PowerPoint information was the only dementia training provided.
On 08/02/2023 at 10:15 AM, the dementia PowerPoint presentation that the facility utilized to train staff was reviewed. The presentation did not address managing challenging behaviors. Examples of challenging behaviors include, but are not limited to, aggressiveness, wandering, elopement, agitation, yelling out, or delusions. Not being able to effectively manage those types of behaviors could increase the risk of resident abuse and neglect.
On 08/02/2023 at 02:00 PM, this finding was brought to the attention of the Interim Nursing Home Administrator.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on staff interview and observation it was determined the facility failed to ensure that the facility kitchen was managed by fully certified and competent staff, when since October 1, 2023, the f...
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Based on staff interview and observation it was determined the facility failed to ensure that the facility kitchen was managed by fully certified and competent staff, when since October 1, 2023, the facility had no Certified Dietary Manager (CDM) managing the kitchen. The failure to ensure fully certified and competent kitchen management provided effective oversight of practices in the kitchen increased the risk for infection and food borne illness. This had the potential to affect all residents.
The findings include:
On 11/29/23 at 12:47 PM a tour of the kitchen was conducted to follow-up on concerns cited during the annual survey that ended on 8/11/23. Dietary Staff #9 was in the dishwashing area and mentioned to the surveyor that they had been having problems with hot water while washing dishes.
On 11/29/23 at 2:09 PM the surveyor returned to the kitchen to observe the dishwasher while dishes from the lunch service were being washed and sanitized. Observation of the temperature gauges on the outside of the dishwasher failed to reach the required temperature for adequate sanitation. Staff #8 was in the dishwashing area at that time and stated it was the third day with no hot water, which began on 11/27/23. Further observation of the kitchen revealed that the sinks for staff to wash their hands only had cold water.
Cross Reference F812
On 11/29/23 at PM 2:22 PM an interview was conducted with Staff #17, the kitchen manager, who stated she had been the manager for the past 2 months. Staff #17 stated she did not have her CDM, and she asked the surveyor what the dishwasher temperatures were supposed to be.
On 11/29/23 at 4:45 PM the Nursing Home Administrator (NHA) was interviewed and stated Staff #17 had worked at the facility for 18 years as a geriatric nursing assistant and the past 2 1/2 years as a social work assistant. On 9/11/23 Staff #17 was appointed the kitchen manager and had oversight by another dietary manager until 10/1/23. Since 10/1/23 Staff #17 managed the kitchen without specific qualifications and required competencies and certifications necessary to run a kitchen in a long-term care facility.
Without fully certified and competent staff managing the kitchen, facility kitchen staff continued unsafe food preparation and service activities in the kitchen when hot water was not available beginning on 11/27/23 until surveyors addressed the issue on 11/29/23.
The Office of Health Care Quality (OHCQ) surveyors notified the Local Health Department (LHD) of the serious concern with ongoing use of the kitchen with no hot water. On 11/29/23, the LHD investigator came into the facility for an onsite inspection and reported that without hot water, the facility did not meet minimum standards for handwashing, and for sanitizing the pots, pans, trays, and the kitchen food prep surfaces.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on interviews, observations, and documentation review, facility administration failed to effectively allocate resources to meet resident needs and to ensure their highest practicable well-being ...
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Based on interviews, observations, and documentation review, facility administration failed to effectively allocate resources to meet resident needs and to ensure their highest practicable well-being when (1) the facility administration failed to ensure effective management of dietary services with no Certified Dietary Manager (CDM) employed since October 1, 2023, (2) the facility administration failed to ensure and provide a safe and sanitary environment in the facility kitchen when the facility dishwasher and hot water heater had both failed and no hot water was available in the kitchen beginning intermittently on 11/6/23 and finally on 11/27/23; and (3) facility administration for at least three days allowed unsafe practices regarding food preparation, food service, and infection prevention and control requirements by utilizing the facility kitchen with no hot water (a) for hand washing and (b) for sanitization of dishes, utensils, pots, pans, trays and food prep surfaces; and (4) while continuing to operate the kitchen in unsafe and unsanitary conditions for at least 3 days, the facility did not report the serious health and safety concerns to State authorities as required. These failures had the potential to affect all residents of the facility.
The findings include:
1) The facility administration failed to ensure effective management of dietary services with no Certified Dietary Manager (CDM) employed since October 1, 2023.
On 11/29/23 at PM 2:22 PM an interview was conducted with Staff #17, the kitchen manager, who stated she had been the manager for the past 2 months. Staff #17 stated she did not have her CDM and was not aware that temperatures had to be monitored at each meal for dishwashing, food, and refrigeration.
On 11/29/23 at 4:45 PM the Nursing Home Administrator (NHA) was interviewed and stated Staff #17 had worked at the facility for 18 years as a geriatric nursing assistant and the past 2 1/2 years as a social work assistant. On 9/11/23 Staff #17 was appointed the kitchen manager and had oversight by another dietary manager until 10/1/23.
Since 10/1/23 Staff #17 managed the kitchen without specific qualifications and required competencies and certifications necessary to run a kitchen in a long-term care facility.
Cross Reference F801
2) . The facility administration failed to ensure and provide a safe and sanitary environment in the facility kitchen when the facility dishwasher and hot water heater had both failed and no hot water was available in the kitchen beginning on 11/27/23.
On 11/29/23 at 12:47 PM a tour of the kitchen was conducted to follow-up on concerns cited during the annual survey that ended on 8/11/23. Dietary Staff #9 was in the dishwashing area and mentioned to the surveyor that they had been having problems with hot water while washing dishes.
On 11/29/23 at 2:09 PM the surveyor returned to the kitchen to observe the dishwasher while dishes from the lunch service were being washed and sanitized. Observation of the temperature gauges on the outside of the dishwasher failed to reach the required temperature for adequate sanitation. Staff #8 was in the dishwashing area at that time and stated it was the third day with no hot water, which began on 11/27/23. Staff #8 stated the water had been off and on cold since about 11/9/23, and maintenance would have to keep coming in and resetting the breaker for the hot water heater. Staff #8 stated that they did not have hot water for the past 3 days and the Nursing Home Administrator (NHA) knew about it.
On 11/29/23 at 2:15 PM the maintenance supervisor, Staff #16 stated it started around 11/9/23. The hot water heater would throw the breaker and he would have to come in and reset it. Staff #16 stated that it would hold a couple of days and then the breaker would be thrown again. Staff #16 stated it had become more often that he would have to come and reset the breaker and the time that it would last started to diminish until this past Monday, 11/27/23, when there was no hot water at all. Staff #16 stated they called a contractor and were waiting for a quote as of 11/30/23 at 2:15 PM. Staff #16 stated the NHA was aware of the situation.
Further observation of the kitchen revealed that the sinks for staff to wash their hands only had cold water and the 3 compartment sinks for the washing of pots and pans only had cold water.
The surveyors notified the Local Health Department (LHD) of the serious concern with ongoing use of the kitchen without hot water. On 11/29/23 at 3:50 PM, the LHD sanitarian came into the facility and reported that without hot water, the facility did not meet minimum standards for handwashing, and for sanitizing the dishes, utensils, pots, pans, trays, and the kitchen food prep surfaces. The LHD sanitarian issued a critical violation for no hot water in the kitchen. The LHD sanitarian informed the facility they could set up a very short-term work around with the expectation that a contract would be in place by 11/30/23 for replacement of the water heater.
Additionally, the kitchen staff could not tell the surveyor if the dishwasher was a heat sanitization dishwasher or a chemical dishwasher. The LHD sanitarian confirmed the dishwasher was a chemical dishwasher, however the chemicals for the dishwasher were not flowing and not registering on the dish probe in the dishwasher.
The LHD sanitarian issued a critical violation for the dishwasher not registering the sanitizing agent.
3) For at least three days, the facility administration allowed food service activities in the kitchen to continue without hot water sufficient for hand washing, and sterilization of dishes, eating utensils, pots, pans, food trays, and food preparation surfaces. Only after authorities put a temporary work around in the kitchen for food preparation and service activities on 11/29/23, did the facility expedite for service and repair of the essential equipment.
4) While continuing to operate the kitchen in unsafe and unsanitary conditions, the facility administration did not report the serious health and safety condition to State authorities, as required.
There was no documentation supplied to the surveyors that OHCQ was notified of the lack of hot water in the kitchen as required. The kitchen staff continued conducting food preparation and services activities in the kitchen in an unsanitary manner every day for 3 days.
While the LHD sanitarian was on site he was not aware of the hot water issue in the kitchen and that the local health department had not been notified by facility administration.
On 9/29/23 the LHD cited the facility for critical violations and allowed the facility to put a short-term work around in place with the LHD's plan to inspect the kitchen daily until the critical violation was corrected.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on staff interviews and record review, it was determined that the facility failed to ensure that the infection line lists were updated and proper hand hygiene was performed during a medication a...
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Based on staff interviews and record review, it was determined that the facility failed to ensure that the infection line lists were updated and proper hand hygiene was performed during a medication administration. This was evident for 3 of 3 monthly line lists reviewed and 2 (#13, #12) out of 2 staff observed for hand hygiene during medication administration.
The findings include:
A Line List is a detailed list used by a team of clinicians to identify, track, and monitor suspected infections to ensure appropriate treatments. Information that can be gathered from the line list include, but are not limited to, residents, their locations, types of infections, dates of onsets, organisms, antibiotic resistance, antibiotics prescribed, classification, and dates resolved. It is an integral part of the infection surveillance process.
1) On 08/03/2023 at 9:30 AM the facility line lists, also called monthly infection control logs, were obtained from the Infection Control Preventionist (IP). There were 3 pages for the month of May, 3 pages for the month of June, and 2 pages for the month of July. The lists were reviewed alongside the IP, who acknowledged the lists were incomplete. One out of two sheets for the month of July did not contain any information other than the residents' names. The IP stated that they were incomplete because she isn't getting what [she] needs from nursing.
2. Staff #13 was observed administering a medication administration pass on 8/1/23 at 7:40 AM. After administering medication to a resident, she was observed at 7:50 AM to have failed to wash her hands after the administration before she began pouring medication for the next resident.
3. Staff #12 was observed administering a medication administration pass on 8/01/23 at 8:01 AM. After administering medication to a resident, she was observed at 8:04 AM to have failed to wash her hands after the administration before she began pouring medication for the next resident.
The Administrator, Acting Administrator, and the Director of Nursing were interviewed on 8/4/23 at 12:45 PM. The findings were discussed and facility staff expressed an understanding of those findings.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation, interviews, and documentation review, it was determined the facility failed to ensure that essential equipment was operational and safe (1) when the facility hot water heater tha...
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Based on observation, interviews, and documentation review, it was determined the facility failed to ensure that essential equipment was operational and safe (1) when the facility hot water heater that supplied hot water to the kitchen began to fail intermittently on or around 11/9/23, and permanently on 11/27/23, and was not fixed or replaced, and (2) when the dishwasher failed to register the chemical cleaning agent as of 11/29/23, and it too was not fixed or replaced. With no hot water in the kitchen, all residents were at increased risk for food borne illness.
The findings include:
1) The facility hot water heater that supplied hot water to the kitchen started to fail around 11/9/23 and was not fixed or replaced. On 11/27/23 the hot water heater totally failed to produce hot water to the kitchen on 11/27/23 and the facility was still waiting on contractor quotes as of 11/30/23 at 2:15 PM.
On 11/29/23 at 12:47 PM a tour of the kitchen was conducted to follow-up on concerns cited during the annual survey that ended on 8/11/23. Dietary Staff #9 was in the dishwashing area and mentioned to the surveyor that they had been having problems with hot water while washing dishes.
On 11/29/23 at 2:09 PM the surveyor returned to the kitchen to observe the dishwasher while dishes from the lunch service were being washed and sanitized. Observation of the temperature gauges on the outside of the dishwasher failed to reach the required temperature for adequate sanitation. Staff #8 was in the dishwashing area at that time and stated it was the third day with no hot water, which began on 11/27/23. Staff #8 stated the water had been off and on cold since about 11/9/23, and maintenance would have to keep coming in and resetting the breaker for the hot water heater. Staff #8 stated that they did not have hot water for the past 3 days and the Nursing Home Administrator (NHA) knew about it.
On 11/29/23 at 2:15 PM the maintenance supervisor, Staff #16 stated it started around 11/9/23. The hot water heater would throw the breaker and he would have to come in and reset it. Staff #16 stated that it would hold a couple of days and then the breaker would be thrown again. Staff #16 stated it had become more often that he would have to come and reset the breaker and the time that it would last started to diminish until this past Monday, 11/27/23, when there was no hot water at all. Staff #16 stated they called a contractor and were waiting for a quote as of 11/30/23 at 2:15 PM.
Further observation of the kitchen revealed that the sinks for staff to wash their hands only had cold water and the 3 compartment sinks for the washing of pots and pans only had cold water.
Staff #8 was asked to see the dishwasher temperature logs. Staff #8 stated they did not take and record the temperatures for the dishwasher.
On 11/29/23 at 2:22 PM the dietary manager, Staff #17 was asked about the temperature logs. Staff #17 stated she had been at the facility for about 1-2 months. Staff #17 asked the surveyor what the temperature of the dishwasher should be as she did not know. Staff #17 stated that she was only given a week's training and she had no formal training in the kitchen. Cross Reference F801.
The surveyors notified the Local Health Department (LHD) of the serious concern with ongoing use of the kitchen without hot water. On 11/29/23 at 3:50 PM, the LHD investigator came into the facility and reported that without hot water, the facility did not meet minimum standards for handwashing, and for sanitizing the dishes, utensils, pots, pans, trays, and the kitchen food prep surfaces. The LHD sanitarian issued a critical violation for no hot water in the kitchen. The LHD sanitarian informed the facility they could set up a very short-term work around with the expectation that a contract would be in place by 11/30/23 for replacement of the water heater.
2. The chemicals for the dishwasher were not flowing and not registering on the dish probe in the dishwasher.
On 11/29/23 at 2:09 PM observation was made of the running of the dishwasher. Staff stated that there had not been any hot water for a couple of days. The wash temperature reached a temperature of 125 degrees Fahrenheit, and the rinse temperature was 110 degrees Fahrenheit. The final rinse had steam coming out of the unit, but the gauge was documenting between 70-80. The surveyor was trying to ascertain from staff if the dishwasher was a heat sanitization or chemical sanitization dishwasher. A heat sanitization dishwasher has a wash temperature of 150-165 degrees F and a final rinse of 180 F which was documented on the front of the dishwasher. A chemical sanitization dishwasher has wash temperature of 120 F and a final rinse temperature of 50 ppm. At that time no one could tell the surveyor what kind of a dishwasher was in the kitchen.
On 11/29/23 at 3:55 PM the surveyors met in the kitchen with the sanitarian from the local health department. The sanitarian looked at the dishwasher and said it was a chemical dishwasher, however the chemicals were not flowing and not registering on the dish probe in the machine.
On 11/29/23 at 2:15 PM the maintenance supervisor, Staff #16, along with Staff #8 stated that the dishwasher was replaced in August 2023, and they had several problems, and it still did not work correctly.
The LHD sanitarian issued a critical violation for the dishwasher not registering the sanitizing agent.
For at least three days, the facility continued food service activities in the kitchen without hot water sufficient for hand washing, and sterilization of dishes, eating utensils, pots, pans, food trays, and food preparation surfaces. Only after authorities put a temporary work around in the kitchen for food preparation and service activities on 11/29/23, did the facility expedite for service and repair of the essential equipment.
The failure to ensure the essential equipment was in safe operational condition resulted in unsafe and unsanitary conditions in the kitchen and resulted in multiple interrelated noncompliant practices that placed all residents, staff, and visitors at increased risk for harm.
Jan 2023
7 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 observation, review of medical records, facility investigative file, and staff and resident interviews it was determine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of medical records, facility investigative file, and staff and resident interviews it was determined the facility failed to ensure a resident was free from physical abuse. This was evident for 1 (resident #2) out of 1 resident reviewed for abuse. As a result, this deficient practice was identified as a Harm.
The findings include:
On 01/09/2023 at approximately 9:45 AM a review of the facility investigative report submitted to the Maryland Office of Health Care Quality (OHCQ) revealed a physical altercation occurred on 12/29/2022 between an alleged perpetrator who was a maintenance assistant and a resident (resident #2). The employee (alleged perpetrator) was interviewed and relieved of his/her duty until the conclusion of the investigation. Resident #2 was interviewed and alleged s/he had tried to open the door to his/her room to ask for a spoon to eat. The employee was on the other side of the door and pulled on it to keep the door closed. The resident stated that the employee then cursed at him/her, poked them in the eye, and choked them.
During an interview conducted on 01/09/2023 at approximately 10:00 AM, the Occupational Therapist Assistant (OTA) # 12 stated she had provided therapy for the resident ' s roommate (resident #12) on the day of the altercation and had witnessed the events. She stated resident #2 opened his/her door to ask for a spoon and heard the maintenance assistant #14 yell at the resident to close the entry door while pulling the door closed. The resident reopened his/her entry door, the maintenance assistant entered the room, and began to argue with the resident.
The OTA further stated she asked the maintenance assistant multiple times to stop, however he continued to argue. The OTA stated she heard a thud sound, turned around and saw the maintenance assistant grab the front of the resident ' s shirt at which time she left the room to get help.
According to the Centers of Medicare and Medicaid Services (CMS) the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. All assessments are completed within specific guidelines and time frames. In most cases, participants in the assessment process are licensed health care professionals employed by the nursing home. MDS information is transmitted electronically by resident nursing homes to the national MDS database at CMS.
BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively now. It is a required screening tool used in nursing homes to assess cognition.
The resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment.
On 01/09/2023 at approximately 10:00 AM a record review was conducted for resident #2 ' s MDS quarterly assessment dated [DATE]. The assessment revealed the resident scored a 15 for his/her cognitive pattern.
During an interview conducted on 01/09/2023 at approximately 12:20 PM, resident #2 stated that s/he opened the entry door to his/her room to ask for a spoon at which time the maintenance assistant #14 yelled to close the door and then he/she pulled the door closed. The resident stated; s/he reopened the door, the maintenance assistant came inside his /her room and they both began to argue. The resident stated the maintenance assistant choked the resident ' s neck and then poked him/her in the left eye which caused the eye to bleed.
The resident further stated that s/he was still very upset and confused that the maintenance assistant had attacked him/her since they had been friends in the community. The resident also stated he/she refused to go to the emergency room on the day of the incident and had not received a medical assessment of the left eye since the incident occurred on 12/29/2022. However, s/he continued to experience pain and a scratchy feeling in the left eye.
On 01/09/2023 at approximately 12:40 PM the resident ' s roommate #12 with a BIMS of 14 stated in an interview that s/he saw that the maintenance assistant #14 choked the resident but did not see what happened to the resident ' s eye. However, s/he saw resident #2 ' s head go backwards, resident #2 grabbed his/her eye and yelled my eye during the altercation.
On 01/09/2023 at approximately 1:00 PM a review of the resident #2 ' s nurse ' s note dated 12/29/2022 stated writer was notified of injury to eye due to an altercation that occurred. The resident was assessed, and the resident had no complaints at the time of pain although the resident had visible bleeding to left eye, in the corner. The writer discussed in depth the risk vs the benefits of going vs not going for evaluation to ER. The writer spent 35 minutes educating the resident. The resident refused to go to the ER. The resident stated he understood the severity of the eye if there is any internal trauma. The resident stated he will be ok. The writer educated the resident to notify clinical staff right away with any changes to vision or eye pain. resident aware to notify staff of any change in condition or if resident starts to feel bad. The resident agreed. The resident stated, ma'am I know you are just doing your job and I appreciate you. but I had dialysis today and just don't feel like going and sitting all night in the hospital. The writer notified the staff nurse on the unit of the resident not going to ER for evaluation. Also, the staff nurse is aware that the resident will report any change in his/her conditions.
Review of resident #2 ' s medical record on 01/09/2023 at approximately 1:15 PM did not show that physician #17 was notified of the resident's injury.
During an interview conducted on 01/09/2023 at approximately 1:30 PM the [NAME] President (VP) of Clinical for the facility stated maintenance assistant # 14 was terminated on the day (12/29/22022) of incident due to his/her insubordination during the facility ' s interview of the allegation of abuse. Maintenance assistant #14 remained very upset and refused to calm down, the interview escalated, the maintenance assistant was terminated, and escorted out of the building. The VP of Clinical further stated that after the conclusion of the investigation the facility unsubstantiated the allegation of abuse.
During a phone interview conducted on 01/09/2023 at 2:33 PM the physician #17 stated he did not recall that the facility notified him of resident #2 ' s injury to his/her left eye and as such he had not performed an assessment specific to the injury to the resident ' s eye. However, he had seen the resident for another medical concern and had noted no concerns for the resident ' s eyes.
During an interview conducted on 01/09/2023 at approximately 2:50 PM the Assistant Director of Nursing (ADON) showed the surveyor a text message on her cell phone that was sent to physician #17 on 12/29/2022 that stated, We had an employee to resident altercation today, reported to the state. The text message did not say who the resident was or that the resident was injured.
On 01/09/2023 a change of condition was documented; an ophthalmology consult was ordered; the resident was treated for pain for the left eye and an order for Artificial Tears eye drops for irritation for the left eye was initiated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review the facility failed to notify Responsible Party of weight loss for resident # 9. This was evident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review the facility failed to notify Responsible Party of weight loss for resident # 9. This was evident for 1 out of 4 residents reviewed during the complaint survey.
Findings include:
On 1/10/23 at 10 AM a review of resident's #9 Medical record was reviewed. The Responsible Party was not informed resident # 9 had a significant weight loss of approximately 16 lbs (pounds) in less than 3 weeks.
On 4/7/22 a Nutrition note was written: Resident has had ~16.2# wt loss since admission on [DATE]. Resident is NPO (nothing by mouth) and is fed via Tube feeding (TF), TF order of glucerna 1.2 @80 ml/hr x 20 hrs will provide ~2100 cal, 96 prot, and 2488 ml free water, he also receives protein supplement of Active Critical Care 30 ml TID (three times a day) (270 cal, 63g prot) due to multiple wounds. Est. needs on admission ~2070 cal, 103g prot, 2415 ml fluid, tf as prescribed surpasses estimated needs. Now estimated needs based on current wt ~1770 cal, 88.5g prot, 1770 ml fluid, TF more than adequate to meet estimated need and could promote gradual wt gain. Resident has multiple wounds, not improving. Meds reviewed- not on diuretic therapy. Resident has unintentional wt loss of unknown etiology, BMI still WNL (within normal limits). TF will remain the same as it already surpasses est. needs, weekly weights have been requested, supplement still in place. Will monitor weekly wts. This information was not provided to responsible party. Administrator aware on 1/10/23 at 3:29 PM
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint from daughter and medication administration record and staff interview, the facility failed to give or sign o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint from daughter and medication administration record and staff interview, the facility failed to give or sign off on the medical record that resident # 9 has received his/her tube feeding as ordered. This is evident for 1 out of 4 residents reviewed.
Findings include:
On [DATE] a concern came into Office Of Health Care Quality, from the Daughter of resident # 9 who stated in her concern that resident was loosing too much weight and also, resident had an unexpected death on [DATE].
On [DATE] an investigation was conducted by viewing the medical record and speaking with staff members. Resident # 9 entered the facility in Feb. of 2022, and discharged May of 2022. When resident was admitted to the facility he/she weighed 147 lbs. at the time of his death he weighted on [DATE] 130 lbs. In [DATE], daughter came in to visit father and noticed a large amount of weight loss had occurred. Daughter also looked at feeding tube bag and noticed it was full of tube feeding but not running. The bag of tube feeding was dated two days prior. There was no note in chart stating the tube feeding was on hold or why the tube was not running. Daughter called for help and Acting DON (Director of Nursing) arrived. She had the tube feeding changed with the correct date. However when going through additional medication records Tube feeding was not signed off for [DATE], [DATE], [DATE], [DATE], and [DATE]. Director of Nursing and Administrator was made aware on [DATE] at 2:07 PM
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews the facility failed to maintain a safe and effective system for securing medication, treatment supplies, and hazardous medical equipment in their designated ...
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Based on observations and staff interviews the facility failed to maintain a safe and effective system for securing medication, treatment supplies, and hazardous medical equipment in their designated carts on the nursing units. This was found to be evident for 3 out of 3 nursing units observed during the initial tour of the facility.
The findings include:
A Medication Blister Pack is a card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles (or blisters). Each pack is secured by a strong, paper-backed foil that protects the pills until dispensed. When it's time to take a dose of medication, the caregiver or patient simply pushes a blister of pills through the foil backing to distribute an accurate dose effortlessly.
During the initial tour of the nursing units conducted on 01/09/2023 at approximately 6:30 AM, the surveyor observed 1 unlocked medication cart and 1 unlocked treatment cart on the Antioch nursing unit. The Surveyor was able to open each medication drawer that had labeled medications packets with the resident's name and room number, insulin pens, in-house liquid medications, eye drops and inhalers. The surveyor was able to open each treatment drawer, the treatment cart had scissors, labeled wound care medications that had the resident's name and room number, bandages and tapes.
The surveyor also observed 1 Blister Pack of medication for resident #13 of Mirtazapine 15mg/tab and 1 Blister Pack of medication for resident #14 of Atorvastatin 40 mg that laid on top of the nursing station.
During an interview conducted 01/09/2023 at 6:40 AM, the Licensed Practical Nurse (LPN) confirmed the unattended medication and treatment carts had been unlocked and that the two blister packs of medications were on top of the unattended nursing station. The LPN further stated the facility policy to ensure all carts are always locked if not in use and all medications are required to always be locked in the cart unless the medication is to be administrated immediately to the resident.
During the continued tour of the facility, the surveyor observed 1 unattended and unlock medication cart on the locked memory care unit, Chase nursing unit. The Surveyor was able to open each medication drawer that had labeled medications packets with the resident's name and room number, insulin pens, in-house liquid medications, and eye drops. The surveyor asked Geriatrics Nursing Assistant (GNA) #8 & #9 who was assigned to the medication cart and who was the nurse for the unit, both GNAs stated they did not know. The Surveyor than asked the Certified Medication Assistant (CMA) #10 who was assigned to the medication, the CMA stated a nurse and walked away. The surveyor stood next to the unlocked and unattended medication cart for 10 minutes until the Director of Medical, Purchasing and Transportation #1 arrived at the Chase nursing unit. The surveyor asked did s/he know who was assigned to the unattended and unlocked medication cart, the Director stated LPN #11 was assigned to the unit and medication cart, and then the Director locked the medication cart.
During the final tour of the facility the surveyor and Director of Medical, Purchasing and Transportation observed LPN #11 walk towards the Chase nursing unit from the lobby of the facility.
During an interview conducted on 01/09/2023 at approximately 6:50 AM, the surveyor advised LPN #11 that the medication cart s/he was assigned to was unattended and unlocked. The LPN stated Oh and kept walking towards the Chase nursing unit.
On 01/09/2022 at approximately 8:10 AM, the surveyor advised the Administrator of the observations of the unattended and unlocked medication and treatment carts.
On 01/11/2022 at Approximately 1:30 PM, the Infection Control Preventionist/ Staff Educator provided the surveyor with an in-service conducted for all staff on Medication Cart Education.
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
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based upon observation and staff interviews, it was determined that facility staff failed to take steps to repair the facility Hoyer lift scales. This was evident for 3 of 3 mechanical lifts with a sc...
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Based upon observation and staff interviews, it was determined that facility staff failed to take steps to repair the facility Hoyer lift scales. This was evident for 3 of 3 mechanical lifts with a scale reviewed during a revisit survey.
The findings included:
A Hoyer lift is a mechanical lift designed to safely transfer a resident from one surface to another in a manner that requires minimal assistance from the resident. Some Hoyer lifts can also weigh residents. Safe operation of the Hoyer lift includes the use of two staff persons, appropriate choice and placement of the sling under the resident, correct use of the lift controls, and careful maneuvering and management of the resident's position while the resident is suspended by the sling. Failure to use the Hoyer lift correctly can result in a resident sustaining a fall that could injure themselves or others.
During an observation of the 100 nursing hall, the nurse surveyor requested staff to obtain a weight on Resident #1. This request was based on reviews of Resident #1's documented weights, current medical conditions, and that Resident #1 is totally dependent upon the nursing staff for all care needs including nutrition and hydration. The surveyor requested that the GNA providing care to Resident #1 on 03/20/23 at 2:41 PM to please obtain a weight on Resident #1. GNA #1, staff member #11, then stated that Resident #1 needed to be weighed with a Hoyer lift scale because Resident #1 could not stand. GNA #1 also stated that the only facility Hoyer scale was not currently working due to broken parts.
In an interview with the facility maintenance director on 03/20/23 at 2:47 PM, the maintenance director stated that the facility has 3 mechanical lifts that can also weigh the residents and that all 3 of these scales are out of service.
In a follow-up interview with the facility maintenance man on 03/20/23 at 3:10 PM, the facility maintenance man stated that 2 of the 3 mechanical lifts with scales are out of service due to a missing charger and that these mechanical lifts have been out of service for at least 1.5 months. The facility maintenance man stated that s/he was in the process of calling the vendor to come to the facility and fix the 3 mechanical lifts with scales.
Cross reference F 842
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 F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order. This was evident for 1 of 4 nursing units observed dur...
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Based on observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order. This was evident for 1 of 4 nursing units observed during a revisit survey.
The findings include:
During an observation of the 400-hall nursing unit on 03/21/23 at 1:12 PM, the nurse surveyor observed the nursing unit main resident call light was illuminated, on the main hall ceiling, at the nursing station. This light indicates that one or more residents have requested assistance from the nursing staff. At this time, the activated call bell lights were not enunciating at the nurse's station. The 400 hall call bell system uses a computer based monitor that hangs behind the nurses' station.
In an interview with the 400 hall charge nurse, staff member #7, on 03/21/23 at 1:12 PM, the charge nurse stated that s/he was aware that the call bell system does not enunciate but was not aware how long the call bell enunciator had not been working. The charge nurse stated that the nursing staff are aware to look for a resident's call bell lights in the hallway.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on reviews of medical records and staff interviews, it was determined the facility staff failed to maintain a medical records in the most accurate form. This was evident for 4 (Residents #1, #2,...
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Based on reviews of medical records and staff interviews, it was determined the facility staff failed to maintain a medical records in the most accurate form. This was evident for 4 (Residents #1, #2, #3, #4) of 4 residents reviewed during a revisit survey.
The findings include:
A medical record is official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.
A review of Resident #1's medical record on 03/20/23 revealed the following documented weights:
03/13/23 at 1:33 PM - 174.0 pounds
03/09/23 at 1:52 PM - 174.0 pounds
03/07/23 at 2:26 PM - 174.0 pounds
03/02/23 at 11:40 AM - 174.0 pounds
02/27/23 at 1:01 PM - 174.0 pounds
02/26/23 at 12:05 PM - 174.0 pounds
02/19/23 at 12:35 PM - 174.0 pounds
02/13/23 at 1:52 PM - 174.0 pounds
02/09/23 at 1:15 PM - 174.0 pounds
02/03/23 at 2:59 PM - 174.0 pounds
01/26/23 at 1:50 PM - 174.0 pounds
01/26/23 at 1:48 PM - 174.0 pounds
01/20/23 at 2:49 PM - 174.0 pounds
01/19/23 at 2:59 PM - 174.0 pounds
01/18/23 at 2:59 PM - 174.0 pounds
01/13/23 at 2:24 PM - 174.0 pounds
A review of Resident #2's medical record on 03/20/23 revealed the following documented weights:
03/20/23 at 9:02 AM - 151.0 pounds
03/16/23 at 10:37 AM - 151.0 pounds
03/15/23 at 10:27 AM - 151.0 pounds
03/13/23 at 11:57 AM - 151.0 pounds
03/09/23 at 10:02 AM - 151.0 pounds
03/07/23 at 11:07 AM - 151.0 pounds
03/06/23 at 9:37 AM - 151.0 pounds
03/04/23 at 10:25 AM - 151.0 pounds
03/03/23 at 9:04 AM - 151.0 pounds
03/02/23 at 8:05 AM - 151.0 pounds
02/27/23 at 10:51 AM - 151.0 pounds
02/26/23 at 11:30 AM - 151.0 pounds
A review of Resident #3's medical record on 03/21/23 revealed the following documented weights:
03/20/23 at 8:56 AM - 284.0 pounds
03/18/23 at 10:28 AM - 284.0 pounds
03/16/23 at 8:54 AM - 284.0 pounds
03/15/23 at 10:14 AM - 284.0 pounds
03/13/23 at 9:06 AM - 284.0 pounds
03/09/23 at 9:57 AM - 284.0 pounds
03/07/23 at 11:00 AM - 284.0 pounds
03/06/23 at 9:32 AM - 284.0 pounds
03/04/23 at 10:21 AM - 284.0 pounds
03/03/23 at 8:57 AM - 284.0 pounds
03/02/23 at 8:00 AM - 284.0 pounds
02/27/23 at 10:44 AM - 284.0 pounds
02/26/23 at 8:18 AM - 284.0 pounds
02/19/23 at 12:35 PM - 284.0 pounds
02/13/23 at 11:34 AM - 284.0 pounds
02/09/23 at 11:22 AM - 284.0 pounds
02/03/23 at 9:37 AM - 284.0 pounds
01/26/23 at 11:15 AM - 284.0 pounds
01/26/23 at 1:48 PM - 284.0 pounds
01/15/23 at 2:42 PM - 284.0 pounds
01/14/23 at 11:01 AM - 284.0 pounds
01/13/23 at 2:24 PM - 284.0 pounds
A review of Resident #4's medical record on 03/21/23 revealed the following documented weights:
03/18/23 at 11:17 AM - 286.0 pounds
02/19/23 at 9:30 AM - 286.0 pounds
02/11/23 at 12:53 PM - 286.0 pounds
01/20/23 at 10:07 AM - 286.0 pounds
01/19/23 at 12:23 PM - 286.0 pounds
01/18/23 at 10:00 AM - 286.0 pounds
01/08/23 at 11:48 AM - 286.0 pounds
01/04/23 at 14:59 PM - 286.0 pounds
12/30/22 at 14:59 PM - 286.0 pounds
12/18/22 at 14:59 PM - 286.0 pounds
In an interview with GNA #2, staff member #12, on 03/21/23 at 10:51 AM, GNA #2 stated that s/he had not physically weighed Resident #1 all of the dates between 01/13/23 and 03/13/23 that indicates s/he documented a weight for Resident #1. GNA #2 stated that when s/he would document care provided to each resident during day shift, s/he would note in the computer each resident's last documented weight.
In an interview with the 100 unit nurse manager, staff #13, on 03/21/23 at 11:05 AM, the 100 unit nurse manager stated that at the beginning of each month, the nursing staff is handed a weight sheet to write down each resident's monthly weights. The licensed staff are responsible to document each resident's weight in the medical record. The GNA staff are not responsible for documenting a resident's weight in the medical record.
In an interview with the facility director of nurses (DON) on 03/21/23 at 12:50 PM, the facility DON stated that GNA #2 was inaccurately noting each resident's previously known weight daily when s/he worked. The facility DON stated that GNA #2 was to document N/A (not applicable) when documenting in the daily weight section in the electronic medical record. Based on surveyor intervention, the facility staff was identified as inaccurately documenting a resident's weight in the electronic medical record after providing daily morning care.
Feb 2019
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations and interview of facility staff. it was determined that the facility staff failed to promote and enhance a resident's dignity while assisting the resident with their breakfast an...
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Based on observations and interview of facility staff. it was determined that the facility staff failed to promote and enhance a resident's dignity while assisting the resident with their breakfast and lunch. This was evident for 1 of 2 residents reviewed during the annual survey process.
The findings include:
An observation was made on 2/12/19 at 1:30 PM of resident # 310 as s/he was being fed by GNA #5. GNA # 5 was standing above the resident feeding her/his lunch to the resident. The resident was leaning towards the right side of the bed and the GNA was standing on the left side of the bed leaning over the resident.
An observation was made on 02/13/19 08:41 AM of resident # 310 as s/he was being fed by GNA # 6. GNA # 6 was standing above the resident feeding her/his breakfast to the resident.
Interview with the Chief Nurse on 2/13/19 at 2:00 PM confirmed the facility staff failed to provide Resident # 310 with the most dignified existence while providing meals.
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 interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident represe...
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Based on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative. This was found to be evident for 2 out of 8 residents reviewed for a facility-initiated transfer during the investigative portion of the survey.
The findings include:
1. A medical record review for Resident # 310 was conducted on 02/14/19. Review of the physician order written on 1/30/19 revealed that Resident # 310 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the ombudsman.
2. A medical record review for Resident # 112 was conducted on 02/14/19. Review of the physician order written on 11/15/2018 revealed that Resident # 112 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the ombudsman.
The Chief Nurse was made aware of this concern on 02/14/19 at 03:55 PM. The Chief Nurse stated the facility did not notify the family in writing only verbally nor did they facility notify the ombudsman of the hospitalization.
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
2. Review of the medical record for Resident #108 on 2/13/19 revealed Resident #108 had physician orders to obtain pre and post-dialysis vitals and weights. Monitoring a dialysis patient's weight help...
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2. Review of the medical record for Resident #108 on 2/13/19 revealed Resident #108 had physician orders to obtain pre and post-dialysis vitals and weights. Monitoring a dialysis patient's weight helps the healthcare professional decide how much fluid needs to be removed from the body during dialysis. Maintaining a regular record of a patient's weight is necessary to avoid removing too much or too little fluid from the body.
Review of Resident #108's Treatment Administration Record (TAR) revealed that post dialysis weights had not been obtained on 1/17/19 and 1/31/19. Review of Resident #108's Weight History showed no recorded weights on 1/17/19 and 1/31/19. Review of Resident #108's Dialysis Communication Forms from 1/17/19 and 1/31/19 showed no recorded weights by the facility. A Dialysis Communication Form is completed by both facility nurses and dialysis center nurses. It records vitals such as weight and temperature for the dialysis patient. Resident #108's Licensed Practical Nurse (LPN) (Staff #3) was asked on 2/14/19 at 8:42 AM about the missing weights and was unable to locate them.
These findings were discussed with the Corporate Nurse (Staff #2) on 2/15/19.
Based on medical record review, observation and interview, it was determined the facility staff failed to provide residents with care that promoted the highest practicable well-being (#47) and to follow the physician's orders to collect pre-dialysis and post-dialysis weights for a resident (#108). This was evident for 2 of 2 residents selected for review during the survey process.
The findings include:
1. The facility staff failed to apply as ordered for Resident # 47:
a. Left wrist cock
b. Zero G Boots
c. pillow/ bath blanket placed in between arms and flank to prevent flexion
d. folded towel in her left elbow crease to decrease flexion.
Medical record review for Resident #47 revealed on 5/25/18 the physician ordered: Apply left wrist cock up splint in the day time after AM care. Place a folded towel in her left elbow crease to decrease flexion. A wrist cocks up splint places the wrist in a neutral position and minimizes deviation. Provides comfortable, circumferential support to hold the wrist in the desired angle of flexion or extension.
Flexion is the bending of a joint so that the bones that form that joint are pulled closer together. Flexion typically occurs when muscles contract and the bones thus move the nearby joint into a curved or bent fix position.
Further medical record revealed a physician order on 4/25/18 for Zero G Boots on at all time. Zero G Boots combines an aggressive design with hi-performance fabrics to eliminate pressure and friction to the skin.
Surveyor observation of the resident on 02/11/19 at 12:30 PM revealed no pads between flank and arm, no left wrist cocks up splint, and no Zero G Boots. The Resident was sitting in a Geri-chair at that time.
Surveyor observation of the resident on 02/12/19 at 11:06 AM, 12:32 PM and 3:32 PM revealed no pads between flank and arm, no left wrist cocks up splint, and no Zero G Boots. The Resident was sitting in a Geri-chair at that time.
Interview with the Chief Nurse on 2/13/19 at 12:00 PM confirmed the facility staff failed to apply left wrist cock up splint, Zero G Boots, pillow/ bath blanket placed in between arms and flank to prevent flexion and folded towel in her left elbow crease to decrease flexion for Resident # 47 as ordered by the physician.
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 medical record review and staff interview it was determined the facility staff failed to administer oxygen to Resident #6 in accordance with the standard of practice. This was evident for 1 o...
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Based on medical record review and staff interview it was determined the facility staff failed to administer oxygen to Resident #6 in accordance with the standard of practice. This was evident for 1 of 2 residents selected for review during the survey process.
The findings include:
Review of the medical record for Resident # 6 revealed diagnosis including but limited to Chronic Obstructive Pulmonary Disease (COPD). COPD is a lung disease characterized by chronic obstruction of the lung airflow that interferes with normal breathing and is not fully reversible.
Surveyor observation of Resident #6 on 02/12/19 at 09:46 AM revealed the resident in bed with the use of oxygen via nasal cannula. Further observation revealed the oxygen was being delivered using a concentrator which are medical devices that deliver medical grade oxygen (greater than 88% pure oxygen) to a patient via either a nasal cannula or mask. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils. Oxygen flows from these prongs. The nasal cannula is connected to an oxygen tank, a portable oxygen generator.
Further review of the medical record revealed a Physician's order May initiate O2 at 2L NC (Oxygen at 2 liters via nasal cannula) for O2 sats (saturations) less than 90% by pulse OX. Pulse Oximetry is a noninvasive test to measure the oxygen level or saturation of the blood. Review of the electronic vital sign record, the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) further revealed the last documentation of oxygen saturations recorded for Resident #6 was on 2/6/19. Interview on 2/12/19 with Resident # 6 revealed that she/he uses oxygen continuously at night and when she/he is in the room.
Interview with the Chief Nurse on 02/14/19 at 2:00 PM confirmed the facility staff failed to maintain oxygen within the standard of practice for Resident #6.
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 (# 65). This was evident for 1 of 1 resident selected for review during t...
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Based on medical record review and interview, it was determined the facility staff failed to conduct AIMs testing on Residents (# 65). This was evident for 1 of 1 resident selected for review during the 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.
The facility staff failed to conduct an AIMS on Resident # 65.
Medical record review for Resident # 65 revealed on: 1/4/19 the physician in collaboration with the psychiatric consultation ordered, Seroquel for anxiety. 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 # 65 prior to or as early initiation of the Seroquel.
Interview with the Chief Nurse on 02/14/19 at 12:17 PM confirmed the facility staff failed to conduct an AIMS test on Resident # 65 while administering an anti-psychotic medication.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview it was determined that the facility staff failed to ensure staffing hours for nursing s...
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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 staffing hours for nursing staff were posted and to ensure 18 months of posted nursing data were maintained. This was true for 3 out of 3 nursing units.
The findings are:
This surveyor requested the staff postings from the past 18 months. The Chief Clinical Officer (CCO) stated at 4:02 PM that they are not maintaining 18 months of staff postings. I toured the facility on 2/14/19. Observation of the staff postings for the Chase unit revealed that at 4:13 PM the actual hours worked for the nurses, Geriatric Nursing Assistants (GNA's), and the Certified Medicine Aides (CMA) was not on the staffing sheet. Observation of the staff postings for the Antioch unit revealed actual hours worked for the nurses, GNA's, and CMA's were not posted. Observation of the [NAME] unit revealed that the staff postings did not include actual working hours for the nurses, GNA's, and the CMA's.
The CCO was interviewed on 02/14/19 at 04:56 PM. The findings were discussed, and she confirmed that the records were not maintained for 18 months. She asked if they could use 1 master sheet each day since the regulation does not specify per unit. Said she would correct and post a master sheet from now on.
Sept 2017
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0241
(Tag F0241)
Could have caused harm · This affected 1 resident
Based on resident observation and staff interview it was determined the facility staff failed to ensure residents were fed in a dignified manner (# 146). This was true for 1 out of the 29 residents in...
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Based on resident observation and staff interview it was determined the facility staff failed to ensure residents were fed in a dignified manner (# 146). This was true for 1 out of the 29 residents in the stage 2 sample.
The findings include:
This surveyor observed on 9/27/17 at 1:00 PM Resident # 146 to be in bed with a tray food on the nightstand. The food was covered and untouched. The resident's roommate was eating lunch in bed. This surveyor observed the resident at 1:19 PM to still be in bed with food on the nightstand. A Geriatric Nursing Assistant (GNA) entered the room at 1:22 PM and asked the resident if he/she was hungry and wanted to eat. The resident answered yes and the GNA started to feed the resident.
The corporate nurse was interviewed on 9/28/17 at 9:01 AM. The observations were discussed with her. She said she understood and would evaluate the process of meal time delivery.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0246
(Tag F0246)
Could have caused harm · This affected 1 resident
Based on record review and resident interviews, it was determined that the facility staff failed to provide showers to Residents as ordered and per facility policy (# 28 and # 128). This was evident f...
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Based on record review and resident interviews, it was determined that the facility staff failed to provide showers to Residents as ordered and per facility policy (# 28 and # 128). This was evident for 2 of 28 residents selected for review in the stage 2 survey sample.
The finding include:
1. The facility staff failed to provide Resident # 28 with showers.
Interview with Resident # 28 on 9/25/17 at 1:38 PM revealed the resident stated that showers are not always provided and she/he would like showers. Review of the medical record revealed Resident # 28 was scheduled showers on the Monday/Thursday on the 7 AM to 3 PM shift. Review of staff documentation revealed the facility staff failed to administer a shower to the resident on: 8/31/17, 9/4/17, 9/7/17, 9/11/17, 9/14/17 and 9/25/17; however, documented the resident received full bed bath.
2. The facility staff failed to provide Resident # 128 with showers.
Interview with Resident # 128 on 9/26/17 at 10:30 AM revealed the resident stated that showers are not provided and she/he would like a shower. Record review revealed the resident was to receive showers on Monday/Thursday 3-11 shift. Further review of documentation revealed the facility staff documented the facility staff failed to provide showers to Resident # 128 on 8/31/17 and 9/4/17; however administered bed baths to the resident. Further review of the facility staff documentation revealed no indication of the resident receiving a shower or bed bath from 9/4/17 to 9/28/17.
Interview with the Director of Nursing on 9/28/17 at 1:30 PM revealed the facility staff failed to administer showers to Residents # 28 and # 128 per facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0278
(Tag F0278)
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 document accurate assessments for Residents (# 92, # 12 and # 146) on the MDS. This was evident f...
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Based on medical record review and staff interview it was determined that the facility staff failed to document accurate assessments for Residents (# 92, # 12 and # 146) on the MDS. This was evident for 3 of 29 residents selected for review in the stage 2 survey sample.
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.
The findings include:
1. Medical record review for Resident # 92 revealed on 9/27/2017, the facility staff assessed the resident and documented in Section O-O100 - K. Special Treatments, Procedures, and Programs; the resident was not receiving Hospice Care. A Physician order written on 8/17/2017 indicated that the resident was ordered Hospice Care and on the same day and was assessed by the Hospice Nurse. Hospice care is end-of-life care. A team of health care professionals and volunteers provides it. They give medical, psychological, and spiritual support.
Interview with the Director of Nursing (DON) on 9/28/2017 at 8:30 AM confirmed the MDS assessments on 9/27/16 was in error.
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.
2. A review of Resident # 12's clinical record revealed that the nursing home staff completed a MDS on 7/29/17. Section E1000A Wandering: risk of getting to dangerous place was scored as a Yes. A review of the resident's Wandering assessment completed on 7/22/17 noted the resident to be at low risk for wandering and the Wandering assessment completed on 9/15/17 noted the resident to be at low risk for wandering.
The corporate nurse was interviewed on 9/27/17 at 12:45 PM. She stated she discussed the findings with the social worker who completed Section E. The social worker coded the MDS based on potential not on actual behavior. She further stated the MDS would be corrected.
3. A review of Resident # 146's clinical record revealed that the nursing home staff completed a MDS on 7/28/17. Section E1000A Wandering: risk of getting to dangerous place was scored as a Yes. A review of the resident's Wandering assessment completed on 7/21/17 noted the resident to be at low risk for wandering.
The corporate nurse was interviewed on 9/27/17 at 12:45 PM. She stated she discussed the findings with the social worker who completed Section E. The social worker coded the MDS based on potential not on actual behavior. She further stated the MDS would be corrected.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0279
(Tag F0279)
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 plan addressing insomnia for Resident (# 163). This was evident for 1 o...
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Based on review of medical record and staff interview, it was determined the facility staff failed to develop comprehensive care plan addressing insomnia for Resident (# 163). This was evident for 1 of 29 residents selected for review in the stage 2 survey sample.
The findings include:
A care plan is an outline of nursing care showing all of 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.
Insomnia is a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep.
A care plan for Insomnia could include some of the following non-pharmacological approaches and home remedies for insomnia including:
Improving sleep hygiene - not sleeping too much or too little, exercising daily, not forcing sleep, maintaining a regular sleep schedule, avoiding caffeine at night, avoiding smoking, avoiding going to bed hungry, and ensuring a comfortable sleeping environment
Using relaxation techniques - such as meditation and muscle relaxation
Cognitive therapy - one-on-one counseling or group therapy
Stimulus control therapy - only go to bed when sleepy, avoid watching TV/ reading/ eating/ worrying in bed, set an alarm for the same time every morning (even weekends), avoid long daytime naps
Sleep restriction - decrease the time spent in bed and partially deprive the body of sleep, this increases tiredness ready for the next night
Review of the medical record for Resident # 163 revealed on 6/19/17, 8/13/17 and 9/15/17 the physician ordered: Clonazepam 1 milligram hour of sleep for insomnia. Clonazepam (Klonopin) belongs to a class of drugs called benzodiazepines. They have been used as sleeping agents for decades; however, the facility staff failed to initiate a care plan addressing insomnia for Resident # 163.
Interview with the Director of Nursing on 9/28/17 at 1:30 PM confirmed the facility staff failed to initiate a care plan to address insomnia for Resident # 163.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0309
(Tag F0309)
Could have caused harm · This affected 1 resident
Based on medical record review, observation, and interview, it was determined the facility staff failed to administer a medication as ordered by the physician for Resident # 58. This was evident for 1...
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Based on medical record review, observation, and interview, it was determined the facility staff failed to administer a medication as ordered by the physician for Resident # 58. This was evident for 1 of 29 residents selected for review in the stage 2 survey sample.
The findings include:
Review of Resident # 58 medical record revealed on 7/7/17 the physician ordered clonidine tablet every 6 hours for systolic blood pressure (BP) greater than 160 and diastolic blood pressure greater than 90: clonidine is to treat hypertension (high blood pressure).
A review of the Resident's Medication Administration Record (MAR) for the month of September 2017, revealed that Resident # 58's BP was greater than 160/90 26 different times and the facility staff failed to administer the medication clonidine
9/27/2017 12:48 PM Interview with the Director of Nursing confirmed the facility staff failed to follow physician orders for medication administration of clonidine.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0431
(Tag F0431)
Could have caused harm · This affected 1 resident
Based on observation and staff interview it was determined that the facility staff failed to ensure the security of residents' medications and privacy. This was true for 2 out of the 5 units in the fa...
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Based on observation and staff interview it was determined that the facility staff failed to ensure the security of residents' medications and privacy. This was true for 2 out of the 5 units in the facility.
The findings include:
This surveyor observed a medication cart at on 9/27/17 at 2:40 PM to be unlocked and unattended with the computer screen on with resident information visible. Two nursing staff were at side door opening door while an ambulance crew was attempting entry to bring a resident into the facility. No staff were in the vicinity of the cart. Waited two minutes until the unit manager appeared from the back room and informed her of the finding. The two nurses walked from the side door to the cart. I discussed with the three nursing staff the need to lock the medication carts. They each said they understood. I walked around the corner of the nursing station and observed a second cart unlocked with no staff present. I got the attention of the unit manager and demonstrated that I could open the drawers. Unit Manager locked the cart and she said she would get the Certified Medication Aid and tell her of the findings.
The Administrator and two corporate nurses were interviewed on 9/27/17 at 3:20 PM. They said they understood the significance of the findings and would address it immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0514
(Tag F0514)
Could have caused harm · This affected 1 resident
Based upon record review and staff interview it was determined that facility staff failed to ensure the resident's medical record was accurate and complete. This is evident for 1 of 29 resident's (# 9...
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Based upon record review and staff interview it was determined that facility staff failed to ensure the resident's medical record was accurate and complete. This is evident for 1 of 29 resident's (# 92) reviewed during Stage 2 of the Quality Indicator Survey.
The findings include:
The facility staff failed to maintain the medical record in the most complete form for a resident.
A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.
Medical record review for Resident # 92 revealed a physician ordered dated 8/17/17 for Hospice Care. Hospice care is end-of-life care. A team of health care professionals and volunteers provides it. They give medical, psychological, and spiritual support. The Hospice nurse did an initial assessment on 8/17/17 and the initial assessment documents were in the resident's medical record.
Medical record also revealed the absence of any other summaries from the nurses and team members. When said documents were requested for review on 9/27/17, the facility staff was unable to provide the information. The Director of Nursing (DON) stated that the documents were not in the resident's chart and the facility was in the process of acquiring the documents from the Hospice Agency. On 9/28/17, the documents obtained from the Hospice Agency and place in Resident # 92 medical record.
Interview with the Director of Nursing on 9/28/17 at 8:30 AM confirmed the facility staff failed to maintain the medical record in the most complete and accurate form for Resident # 92.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), 2 harm violation(s), $197,970 in fines, Payment denial on record. Review inspection reports carefully.
- • 68 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $197,970 in fines. Extremely high, among the most fined facilities in Maryland. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Manokin Nursing And Rehab's CMS Rating?
CMS assigns MANOKIN NURSING AND REHAB an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Manokin Nursing And Rehab Staffed?
CMS rates MANOKIN NURSING AND REHAB's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 49%, compared to the Maryland average of 46%.
What Have Inspectors Found at Manokin Nursing And Rehab?
State health inspectors documented 68 deficiencies at MANOKIN NURSING AND REHAB during 2017 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 63 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Manokin Nursing And Rehab?
MANOKIN NURSING AND REHAB 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 KEY HEALTH MANAGEMENT, a chain that manages multiple nursing homes. With 135 certified beds and approximately 107 residents (about 79% occupancy), it is a mid-sized facility located in PRINCESS ANNE, Maryland.
How Does Manokin Nursing And Rehab Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, MANOKIN NURSING AND REHAB's overall rating (1 stars) is below the state average of 3.0, staff turnover (49%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Manokin Nursing And Rehab?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Manokin Nursing And Rehab Safe?
Based on CMS inspection data, MANOKIN NURSING AND REHAB has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Maryland. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Manokin Nursing And Rehab Stick Around?
MANOKIN NURSING AND REHAB has a staff turnover rate of 49%, 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 Manokin Nursing And Rehab Ever Fined?
MANOKIN NURSING AND REHAB has been fined $197,970 across 2 penalty actions. This is 5.6x the Maryland average of $35,059. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Manokin Nursing And Rehab on Any Federal Watch List?
MANOKIN NURSING AND REHAB 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.