AUTUMN LAKE HEALTHCARE AT OAKVIEW
For profit - Corporation
138 Beds
AUTUMN LAKE HEALTHCARE
Data: November 2025
Trust Grade
50/100
#142 of 219 in MD
Photo by Autumn Lake Healthcare at Oakview
Photo by Alex Scharg
Photo by Autumn Lake Healthcare at Oakview
1 / 5 photos
Last Inspection: November 2023
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Autumn Lake Healthcare at Oakview has received a Trust Grade of C, indicating it is average and in the middle of the pack compared to other facilities. It ranks #142 out of 219 in Maryland, which places it in the bottom half of state facilities, and #28 out of 34 in Montgomery County, meaning only one local option is better. The facility is improving, with the number of issues reducing significantly from 30 in 2023 down to just 4 in 2025. Staffing is a relative strength, with a 4/5 star rating and only a 30% turnover rate, which is below the state average; however, RN coverage is average. While there are no fines, which is a positive sign, there have been concerns raised by inspectors, including the lack of qualified dietary supervision and failure to meet residents' meal preferences, as well as issues with the facility's environment, such as damaged blinds and stained ceilings. Overall, while there are strengths in staffing and no fines, there are notable weaknesses that families should consider.
- Trust Score
- C
- In Maryland
- #142/219
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 30% turnover. Near Maryland's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Maryland facilities.
- Skilled Nurses ○ Average
- Each resident gets 35 minutes of Registered Nurse (RN) attention daily — about average for Maryland. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 63 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 36%
No red flags
30 → 4 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 30 issues
2025: 4 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (30%)
18 points below Maryland average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Maryland average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 30%
16pts below Maryland avg (46%)
Typical for the industry
Chain: AUTUMN LAKE HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 63 deficiencies on record
Aug 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
Number of residents sampled:
Number of residents cited:
Based on record review, resident interview, and staff interview, it was determined that the facility failed to maintain proper bookkeeping techn...
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Number of residents sampled:
Number of residents cited:
Based on record review, resident interview, and staff interview, it was determined that the facility failed to maintain proper bookkeeping techniques as evidenced by not giving the resident or retaining a copy of a receipt of a transaction. This was evident for 1 (Resident #44) out of 1 resident reviewed for personal funds. The findings include: On 8/1/2025 at 8:32 AM, a review of Complaint #335655 was conducted. The complainant, Resident #44, questioned a deduction of $1000 from his funds on 9/22/2022. On 8/1/2025 at 12:44 PM, an interview was conducted with Resident #44 in regards to Complaint #335655. Resident #44 reiterated wants to know what a $1000 dollar charge was for on 9/22/2022. They stated that they have talked to the Business office and the corporate financial group about the $1000 dollar charge. The resident provided the survey team with a copy of his quarterly statement with the questioned $1000 deduction from his account labeled Personal Needs Items. The resident stated when he requested a copy of the receipt for the transaction, the facility was unable to provide it. On 8/1/2025 at 2:24 PM, an Interview was conducted with the Business Office Manager (Staff #19). When asking the Staff #19 if and when they became aware of Resident #44's concern, they stated a complaint was received by the social services department in the form of a grievance from Resident #44 on 3/28/2025. They stated that the grievance was investigated to see if a receipt and record of the $1000 transaction labeled Personal Needs Items was in the business office records, but It was not found. The Business office manager stated that on 4/4/2025, they reported this to the Nursing Home Administrator (NHA). A copy of the email notification made to the NHA and the original grievance from Resident #44 was provided to the survey team. The grievance form was dated 3/28/2025. The email was dated on 4/4/2025. When asked if they have provided Resident #44 with a response to his concern in writing, Staff #19 stated No.
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
Based on review of facility investigations, resident medical records, and interviews with facility staff, it was determined that the facility failed to ensure that residents remained free of abuse. Th...
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Based on review of facility investigations, resident medical records, and interviews with facility staff, it was determined that the facility failed to ensure that residents remained free of abuse. This was true for 3 (Resident #104, Resident #21 and Resident #146) of 11 residents reviewed for abuse during the survey.The Findings include:1) The facility's investigation related to facility reported incident 335653 was reviewed by the survey team on 8/4/2025 at 8:04 AM. Per medical record review and review of the facility investigation, on 3/18/2025 at 12 PM, Licensed Practical Nurse (LPN) #1 witnessed Resident #104 walk out of their room and walk next to Resident #33, who was sitting in a chair outside of their room. LPN #1 then witnessed Resident #33 hit Resident #104 in the abdomen which caused them to fall and sustain a hematoma to their head and be sent to the emergency room for evaluation.
LPN #1 was interviewed by the survey team on 8/4/2025 at 2:28 PM. LPN #1 confirmed she witnessed Resident #33 push Resident #104 unprovoked, who then fell to the floor and sustained an injury.
2) The facility's investigation related to facility reported incident 335654 was reviewed by the survey team on 8/4/2025 at 9:53 AM. In the investigation, the facility substantiated through witnesses (LPN #20, Geriatric Nursing Assistant (GNA) #21, GNA #22) that Resident #33 pushed Resident #21 which resulted in Resident #21 falling to the floor and being sent to the emergency room due to pain.
On 8/4/2025 at 3:27 PM, GNA #21 was interviewed by the survey team about the incident. GNA #21 stated that Resident #21 was seating in a chair and got up when Resident #33 sat down in the chair. Resident #21 then walked back to the seat when Resident #33 stood up and pushed Resident #21 who fell to the ground.
On 8/4/2025 at 3:40 PM, the Nursing Home Administrator (NHA) was interviewed by the survey team. The NHA verbally stated that both incidents of alleged resident to resident abuse were substantiated through their respective investigations.
3) A medical record review for Resident #146 on 7/29/25 at 7:54 PM revealed the resident had a diagnosis of dementia and resided on the locked unit.
On 7/29/25 at 8:14 PM a review of the facility’s investigation file revealed the initial report form that read the facility received an allegation of abuse involving Resident #146 on 12/6/24 at 7:55 PM. According to the final report form, a family member of a resident who resided on the locked unit, was trying to find the charge nurse to let them out of the locked unit and observed the nurse slapping the Resident #146. The family member reported what they saw to facility staff. The nurse was asked to leave the facility immediately and was terminated when the abuse was substantiated. The resident no longer resided in the facility.
An attempt was made on 8/5/25 at 10:22 AM to call the family member who had witnessed and reported the incident, but it was unsuccessful.
During an interview with the Director of Nursing (DON) on 8/5/25 at 10:25 AM, she confirmed the findings. She stated that the family member, who had been coming to the facility for a long time, was visibly upset by the incident and believable.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on record review, resident interviews, and staff interviews, it was determined the facility failed to protect the resident from misappropriation of property. This was evident for 1 out of 1 resi...
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Based on record review, resident interviews, and staff interviews, it was determined the facility failed to protect the resident from misappropriation of property. This was evident for 1 out of 1 resident reviewed for personal funds.The findings include:On 8/1/2025 at 8:32 AM, a review of Complaint #335655 was conducted. The complainant, Resident #44, questioned a deduction of $1000 from their funds on 9/22/2022. On 8/1/2025 at 12:44 PM, an interview was conducted with Resident #44 in regards to Complaint #335655. Resident #44 reiterated wants to know what a $1000 dollar charge was for on 9/22/2022. They stated that they have talked to the Business office and the corporate financial group about the $1000 dollar charge. The resident provided the survey team with a copy of their quarterly statement with the questioned $1000 deduction from their account labeled Personal Needs Items. The resident stated when they requested a copy of the receipt for the transaction, the facility was unable to provide it.On 8/1/2025 at 2:24 PM, an Interview was conducted with the Business Office Manager (Staff #19). When asking the Staff #19 how they became aware of this incident, they stated a complaint was received by the social services department in the form of a grievance from Resident #44 on 3/28/2025. They stated that the grievance was investigated to see if a receipt and record of this transaction was in the business office records, but it was not found. The Business office manager stated that on 4/4/2025, they reported this to the Nursing Home Administrator (NHA). A copy of the email notification made to the NHA and the original grievance from Resident #44 was provided to the survey team. The grievance form was dated 3/28/2025. The email was dated on 4/4/2025. When asked if they have provided Resident #44 with a response or resolution to their concern, Staff #19 stated No. On 8/1/2025 at 2:48 PM, during an interview with the NHA, when asked if they were aware of Resident #44's concern regarding $1000 missing finances from their account in September of 2022. The NHA stated they were aware and have been trying to get the issue resolved with their corporate finance group. When asked if they reported the alleged incident of misappropriation of Resident #44's funds to the proper authorities on April 4th, 2025; the NHA stated that they did not. On 8/04/2025 at 9:10 AM, an interview was conducted with the NHA. When asked to provide an update on Resident #44's concern, the NHA stated that on 8/1/2025 they requested their finance group to process the return of funds if they are unable to provide the facility with records of the receipt of the 1000 dollar Personal Needs Items transaction.
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 record review and staff interviews, it was determined that the facility failed to: 1) report an injury of unknown origin to the state agency in a timely manner, and 2) ensure that incidents o...
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Based on record review and staff interviews, it was determined that the facility failed to: 1) report an injury of unknown origin to the state agency in a timely manner, and 2) ensure that incidents of alleged abuse were reported to the state agency in a timely manner. This was found to be evident in 3 (Incident 335642, Incident 335653and Complaint 335655) of 29 intakes investigated during the survey. The findings include:
1) On 8/1/2025 at 12:26 PM, documentation provided by facility regarding Incident 335642 was reviewed by the survey team involving Resident #121. Per record review, Resident #121 was noted to have discoloration around their left eye during AM care on 7/20/2024 by staff. Resident #121 has a diagnosis of dementia and could not provide information on injury at the time it was noticed. Further record review revealed that the Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the injury of unknown origin on 7/22/2024. Email documentation showed that the initial report of the injury of unknown origin was sent to the state survey agency on 7/22/2024 at 4:44 PM.
The NHA was interviewed on 8/1/2025 at 2:30 PM. They stated that it’s the facility’s expectation that staff inform the DON and NHA of alleged abuse or injuries of unknown origin immediately so the appropriate state agencies can be notified, and the facility can begin their investigation. The NHA stated the notification of these incidents has been an on-going problem and they have had multiple in-services with staff on this issue. Surveyor addressed concern with the NHA that facility did not report the injury of unknown origin in the appropriate timeframe. 2a.) On 8/4/2025 at 8:04 AM, documentation provided by the facility regarding Incident 335653 was reviewed by the survey team involving Resident #104. Per record review, on 3/18/2025 at 12 PM, Resident #104 was witnessed by Licensed Practical Nurse (LPN) #1 walking next to another resident that was sitting in a chair outside of their room. The resident in the chair then hit Resident #104 in the abdomen resulting in them falling and sustaining a hematoma to their head. Further record review showed the NHA was made aware of the incident on 3/19/2025 at 10:00 AM. Per email confirmation, the incident was reported to the state survey agency on 3/19/2025 at 1:20 PM.On 8/4/2025 at 3:40 PM, the surveyor addressed concerns about the alleged resident-to-resident abuse not being reported in the 2-hour time frame to the state survey agency to the NHA. The NHA verbally substantiated the resident-to-resident abuse and stated that the facility’s expectation is to report the alleged abuse within the 2-hour timeframe. 2b.) On 8/1/2025 at 8:32 AM, a review of Complaint #335655 was conducted. The complainant, Resident #44, questioned a deduction of $1000 from their funds on 9/22/2022. On 8/1/2025 at 2:24 PM, an interview with the Business office manager (Staff #19) was conducted. When asked about when they became aware of the resident's concern, Staff #19 stated that a grievance came from the social services department, and it was investigated to see if a receipt or record of this transaction was in their records. It was not found, so on 4/4/2025 I reported this to Nursing Home Administrator (NHA). A copy of email notification made to NHA dated 4/4/2025 and a copy of the grievance from Resident #44 dated 3/28/2025 was provided to the survey team. On 8/1/2025 at 2:48 PM, during an interview with the NHA, when asked if they were aware of Resident #44's concern regarding $1000 missing finances from their account in September of 2022. The NHA stated they were aware and have been trying to get the issue resolved with their corporate finance group. When asked if they reported the alleged incident of misappropriation of Resident #44's funds to the proper authorities on April 4th, 2025; the NHA stated that they did not.
Nov 2023
30 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, it was determined the facility staff failed to reveal evidence that the resident or resident representative was informed of their right to formulate...
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Based on medical record review and staff interview, it was determined the facility staff failed to reveal evidence that the resident or resident representative was informed of their right to formulate an advanced directive. This was evident for 2 (#3, #104) of 5 residents reviewed for advance directives.
The findings include:
Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is not able to make their own decisions.
1) On 10/12/23 at 1:35 PM, a review of Resident #3's EMR (electronic medical record) and paper medical record failed to reveal evidence that Resident #3 had an advanced directive in place.
On 10/25/23 at 1:09 PM, review of the medical record revealed that Resident #3 resided in the facility for long term care since 2010. Resident #3's quarterly assessment with an assessment reference date (ARD) of 7/29/23, documented that Resident #3's BIMS (brief interview for mental status) summary score was 15, indicating the resident was cognitively intact. Continued review of the medical record failed to reveal documentation that Resident #3 had formulated an advanced directive, that the resident had been informed of his/her right to formulate an advanced directive, or that the facility periodically reviewed with the resident and/or the resident representative regarding treatment, experimental research and any advance directive and its provisions, as preferences may change over time.
On 10/25/23 at 2:02 PM, during an interview, Staff #19, Social Service Designee stated that following a resident's admission to the facility, advanced directives would be discussed with the resident and/or resident' health care agent during a social service assessment. Staff #19 stated that if the resident had an advanced directive, a copy of the advanced directive would be requested, and if they did not have an advance directive, Staff #19 would offer to help, and give them a copy of the Maryland Advanced Directive form. Staff #19 stated that any discussions with the resident/resident representative regarding advanced directives would be documented in the resident's medical record and a copy of a resident's advanced directive would be in their medical record.
On 10/25/23 at 3:48 PM, during an interview, Staff #19 stated that Resident #3 was capable, and indicated that the resident's code status and advanced directives were usually reviewed with the resident during care plan meetings and that Resident #3 did not want an advanced directive. At that time, Staff #19 was made aware of the above finding and that no documentation was found in the medical record to indicate Resident #3 had been informed of his/or her right to formulate an advanced directive. No further comments were offered by Staff #19 at that time.
2) On 10/12/23 at 1:38 PM, a review of Resident #104's EMR and paper medical record failed to reveal evidence that Resident #104 had an advanced directive in place.
On 10/25/23 at 10:07 AM, a review of Resident #104's medical record revealed the resident was initially admitted to the facility in April 2023 for rehabilitation following an acute hospitalization. Resident #104's most recent assessment with an ARD of 10/2/23 documented the resident's BIMS summary score was 15, indicating h/she was cognitively intact. Continued review of the medical record failed to reveal evidence that Resident #104 had formulated advanced directive or that h/she had been periodically informed of his/her right to formulate an advanced directive.
On 10/25/23 at 3:48 PM, Staff # 19, Social Services, was made aware of the above findings and that no documentation was found in the medical record to indicate Resident #104 had been informed of his/her right to formulate an advanced directive, or that the resident was periodically informed of his/her right to formulate an advanced directive. No further comments were offered by Staff #19 at that time.
CONCERN
(D)
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 observation, record review, and interview, it was determined that the facility staff failed to notify a resident's attending provider of a change in condition. This was evident for 1 (# 34) o...
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Based on observation, record review, and interview, it was determined that the facility staff failed to notify a resident's attending provider of a change in condition. This was evident for 1 (# 34) of 4 residents observed during medication administration and 1(#2) of 3 residents reviewed for Nutrition.
The findings include:
Systolic blood pressure is the top blood pressure. It refers to the pressure in the arteries during heart muscle contraction.
The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the necessary care.
1) On 10/23/23 at 9:03 AM, during medication administration for Resident # 34, it was observed by the surveyor that two blood pressure medications were not administered by staff # 45, a licensed practical nurse (LPN) who stated the medications were held because Resident # 34's blood pressure reading was low.
On 10/23/23 at 12:21 PM, a review of the October 2023 medication administration record was done for Resident # 34. The review revealed that two blood pressure medications without blood pressure parameters were held twelve times in October for Resident # 34. However, the review failed to show any documentation that Resident # 34's attending physician was aware of the low blood pressure readings on 10/2, 10/7/23, 10/16/23, 10/17/23, and 10/19/23.
On 10/23/23 at 1:39 PM, during an interview with staff #45, she checked the facility's electronic medical record in the presence of the surveyor. She confirmed there were no parameters for Resident # 34's blood pressure medications nor instructions on when to hold medications. Staff # 45 stated that regardless of the order for parameters, she would usually hold blood pressure medications for all residents when the systolic blood pressure (SBP) was less than 110 mmHg (millimeters of mercury) per facility policy. Staff # 45 also stated that she notified the attending provider every time Resident # 34's blood pressure was less than 110mmHg.
On 10/23/23 at 2:10 PM, during an interview with staff # 20 (an LPN), she stated that she would use her nursing judgment to hold a blood pressure medication if a resident's SBP was less than 110mmHg. Staff # 20 said she would notify the attending provider about the low SBP.
On 10/23/23 at 3:15 PM, during an interview with staff # 32, the Regional Director of Clinical Services, she stated that the facility did not have a policy for blood pressure parameters but followed the attending provider's order.
On 10/23/23 at 4:38 PM, staff # 32 stated that Resident # 34's attending provider was notified of concerns with the resident's blood pressure and medications. After being told, the provider discontinued one medication, added parameters to the other, and decreased the dose.
2) On 10/17/23 at 10:14 AM, a medical record review was done for Resident # 2. The review revealed a quarterly nutrition assessment, dated 9/25/23, which documented that Resident # 2 had been noted to have a weight loss.
A continued review of Resident # 2's medical record showed a Minimum Data Set (MDS) assessment, dated 9/27/23, that documented weight loss in section K for Resident # 2.
On 10/17/23 at 10.30 AM, a medical record review showed that Resident #2 was seen by the attending provider on 10/5/23 with no mention of weight loss in Resident # 2's notes.
On 10/18/23 at 1:00 PM, during an interview with staff # 28, a dietitian, she stated that the attending provider was notified of weight changes through at-risk meetings. Staff # 28 handed a sign-in sheet to the surveyor for an at-risk meeting on 10/2/23, during which weight loss was discussed. However, no documentation was provided to show that the attending provider for Resident #2 was notified of the weight loss seven days before this meeting.
On 10/23/23 at 10:14 AM, an interview was conducted with staff #31, the medical director for the facility, and the attending for Resident # 2. During the interview, she stated that she expected to be notified as soon as staff identified a weight loss for a resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on review of facility documents and staff interview, it was determined the facility failed to report an injury of unknow origin to the State Agency, the Office of Health Care Quality (OHCQ), imm...
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Based on review of facility documents and staff interview, it was determined the facility failed to report an injury of unknow origin to the State Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours of the allegation. This was evident for 1 (#24) of 13 residents reviewed for abuse.
The findings include:
On 11/2/23 at 3:49 PM, a review of the facility reported incident MD00171214 was conducted related to Resident #24 sustaining an injury of unknown origin. The facility's self-report documented that the Nursing Home Administrator was informed of the injury on 8/22/21 at approximately 6:15 PM.
An email confirmation of the facility's self-report to the state agency was provided to the surveyor and reviewed. The email confirmation documented that the incident was reported to the state agency on 8/23/21 at 1:50 PM. Once the facility staff became aware of the injury of unknown origin, the facility failed to forward a first report to the state agency immediately, but not later than 2 hours.
The concerns related to timely reporting an injury of unknown origin within 2 hours to the state office were discussed with the Director of Nurses (DON) on 11/3/23 at 2:00 PM, and the DON offered no further comments at that time.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on review of facility documents and staff interview, it was determined the facility failed to thoroughly investigate when a vulnerable resident who was assessed, and care planned as an elopement...
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Based on review of facility documents and staff interview, it was determined the facility failed to thoroughly investigate when a vulnerable resident who was assessed, and care planned as an elopement risk, left the facility grounds unattended for an unknown amount of time. This was evident for 1 (#136) of 4 residents reviewed for accidents. The findings include:
1) On 10/17/23 at 9:00 AM, a review of facility reported incident MD00175135 revealed documentation that, on 12/19/21 at approximately 2:15 PM, Resident #136 was observed by staff wheeling herself in the neighborhood around the facility. In a handwritten statement, Staff #14, Dining Services, documented that s/he observed Resident #136 at an intersection which was approximately 0.9 miles from the facility. The facility's investigation indicated Resident #136 was not identified as missing from the facility, until the resident was observed in the community by the staff person.
The facility's self-report revealed documentation that Resident #136, accompanied by Staff #16, Activity Aid, was let out of the front of the building by Staff #15, who had not heard the resident's wanderguard alarm. Staff #16, then returned to the inside of the building, leaving Resident #136 outside and unattended by staff, resulting in Resident #136 wandering away from the facility property.
The self-report concluded that it was the error of the 2 employees who were temporarily unaware or distracted of the risk for exiting that the resident posed which resulted in Resident #136's elopement from the facility.
Review of the witness statements revealed, that during the facility's investigation, a statement had been obtained from Staff #15, however, there was no evidence that a statement had been obtained from Staff #16, to indicate why the resident was left outside unattended.
The facility's investigation did not indicate the time the resident was left outside of the facility unattended, or how long the resident was missing before she was found.
The facility's investigation did not indicate the time the resident was left outside of the facility unattended, or how long the resident was missing, before s/he was found. The investigation included inservice attendance logs for elopement training following the incident. Neither staff member #15 nor #16 were listed on the logs.
The [NAME] President of Operations (Staff #5), who was the administrator at the time of the above incident, was interviewed on 10/19/23 at 12:20 PM. During the interview, when made aware of the concerns with failing to do a thorough investigation, Staff #5 asked what that had to do with anything, and that the investigation was there. When asked if any residents had seen anything, Staff #5 responded by asking how he was supposed to remember what happened 2 years ago. When asked why no resident interviews were included in the investigation, Staff #5 stated that he didn't feel he needed to ask the residents what they had seen.
On 10/20/2023 12:54 PM, the NHA was made aware that the facility failed to thoroughly investigate Resident #136's elopement on 12/19/21. The NHA was made aware of the concerns that the investigation had only one staff interview, that no interview was obtained from the Activity Aide (Staff #16) implicated in the elopement, that during an interview, the Activity Director indicated that s/he was unaware of that one of his/her activity staff had been implicated in the elopement and there was no evidence in the facility's investigation to support that either staff was implicated. The NHA indicated he understood the concerns and offered no further comments at that time. On 10/29/23 at 1:10 PM, the NHA stated that he could not confirm that it was an activity staff member who left Resident #136 outside unattended. Cross Reference F689
2) On 10/17/23 at 9:00 AM, a review of facility reported incident MD00177224 documented that, on 4/17/22, at approximately 10:00 PM, Resident #136 was noted to be missing from the facility, that the resident was found by the police at approximately 1:15 AM. The resident was picked up by the regional administrator and returned to the facility. The facility's self-report did not identify where the resident was located.
On 10/17/23 at approximately 1:00 PM, Staff #5, [NAME] President (VP) of Operations, and previous NHA, stated that Resident #136 was located near an intersection, outside a tavern, near a bus stop in a nearby community. Staff #5 indicated someone from the tavern reported seeing the resident to the police and Staff #5 picked the resident up and returned him/her to the facility. Review of a map revealed the intersection where Resident #136 was located included 2 major divided roadways located approximately 3 miles from the facility.
Review of the witness statements included in the facility's investigation revealed a statement had been obtained from the Staff #18, the GNA who reported the resident missing, and Staff #22, the nurse who was assigned to the resident that night. There was no other evidence that any statements were obtained from residents or from any other staff who had on the nursing unit that night. Further review of the facility's self-report revealed that the facility was unable to determine how the resident eloped that night, although the investigation expressed the opinion that the resident probably followed a visitor out of the front door, though the facility's investigation failed to indicate if there were visitors in the facility at the time of the elopement, or how a visitor would have exited the locked facility.
The above concerns with failing to thoroughly investigate Resident #136's elopement from the facility on 4/19/21 were discussed with the NHA and Staff #5, at 11/3/23 at 3:20 PM. At that time, both the NHA and Staff #5 expressed understanding of the concerns.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that the facility failed to provide the resident and the resident representative written notice of the bed hold policy. This was evident for 1 (...
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Based on record review and interview, it was determined that the facility failed to provide the resident and the resident representative written notice of the bed hold policy. This was evident for 1 (Resident #96) out of 3 residents reviewed for hospitalizations.
The findings include:
Resident #96 is a long-term care resident admitted in 2022. On 10/13/23 at 9:35 AM, Resident #96's medical records were reviewed and revealed that the resident was transferred to the hospital in July of 2023.
On 10/18/23 at 12:03 PM, Licensed Practical Nurse (LPN staff#27) was interviewed about the process when a resident is ordered to be transferred to a community hospital for treatment. LPN staff #27 was able to name the different documents and notices that they are required to prepare to facilitate the resident's transfer. The nurse then documents these preparations in the facility's Change in condition/ Concurrent review evaluation form.
On 10/19/23 at 1:20 PM, a review of the Change in condition/Concurrent review form with a reference date of 7/20/2023 signed by a registered nurse (RN staff #46) revealed that section P, was left unchecked where the nurse would mark documentation provided to residents or resident representatives for bed hold policy. There was no evidence found In Resident #96's medical records for this document.
On 11/03/23 at 12:30 PM, in an interview with the Director of Nursing (DON staff #2), the concern was discussed that the surveyor found no evidence that the resident or resident representative was notified in writing, regarding the reason for transfer. The exit conference was conducted at 4:15 PM on the same day, and at that time, the facility had not provided documentation to contradict this finding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility staff failed to complete, within 14 days...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility staff failed to complete, within 14 days, a Significant Change in Status Minimum Data Set (MDS) Assessment. This was evident for 1 (#84) of 3 residents reviewed for Activities of Daily Living.
The findings include:
The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the necessary care.
Activities of Daily Living (ADLs) collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility.
A significant change means a major decline or improvement in a resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions that have an impact on more than one area of the resident's health status and requires interdisciplinary review or revision of the care plan, or both.
A review of Resident 84's medical record on 10/11/23 at 12:23 PM revealed a Minimum Data Set (MDS) assessment dated [DATE]. The assessment recorded that Resident #84 had a diagnosis of Dementia and had severely impaired cognition. A continued review of the MDS assessment showed that Resident #84 required supervision assistance from staff for bed mobility, toilet use, and set-up assistance for transfer.
On 10/16/23 at 11:09 AM, a subsequent review of Resident # 84's medical record was done. The review revealed an MDS assessment dated [DATE] that showed that Resident # 84 required extensive assistance from staff for bed mobility and toilet use and one-person physical help for transfers, a decline in all three areas compared to the 6/20/23 assessment. However, the record review failed to demonstrate that a Significant Change in Status MDS Assessment was completed to reflect Resident # 84's decline in ADLs.
On 10/12/23 at 2:05 PM, an interview with Resident # 84's responsible party revealed that she had noted a decline in Resident #84's ADLs since his/her admission to the facility.
On 10/18/23 at 8:30 AM, during an interview with staff # 40, MDS Coordinator, she revealed that she would complete a Significant Change in Status MDS Assessment for a resident with a decline in more than one area of their ADLs.
On 10/27/23 at 7:57 AM, an interview was conducted with staff # 37, MDS Coordinator. During the interview, staff # 37 stated that she calls her Corporate MDS person regarding a Significant Change in Status Assessment when there is a decline in a resident's status. However, she did not contact them regarding Resident # 84.
On 10/27/23 at 9:38 AM, during a subsequent interview with staff #37, she stated she had contacted her corporate MDS after surveyor's intervention. Her corporate MDS asked her to initiate a Significant Change in Status MDS Assessment for Resident # 84.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined that the facility failed to ensure that a resident with a positive Level I PASARR (Preadmission Screening and Resident Review) screen wa...
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Based on medical record review and interview, it was determined that the facility failed to ensure that a resident with a positive Level I PASARR (Preadmission Screening and Resident Review) screen was evaluated by the designated state-authority through the Level II PASARR process, and approved for admission to the nursing facility. This was found to be evident for one (Resident #88) out of two residents reviewed for PASARR.
The findings include:
On 10/18/23, review of Resident #88's medical record revealed that the resident was admitted in April 2022 after an extended hospitalization on a psychiatric unit.
Review of the Preadmission Screening and Resident Review (PASARR) Level I ID Screen for Mental Illness and Intellectual Disability or Related Conditions form revealed Section C Serious Mental Illness contains three screening questions used to determine if the resident has a Serious Mental Illness. These include diagnosis of a major mental disorder, level of impairment, and recent treatment.
Further review of the electronic medical record revealed a PASARR screen completed 4/14/22 by the facility's Social Service Director (SSD Staff #19) which documented a major mental disorder but Section C failed to identify this as a serious mental illness which would require a Level II PASARR screen.
On 10/18/23 at 2:22 PM, the SSD (Staff #19) reported that, technically, resident's are supposed to come from the hospital with a PASARR but if not, she would complete one and upload it into the system (electronic health record), but that she used to have a binder for storage of the hard copy. She went on to report that, if the PASARR was positive, she would get a clearance from AERS (state Adult Evaluation and Review Services). When asked about Resident #88 specifically, the SSD reported that she completed a PASARR when the resident was admitted and discovered the resident had a major mental disorder, but did not capture the recent treatment. The SSD indicated she would ask medical records if they had received a PASARR Level II screen from the hospital.
On 10/18/23 at 2:55 PM, the SSD provided a copy of a positive Level I PASARR completed by the hospital staff in May 2021, which was 11 months prior to the facility admission as well as another positive Level I PASARR screen completed by the SSD herself on 4/19/22. The SSD reported she does not recall sending the information to AERS for an evaluation.
Further review of the medical record failed to reveal documentation of a Level II PASARR screen in 2022 or 2023.
On 10/20/23 at 2:15 PM, surveyor reviewed the concern with the Director of Nursing regarding the failure to refer a resident with a positive PASARR to AERS for an evaluation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined that the facility failed to provide services consistent with pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, it was determined that the facility failed to provide services consistent with professional standards of practice to prevent the development of pressure ulcers and promote healing of existing pressure ulcers/injuries by 1) failing to follow practitioners orders by failing to accurately transcribe and implement wound treatment orders as prescribed, and 2) failing to ensure that a low air mattress was implemented when recommended. This was evident for 1 (#129) of 4 residents reviewed for pressure ulcers.
The findings include:
1) A pressure ulcer also known as pressure sore, or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue and are staged according the their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A DTI (deep tissue injury) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) resulting from intense and/or prolonged pressure and shear forces at the bone-muscle interface and may evolve rapidly to reveal the actual extent of tissue injury. Once a DTI opens to an ulcer, the ulcer would be reclassified into the appropriate stage.
On 11/2/23 at 12:13 PM, a review of complaint #MD00196508 was conducted. The complainant reported that while residing in the facility, Resident #129 developed a Stage II pressure wound on his/her buttock which became a Stage IV within 30 days.
A review of Resident #129's medical record was revealed that Resident #129 was admitted to the facility in February 2023 with diagnoses of unspecified dementia, muscle weakness, difficulty in walking and other lack of coordination. The medical record document the Resident #129 was transferred to the hospital on 8/24/23, returned to the facility on 8/29/23, and discharged in the beginning of September.
Resident #129's quarterly assessment with an assessment reference date (ARD) of 4/3/23 documented the resident's BIMS summary score was 6, and documented the resident required extensive, one-person physical assistance for bed mobility, transfer, dressing, eating and personal hygiene, and Resident #129 was totally dependent, with 1-person physical assist for toileting, and walking. The MDS assessment documented Resident #129 was a risk for developing pressure ulcers/injuries and Resident #129 did not have any unhealed pressure ulcers/injuries.
Review of Resident #129's medical record revealed the resident was followed by a wound care NP (nurse practitioner) weekly for his/her pressure ulcers. Further review of Resident #129's wound care orders revealed facility staff failed to follow the NP's orders, by failing to implement wound treatment orders by failing to accurately transcribe (copy information from prescribing practitioner's orders) wound treatment orders as prescribed by the NP.
1.1) On 6/15/23 at 3:01 PM, in an initial skin and wound note, Staff #36, Wound Nurse Practitioner (NP), documented that Resident #129 had new pressure DTI (deep tissue injury) on the sacrum, recommended wound treatment orders, and a LAL (low air loss mattress).
On 6/22/23 at 10:17 AM, in a Skin and Wound Note, the NP documented Resident #129's sacral pressure wound status was improving. The NP treatment order recommendation was to cleanse the wound NS (normal saline), apply medical grade honey to the base of the wound, secure with bordered foam and change the dressing daily.
A review of Resident #129's June 2023 Treatment Administration Record (TAR) revealed a 6/23/23 order, Cleanse sacral DTI with NS, apply Medihoney and cover with dressing two times a day, which was documented as done 2 times a day in June, from 6/23/23 to 6/31/23. Review of Resident #129's July 2023 TAR revealed the order was documented as done 2 times a day, every day from 7/1/23 to 7/14/23. The facility staff failed to accurately transcribe the order per the NP's recommendation to provide Resident #129's sacral DTI treatment once a day.
In addition, on 6/29/23 at 11:24 AM, in a Skin and Wound Note, the NP's treatment recommendation for Resident #129's DTI was unchanged and to cleanse the wound with NS, apply medical grade honey to base of the wound, secure with bordered phone, and change daily, and on 7/6/23 at 10:04 AM, the NP's treatment recommendation for Resident #129's DTI was unchanged and to cleanse the wound with NS, apply medical grade honey to base of the wound, secure with bordered foam, and change daily.
The facility staff failed to accurately transcribe the treatment recommendation to provide daily wound care which was made by the NP on 6/23/23, 6/29/23 and 7/6/23 resulting in Resident #129 receiving sacral pressure wound treatment two times a day and not once a day as prescribed by the NP.
1.2) On 7/20/23 at 12:09 PM, in a Skin and Wound Note, the NP documented Resident #129's sacral pressure wound status was worsening with NP's treatment recommendation was to cleanse the wound with NS, apply Dakins moistened fluffed gauze to base of the wound, secure with bordered foam, change BID (twice a day).
Dakins solution (dilute sodium hypochlorite solution) (bleach) is a antimicrobial wound cleanser that comes in 3 sodium hypochlorite percentages (strengths), 0.125 % (quarter strength), 0.25% (half strength) and 0.50% (full strength).
Review of Resident #129's July 2023 TAR revealed a 7/21/23 order to cleanse the resident's sacral pressure wound with Dakins solution and cover with Dakins moist wet to dry, cover with dressing twice daily two times a day, d/c'd 7/27/23. The NP recommendation was to cleanse the wound with NS. The transcribed order stated to cleanse the wound with Dakins solution. The order was not accurately transcribed as prescribed by the NP.
1.3) On 7/27/23 at 12:06 PM, in a Skin and Wound Note, the NP documented Resident #129's sacral pressure wound was worsening. The NP's treatment order recommendation for Resident #129's sacral pressure wound was to cleanse with the wound with Dakin solution 0.125%, apply medical grade honey to base of wound, secure with bordered foam, and change daily.
Review of Resident #129's July 2023 TAR revealed a 7/27/23 order to cleanse sacral wound with Dakins solution and apply Medihoney and cover with dressing daily, which was documented as done from 7/27/23 to 7/31/23. The resident's August 2023 TAR revealed the order was documented as done from 8/1/23 to 8/11/23 then discontinued. The order was transcribed inaccurately as the order failed to indicate the strength of the Dakins solution as prescribed by the NP.
1.4) On 8/10/23 at 12:09 PM, in a Skin and Wound Note, the NP documented Resident #129's unstageable sacral pressure wound was worsening with NP order recommendation for Resident #129's sacral wound pressure wound was to cleanse with the wound with Dakin solution 0.125%, apply Dakins moistened fluffed gauze to base of the wound, secure with bordered foam, and change the dressing two times a day (BID).
Review of Resident #129's August 2023 TAR revealed an 8/11/23 order cleanse sacral wound with Dakins Solution, moist to dry, cover with dressing daily, one time a day, that was documented as done one time a day from 8/12/23 to 8/24/23 and discontinued on 8/26/23. The order failed to indicate the strength of the Dakins solution as prescribed by the NP. In addition, in the TAR, the treatment was inaccurately ordered to be done once a day, not twice a day as prescribed by the NP.
1.5) Following Resident #129's initial visit with the wound NP, on 6/15/23 at 3:01 PM, the NP documented that Resident #129 had new pressure induced deep tissue damage of the sacral region and recommended a low air loss (LAL) mattress (distributes body weight over broad surface and help prevent skin breakdown). In addition, further review of the wound NP visit notes revealed the NP recommended an LAL mattress for Resident #129 on 6/22/23, 6/29/23, 7/6/23 and 7/13/23, indicating a LAL mattress had not been provided to Resident #129. On 7/2023 at 12:09 PM, in a skin a wound note, the NP indicated Resident #129 was on a LAL mattress.
Review of Resident #129's physician orders revealed an order to apply an air loss mattress every shift to prevent skin breakdown with an order date of 6/15/23, and a created on 8/21/23, indicating the order was transcribed to the resident's electronic medical record on 8/21/23.
Review of Resident #129's TARs for June, July and August 2023 was conducted. Resident #129's June 2023 TAR review failed to reveal documentation to indicate that a LAL mattress had been provided to Resident #129 in June. The resident's July 2023 TAR review revealed an order to apply air loss mattress every shift to prevent skin breakdown that had an order date of 6/15/23, however, there was no documentation in the TAR to indicate the order had been implemented, and there was no other documentation in the TAR to indicate the resident received a LAL mattress in July. Resident #129's August 2023 TAR review revealed an 8/18/23 order to apply air loss mattress every shift to prevent skin breakdown, which was signed off as done on 8/18, 8/19, 8/21/2023 then d/c'd, and an order dated 6/15/23, was signed off for 4 days, 8/21, 8/22, 8/23, 8/24/2023 then d/c'd.
Review of Resident #129's care plans revealed a care plan, initiated on 7/6/23, with the focus: Resident #129 has pressure ulcer to the sacrum r/t Immobility, with the goal, Resident #129's pressure ulcer will show signs of healing and remain free from infection by/through review date, that included the intervention Air loss mattress to bed for air distribution and prevent skin breakdown and promote wound healing.
Further review of the medical record revealed that, on 7/13/23 at 12:56 PM, in a Care Plan Note, the nurse documented Resident #129 had a sacral DTI (deep tissue injury) and an air loss mattress had been provided to the bed for air distribution and prevent further skin breakdown.
On 11/1/23 at 8:46 AM, during an interview, Staff #3, RN, Unit Manager, stated the Unit Managers accompanied the NP during resident wound care visits. Staff #3 stated that when the NP made a wound treatment recommendation, the process would be to change the wound treatment orders in the medical record to match the NP's recommendations. Staff #3 indicated the orders would be changed and implemented once the wound NP's written report was received, which was at the end of the day, or the next day. Staff #3 indicated that LAL mattresses were usually available in the facility, that when an order for a LAL mattress was received, a work order would be sent to maintenance, and maintenance would apply the LAL to the resident's bed. Staff #3 indicated that if a wound was identified on a resident, the first process would be to provide a low air loss mattress. When asked if h/she could recall when Resident #129 received a LAL mattress following the NP's recommendation on 6/15/23, Staff #3 stated the LAL mattress would have been applied to the resident's bed immediately. When made aware that the wound NP recommended a LAL mattress for Resident #129 on 6/15/23, 6/22/23, 6/29/23, 7/6/23 and 7/13/23, with no documentation to indicate the resident received a LAL mattress except for the care plan note in mid-July 2023, Staff #3 stated that an LAL mattress had been applied to Resident #129's bed following the wound NP's initial recommendation, and that h/she just forgot to transcribe the NP's order into the resident's medical record. When asked why, if Resident #129 had a LAL mattress, the NP continued to recommend one, Staff #3 indicated that anytime the NP came into the resident's room, the NP saw the LAL mattress on the bed and indicated that the some of the NP's documentation just rolled over in the NP visit notes.
On 11/1/23 at 12:27 PM, during an interview, Staff #29, Maintenance Director, indicated that when a resident had an order for a low air loss mattress, the nursing would put the request in TELS (building management platform) and maintenance would provide one. Staff #29 stated that the LAL mattress would generally be applied to the resident's bed within a couple of hours of receiving the request as LAL mattresses were usually available. At that time, Staff #29 stated that h/she would provide the surveyor with documentation of when a LAL mattresses for Resident #129 was requested in TELS. On 11/1/23 at approximately 1:25 PM, Staff #29 provided a printed copy of a work order created on 7/13/23 at 11:30 AM that had Air loss mattress to room [ROOM NUMBER] B bed due to sacral wound printed on the page, and included an updated status that indicated that the work order was completed 7/13/23 at 4:45 PM.
The above concerns were reviewed with the Director of Nurses (DON) on 11/1/23 at 5:14 PM. When made aware that of the wound care orders for Resident #129 that were not accurately transcribed, resulting in the resident not receiving wound care as prescribed, the DON stated that treatment orders should be transcribed exactly as written by the practitioner, including the strength of the Dakin Solution. The DON stated that treatment orders with Dakin Solution should be sent to the pharmacy, and the pharmacy would provide the prescribed strength of the Dakin Solution and when a prescriber's order the does not include the strength then full strength Dakin Solution would be used. The DON also stated that they realized that the nurse failed to correctly transcribe the orders as written by the provider and the same nurse had transcribed Resident #129's treatment orders. The DON stated that the transcribing nurse was disciplined and educated to transcribe orders as written by the provider.
At that time, the DON was also made aware of the that a LAL mattress had not been provided timely for a resident with a sacral pressure wound when recommended by the wound NP, that the concerns with the orders in the medical record that did not accurately reflect when an LAL mattress had been applied to the resident's bed. The DON offered no further comments at that time.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to prevent a vulnerable resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to prevent a vulnerable resident who was assessed, and care planned as an elopement risk, from leaving the facility grounds unattended for an unknown amount of time. This was evident for 1 (#136) of 4 residents reviewed for accidents.
The findings include:
Elopement occurs when residents who are incapable of protecting themselves from harm are able to successfully leave the facility unsupervised and unnoticed and possibly enter into harm's way.
1) On 10/16/23 at 8:42 AM, a review of Resident #136's medical record revealed the resident was admitted to the facility in August 2020, with diagnoses that included schizoaffective disorder (bipolar type) and schizophrenia. Resident #136's admission assessment with an Assessment Reference Date (ARD) of 8/23/20 and quarterly assessment with an ARD of 11/23/20 documented Resident #136 had a Brief Interview of Mental Status (BIMS) score of 8, indicating the resident was mildly cognitively impaired. The medical record review revealed two Physician Certifications Related To Medical Condition, Substitute Decision Making, And Treatment Limitations. One, dated 8/17/20, stated Resident #136 was incapable of making an informed decision regarding all medical decisions, and the diagnosis or reason for the incapacity was dementia, and schizophrenia with poor cognition. The other was dated 8/19/20 and stated the resident was incapable of making an informed decision regarding all medical treatments and the reason for incapacity was schizoaffective disorder, bipolar type/poor cognition. Resident #136 no longer resides in the facility after being transferred to another facility in November 2022.
Further review of the medial record revealed that on 9/29/21, Resident #136 exited the facility without supervision. In a brief synopsis of change note on 9/29/21 at 6:06 PM, Staff #13, LPN documented that Resident #136 was found on top of the hill on the left side of the facility where there were houses and when the writer asked why the resident was going in that direction, Resident #136 stated s/he was going to visit the resident's sister. The nurse documented an elopement watch every 15 minutes was initiated and the resident was not to go outside the building.
The medical record review revealed a wanderguard (tracking device) bracelet was ordered on 9/30/21. In addition, an elopement care plan was added on 9/30/21: Resident #136 is an elopement risk/wanderer AEB (as evidenced by) history of attempts to leave facility unattended, with the goal, Resident #136's safety will be maintained in the facility through her next review date, which had the interventions Document wandering behavior, Identify wandering patterns,, and Wander Alert in place; monitor for placement and function.
On 10/17/23 at 8:57 AM, the surveyor asked the Nursing Home Administrator (NHA) if the resident's elopement had been investigated and reported to the Office of Health Care Quality (OHCQ), the State Survey Agency. NHA responded that when the incident occurred, he was not the facility's administrator and would try to find out.
On 10/17/23 at 12:55 PM, Staff #5, [NAME] President (VP) of Operations, and previous NHA, reported to the surveyor that he was Corporate at the time of the incident, and could not recall the events of the Resident #136's elopement on 9/29/21, or whether the incident had been investigated or whether the elopement would have been reported to the State Agency if the resident hadn't left the property. Staff #5 stated that he had reviewed progress notes, searched emails, and requested access to the previous Director of Nurses (DON) emails, and that a facility report of the incident had not been found.
On10/23/23 at approximately 3:45 PM, during an interview, Staff #13, LPN, stated s/he thought Resident #136's elopement on 9/29/21 happened at the end of the day shift. Staff #13 stated when s/he arrived on the floor for the evening shift, the resident was in his/her room. Staff #13 recalled the nurses told Staff #13 in report that Resident #136 had left, and someone brought the resident back to the facility. Staff #13 could not recall which nurse gave him/her report, who found and returned the resident, or who reported the incident and stated that the reporting nurse didn't say much, just that the resident had been going up the hill on the street. Staff #13 stated that Resident #136 was angry when brought back to the facility, and wouldn't let staff interview them, however when Staff #136 spoke with the resident, the resident was calm, and when asked what happened, the resident said s/he wanted to speak to their sister. Staff #13 stated when going to write a note in Resident #136's electronic medical record (EMR), no documentation about Resident #136's elopement was found in the EMR, which Staff #13 reported to the evening shift supervisor who then told Staff #13 to complete a Change in Condition (COC) in the EMR. Staff #13 stated s/he completed the COC with the details of Resident #136's elopement that were provided to him/her in report and did not know who created the resident's elopement care plan.
On 11/01/23 at 4:36 PM, during an interview, when asked what the nurse recalled about Resident #136's elopement, Staff #41, LPN, Supervisor recalled the incident happened at the end of day shift, and that there had been no documentation about the resident's elopement in the medical record. Staff #41 indicated h/she directed the evening shift nurse (Staff #13) to document the elopement in the medical record, and that, in order to document the incident, the nurse documented what s/he was told in report.
Continued review of Resident #136's medical record failed to reveal evidence that an investigation into Resident #136's elopement on 9/29/21 had been conducted. On 11/03/2023 at 3:20 PM, the above concerns were reviewed with the NHA, and no additional information to indicate an investigation had been completed was provided to the surveyor as of the time of exit on 11/3/23 at 4:00 PM.
2) On 10/17/23 at 9:00 AM, a review of facility reported incident MD00175135 documented that on 12/19/21 at approximately 2:15 PM, Resident #136 was observed by staff wheeling herself in the neighborhood around the facility. In a handwritten statement, Staff #14, Dining Services, documented s/he observed Resident #136 at an intersection which was approximately 0.9 miles from the facility.
The facility's investigation indicated Resident #136 was not identified as missing from the facility, until the resident was observed in the community by the staff person.
The facility's self-report documented that Resident #136, accompanied by Staff #16, Activity Aid, was let out of the front of the building by Staff #15, who had not heard the resident's wanderguard alarm. Staff #16, then returned to the inside of the building, leaving Resident #136 outside and unattended by staff, resulting in Resident #136 wandering away from the facility property. The self-report concluded that it was the individual error of the 2 employees who were temporarily unaware or distracted of the risk for exiting that the resident posed which resulted in Resident #136's elopement from the facility.
Review of the witness statements revealed, that during the facility's investigation, a statement had been obtained from Staff #15, however, there was no evidence that a statement had been obtained from Staff #16, to indicate why the resident was left outside unattended.
The facility's investigation did not indicate the time Resident #136 was left outside of the facility unattended or how long the resident was missing before s/he was found. The investigation included inservice attendance logs for elopement training following the incident. Neither staff member #15 nor #16 were listed on the logs.
Based on the investigation, Resident #136 was not identified as missing until an employee observed the resident, who was unaccompanied by a staff member, at intersection approximately 0.9 miles from the facility. The intersection of the roads where the resident was located included a divided highway.
On 10/17/23 at 3:00 PM, Resident #136's medical record was reviewed again. The record revealed a change in condition progress note, dated 12/19/21 at 10:54 PM. The progress note stated, Resident was observed by staff wheeling themselves towards the neighborhood adjacent to the facility, was brought back to the facility and assessed. No injury noted. Resident said they were trying to get a cab to go home. Resident was redirected to their room and placed on one-to-one observation until cleared.
Dining Services Staff #14 was interviewed on 10/18/23 at 1:00 PM. During the interview, Staff #14 stated that s/he was the staff member who had found Resident #136 during the resident's 12/19/21 elopement. Staff #14 stated s/he saw the resident wheeling along in his/her wheelchair about one mile away on Georgia Avenue, a busy multi-lane divided highway with dense traffic patterns in an [NAME] setting.
During an interview on 10/18/23 at 3:25 PM, Receptionist, Staff #15 stated that s/he did not recall being aware Resident #136 was an elopement risk at the time the resident was left outside. Staff #15 also stated that s/he did not recall the resident's wanderguard alarming when the resident was escorted outside by Staff #16. Staff #15 stated s/he would know that a resident was an elopement risk, because there were pictures of the residents at the front desk, and an elopement notebook at the front desk and on every unit. Staff #15 also stated that residents who are elopement risks would have wanderguard, and when the resident was taken outside, the system would alarm.
The Activities Director, Staff #21 was interviewed on 10/19/23 at 8:55 AM. During the interview, Staff #21 stated that s/he was unaware that Activity Aide #16 was involved in Resident #136's elopement on 12/19/21. When asked how s/he becomes aware of which residents are elopement risks, Staff #21 stated that s/he attended morning meetings and that residents who were an elopement risk were discussed then. Staff #21 stated that the only residents in the facility who were elopement risks were residing on the secured unit (3A, Memory Garden). Staff #21 recalled that Resident #136 would often remove his/her wanderguard bracelet, and s/he had the habit of checking the resident's wheelchair anytime s/he saw Resident #136 to ensure the wanderguard was still in place.
The [NAME] President of Operations (Staff #5), who was the administrator at the time of the above incident, was interviewed on 10/19/23 at 12:20 PM. During the interview, Staff #5 stated that Staff #16 should have known that Resident #136 was an elopement risk. When asked how Staff #16 would know the resident was an elopement risk, Staff #5 stated that there was an elopement book at the front desk that would have had Resident #136's picture in it and that Staff #16's supervisor (the Director of Activities, Staff #21) would communicate that with staff. During the interview, Staff #5 also stated that the facility had no current residents that were an elopement risk who were not on the locked unit (Unit 3A, Memory Garden).
Further review of the facility's self-report for this elopement revealed the statements Re-education of receptionists / front desk staff of residents for risk of exiting the building monthly, Counseling / disciplinary action process is being performed for [Staff #15] and [Staff #16] by their department heads or Administrator, and Quarterly education for receptionists and Activity staff is included as part of our plans of correction. None of this education or disciplinary action were provided to the survey team. Staff #15 and #16's employee and education files were reviewed on 10/20/23 at 11:00 AM. The review failed to reveal any evidence that either staff received any of the above education.
On 10/20/2023 12:54 PM, the NHA was made aware that the facility failed to thoroughly investigate Resident #136's elopement on 12/19/21, that there was only one staff interview, that no interview was obtained from the Activity Aide (Staff #16) implicated in the elopement, that when interviewed, the Activity Director indicated s/he was unaware of that one of his/her activity staff had been implicated in the elopement and there was no evidence in the facility's investigation to support that either staff was implicated.
On 10/20/23 at 1:10 PM, the Activities Director, Staff #21, along with the NHA, were interviewed. During the interview, the Staff #21 stated s/he became aware of Resident #136's elopement when s/he had received a call, however, s/he did not know that Staff #16, Activity Aide had been implicated. Staff #21 stated that Resident #136 was in activities just about all the time, and the activity staff knew the s/he was a wander risk. Staff #21 stated that following the incident, that s/he could not recall being told to re-educate his/her staff about staying with the residents when outside, but now that s/he knows, s/he would re-educate the activity staff about staying with the resident.
At that time, during the interview, the Nursing Home Administrator stated that he could not confirm that it was an activity staff member who left Resident #136 outside unattended.
Activity Aide, Staff #16, was interviewed on 10/20/23 at 1:46 PM. During the interview, Staff #16 stated that s/he became aware of Resident #136's elopement when s/he came to work, that the elopement had not occurred while Staff #16 was in the facility, and that s/he had never left Staff #136 alone outside. When asked if s/he received any training following Resident #136's elopement, Staff #16 stated that s/he could not remember having any elopement training following the resident's elopement.
3) On 10/17/23 at 9:00 AM, a review of facility reported incident MD00177224 documented that on 4/17/22, at approximately 10:00 PM, Resident #136 was noted to be missing from the facility, that the resident was found by the police at approximately 1:15 AM. The resident was picked up by the regional administrator and returned to the facility. The facility's self-report did not identify where the resident was located.
At that time, a review of Resident #136's medical record revealed a progress note, dated 4/19/22. that indicated Resident #136 had eloped from the facility during the night. The note stated that Resident #136 was determined to be missing at 10:30 PM, that supervisory and administrative staff were notified, and that the police were called. The note stated that the resident was returned to the facility with no apparent injury around 1:30 AM the next morning.
On 10/17/23 at approximately 1:00 PM, Staff #5, [NAME] President (VP) of Operations, and previous NHA, stated that Resident #136 was located near an intersection, outside a tavern, near a bus stop in a nearby community. Staff #5 indicated that someone from the tavern reported seeing the resident to the police and Staff #5 picked the resident up and returned him/her to the facility. Review of a map revealed the intersection where Resident #136 was located included 2 major divided roadways located approximately 3 miles from the facility.
A review of Resident #136's medical record revealed a progress note, dated 4/19/22 that indicated Resident #136 had eloped from the facility during the night. The note stated that Resident #136 was determined to be missing at 10:30 PM, that supervisory and administrative staff were notified, and that the police were called. The note stated that the resident was returned to the facility with no apparent injury around 1:30 AM the next morning.
Review of the witness statements included in the facility's investigation revealed, a statement had been obtained from the Staff #18, the GNA who reported the resident missing, and Staff #22, the nurse who was assigned to the resident that night. There was no other evidence that any statements were obtained from residents or from any other staff who had on the nursing unit that night. Further review of the facility's self-report revealed that the facility was unable to determine how the resident eloped that night, although the investigation expressed the opinion that the resident probably followed a visitor out of the front door.
Staff #18, Geriatric Nursing Assistant (GNA) was interviewed on 10/19/23 at 7:30 AM. During the interview, Staff #18 stated s/he heard the wanderguard alarm at the start of his/her break on 4/19/22, could not locate Resident #136 in his/her room, and notified the supervisor. Staff #18 stated that Resident #136 was known to be an elopement risk an at the time of the resident's elopement, there was no receptionist at the front desk as it occurred during the night.
In response to this incident, the facility implemented the intervention to schedule a receptionist 24 hours a day. This was confirmed by observation during the survey and review of employee schedules. During an interview with the Director of Maintenance at 10/20/23 at 10:15 AM, the Director stated that no cameras in the facility were operational, and he knew of no way to search for footage from the times of the elopements.
The above concerns with the facility's failure to prevent a vulnerable resident from exiting the facility, unsupervised, and failing to thoroughly investigate previous elopements and implement adequate measures to prevent further elopements were discussed with the NHA and Staff #5, VP of Operations at 11/3/23 at 3:20 PM. At that time, both the NHA and Staff #5 expressed understanding of the concerns.
Cross Reference F610.
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
Based on review of resident medical record and interview with facility staff, it was determined that the facility failed to promptly address a resident's significant weight loss. This was evident for ...
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Based on review of resident medical record and interview with facility staff, it was determined that the facility failed to promptly address a resident's significant weight loss. This was evident for 1 (Resident #132) of 6 residents reviewed for nutrition. The findings include:
Resident #132's medical record was reviewed on 11/1/23 at 12:37 PM. The review revealed that the resident had been admitted to the facility in July, 2021, and was discharged from the facility to the hospital in October, 2021. The resident did not return from the hospital.
Review of the resident's weights revealed the following weights:
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7/2/21, 9:06 PM: 190.8 lbs
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7/3/21, 12:27 PM: 190.7 lbs
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7/9/21, 2:51 PM: 190.7 lbs
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7/16/21, 2:43 PM: 190.7 lbs
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7/30/21, 5:15 PM: 156.7 lbs
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8/3/21, 11:19 AM: 156.4 lbs
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8/5/21, 12:39 PM: 156.8 lbs
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8/6/21, 3:53 PM: 156.5 lbs
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9/9/21, 12:03 PM: 146.6 lbs
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9/10/21, 12:06 PM: 146.6 lbs
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9/22/21, 11:02 PM: 146.8 lbs
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9/23/21, 2:09 PM: 146.8 lbs
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9/29/21, 11:48 AM: 146.7 lbs
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10/6/21, 2:18 PM: 144.3 lbs
These weights demonstrated that a significant weight loss (of greater than 5% of the resident's body weight within 30 days) occurred between 7/16/21 and 7/30/21. The weight change was 34 lbs or 17.9% of the resident's weight and had been confirmed by three follow-up weights (on 8/3/21, 8/5/21, and 8/6/21).
Ongoing review of the resident's medical record revealed an admission nutrition note, dated 7/5/23, that stated the resident's usual weight prior to admission was 230 - 235 lbs and that the resident's admission weight of 190.8 lbs already represented severe and unintended weight loss of unknown reason. That was before the facility had documented an additional weight loss between 7/16/21 and 7/30/21. Further review revealed that the first nutrition note written after the facility's documented weight loss (on 7/30/21) was dated 8/30/21, more than 30 days later. This follow-up nutrition note referred to the additional 34 lbs loss as severe but intended and favorable, despite the resident's prior weight loss being described as unintended from an unknown cause.
Review of the medical record (including nursing progress notes and change in condition evaluations) failed to reveal any evidence that Resident #132's attending physician had been notified of the 34 lb weight loss prior to 8/30/21.
Review of physicians order for the resident show that there were no changes to the resident's dietary and nutrition orders following the resident's 34 lbs weight loss on 7/30/21. The first change to the resident's dietary and nutrition orders occurred on 9/13/21 after the resident was documented as having lost another 10 lbs between 8/6/21 and 9/9/21. The order on 9/13/21 was for 60 milliliters of Liquid Protein supplement to be given three times a day for wound healing.
On 11/3/23 at 8:30 AM, the Director of Nursing (DON) was interviewed and confirmed the significant weight loss that occurred for Resident #132 between 7/15/21 and 7/30/21. The DON stated that she would investigate what occurred and would respond to the surveyors.
On 11/3/23 at 10:20 AM, the DON was interviewed again. The DON stated that she had found the same nutrition notes and dietary orders as the survey team had. The DON couldn't show any evidence that the weight loss was reviewed prior to 8/30/21 or that any interventions were put into place prior to 9/13/21. The first medical provider note that the DON could find that addressed the weight loss was dated 10/8/21. That provider note stated that the resident had lost 24% of his/her body weight since admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, it was determined that the facility failed to provide appropriate treatment and services to residents receiving tube feedings. This was evident for 2 (Resident ...
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Based on record reviews and interviews, it was determined that the facility failed to provide appropriate treatment and services to residents receiving tube feedings. This was evident for 2 (Resident #96, #80) of 2 residents reviewed for tube feeding. The findings include:
1) Resident #96 had been residing in the facility since 2022 and received g-tube feedings for increased nutrition.
a) On 10/16/23 at 10:56 AM, Resident #96's medication administration record (MAR) for the month of July revealed two separate and different orders for tube feeding (TF):
One time a day, Glucerna 1.5 @ 55 ml/hr x 12 hours, starts at 6 pm and ends at 6 am or until total volume is diffused. (order date 7/11/23, D/C date 7/20/23)
Every evening and night shift, Glucerna 1.5 @75 ml/hr x 12 hours/day; up at 6 pm and down at 6 am or until 900 ml have infused. (order date 5/4/23, D/C date 7/20/23)
From 7/11/23 - 7/20/23, the staff was documenting that the resident was receiving both these feedings. The resident was sent to the hospital on 7/20/23.
On 10/17/23 at 9:43 AM, the 2nd floor unit manager (UM, Staff #3), a registered nurse (RN), was interviewed about the process when the facility admits a resident that receives tube feedings. The UM stated that the Registered Dietician (RD) comes in and decides what type of feeding, amount, how long it should run, when to start and stop the feeding, and how much flush is needed.
On 10/17/23 at 9:58 AM, the DON (staff #2) was interviewed and verified the information given by the UM. The DON indicated that if there is a change in residents' enteral feeding orders, the RD is the one who would put it in the computer.
On 10/18/23 at 1:00 PM, the Registered Dietician Eligible (RDE staff #28) was interviewed about her process, and she reported that, when she determines the caloric need of the resident, she puts the order in as to what kind of enteral feeding, rate of administration, and the run time of the tube feeding. Then, it is discussed with the physician during morning meetings to get their approval. In the same manner, if she determines that a change in the order is necessary, she would put the new order in so the physician can see and compare, and then authorize the change. The RDE staff #28 stated that she was not sure what happened but confirmed that, from July 11th up to the 20th, Resident #96 had 2 different orders for enteral nutrition, and both were being signed by the nurses.
On 10/23/23 at 10:08 AM, the Medical Director (Staff #31) was interviewed specifically about tube feeding and the process when a change in the order is needed. The Medical Director reported that when the RDE (staff #28) recommends a change, they would usually discuss it in their risk meeting where the RDE would show her the intakes to see if she agrees with the recommendation or not. Then, the RDE (staff #28) would implement the change and put the new order in.
b) There are risks associated with residents using feeding tubes for nutrition. These risks include: aspiration (accidentally inhaling your stomach contents), accidental dislodgement (tube moving out of place or coming out), bleeding and perforation (hole in the wall of your bowel or intestine), infection near the site, pain, and stomach leakage to name some. Appropriate treatment and services are required to prevent complications of enteral feeding.
Further review of the medical record revealed that, prior to the hospitalization in July, the resident had the following orders related to the resident's g-tube: 1) Cleanse feeding tube site daily. Apply clean drain daily. 2) Change spike set with each new bottle. 3) Change flush syringe every 24 hours. 4) Change tubing and feeding bag every 24 hours. 5) Check residual every 8 hours; if greater than 100ml, hold TF for 1 hour, and recheck. If residual remains greater than 100ml, notify physician. 6) Check feeding tube placement with auscultation every shift and as needed. 7) elevate the head of bed 30-40 degrees at all times during feeding and for 1 hour after feeding is complete. 8) Flush tube feeding with 50 ml water before and after administering medications. Flush with 5 ml water in between each medication
On 10/16/23 at 11:36 AM, further review of the medical records revealed when Resident #96 was readmitted after the July hospitalization, the facility did not re-establish the above orders related to the use of the g-tube. No documentation was found to indicate that the g-tube site was being cleaned daily, that the tubing was being changed or that the staff was checking for residual on a regular basis.
On 10/17/23 at 9:00 AM, review of the care plan revealed a care plan was initiated on 10/12/23 related to the g-tube and the resident's risk for aspiration. There was only one intervention found for this particular care plan: Follow GT protocols and orders as indicated.
On 10/17/23 at 9:43 AM, the UM reported that the facility has a policy regarding tube feeding.
Review of the facility policy for Gastrostomy Site Care, with an implemented date of 12/14/22, revealed: It is the policy of this facility to perform gastrostomy site care as ordered and per current standards of practice. The first step in the guidelines is to verify there is a physician order for gastrostomy site care.
During the 10/17/23 interview, the UM also stated that when a new admission is identified as a resident with a G-tube, their computer system has a batch order which carries over the facility's G-tube protocol in the resident's orders. If there was anything in the batch order that was not appropriate for the care of the specific resident, the nurse entering the order would manually uncheck it from the list of batch orders. Because of this process, the UM stated that it is his expectation that a resident with a G-tube would have orders for care and treatment of feeding tubes.
On 11/03/23 at 12:30 PM, surveyor reviewed with the Director of Nursing (DON) the concern that the resident was found having two different tube feeding orders and staff were documenting as administering both, and that orders for G-tube care were not re-established when the resident was readmitted to the facility. The DON (staff #2) did not provide any additional information or documentation regarding these concerns prior to survey exit at 4:15 PM.
2) Resident #80 is a long-term care resident admitted in 2021 and requires tube feeding for nutrition.
On 10/18/23 at 9:18 AM, Resident #80's medication administration records (MAR) for October was reviewed and revealed an order, in effect since 9/29/21, to: Check every shift for residual and record. The order also included HOLD feeding if greater than ____cc (area of order noted to be blank), and notify the physician.
Residual refers to the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding. Checking and knowing how much the residual is, can reduce the risk of aspiration.
This order was being marked as complete by the nurses. On the same day at 10:14 AM, further review of Resident #80 's medical records failed to reveal documentation of the amount of residual that the nurses were obtaining.
On 10/18/23 at 12:03 PM, the licensed practical nurse (LPN staff #27), who was assigned to the resident, was interviewed. She reported about the measures she takes before administering medication to the resident and the care she provides to the G-tube site. LPN staff #27 also stated that she checks the resident for residual before starting an enteral feeding. The LPN was asked by the surveyor if she documents the amount of residual. The LPN staff #27 started looking at the order for Resident #80 and confirmed that the order was incomplete as it did not specify the amount at which they were supposed to hold the feeding and notify the physician. She also confirmed in this interview that there is no place to document the residual amount in the resident's MAR, and that is why the nurses just mark it as completed.
On 11/03/23 at 12:30 PM, surveyor reviewed with the DON the concern that nursing staff was failing to follow a physician's order to record the amount of residual every shift and failed to clarify the order in regard to what amount of residual the physician would need to be notified. The DON (staff #2) did not provide any additional information or documentation regarding these concerns prior to survey exit at 4:15 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 F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on review of pertinent documentation and interviews, it was determined that the facility failed to provide documentation of peritoneal dialysis (PD) training to their nursing staff prior to the ...
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Based on review of pertinent documentation and interviews, it was determined that the facility failed to provide documentation of peritoneal dialysis (PD) training to their nursing staff prior to the staff providing care to residents receiving PD treatment. This was evident for 2 (Resident #138 and # 130) out of 4 residents reviewed for dialysis during the survey. The findings include:
1. On 10/16/23, a review of Intake #MD00175057 revealed a concern regarding the peritoneal dialysis administration and care provided to Resident # 138.
Peritoneal dialysis is a treatment for kidney failure, a condition where the kidneys are no longer able to filter blood well enough . Because peritoneal dialysis works inside the body, it's different from a more-common procedure to clean the blood, called hemodialysis. That procedure filters blood outside the body, in a machine. Peritoneal dialysis treatments can be done at a long-term care facility and at home.
On 10/19/23 at 3:13 PM, the second-floor evening unit nurse manager (staff #41) was interviewed. He reported that residents were administered PD treatments in the evening and the night shifts. He reported that he provided supervision for the residents that were administered PD treatments. During the interview he stated that the nurses that provided PD care were required to be trained by DaVita healthcare company prior to providing PD care to the residents.
Further review of Intake MD00180086 on 10/16/23 revealed a concern with the administered PD treatment and care of Resident #138 from 11/19/21 through 12/28/21. Review of the treatment administration record (TAR) of Resident #138 on 10/24/23 at 10:10 AM revealed the following:
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Nursing Staff #47 documented that he/she administered PD treatment for Resident #138 on the night shift of 12/4/21 and 12/18/21.
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Nursing Staff #48 documented that he/she provided PD treatment for Resident # 138 on the evening shift of 12/19/21 and 12/15/21.
On 10/23/23, the PD educational training for Staff # 47 and Staff #48 was requested. The staff development coordinator could not produce any documentation that Staff # 47 and Staff #48 had received PD training. The Director of Nursing (DON) reported that she had contacted the training company DaVita and they were unable to provide any additional training documentation for Staff #47 and #48.
2. On 10/16/23, a review of intake #MD00180086 revealed a concern regarding the peritoneal dialysis administered and care provided to Resident #130.Further review of Intake # MD00175057 revealed a concern for PD care and administered from 4/2/22 to 4/5/22. Review of the TAR on 10/24/23 at 8:07 AM revealed the following:
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Nursing Staff #13 documented that he/she provided PD treatment for Resident #130 on 4/4/22 and 4/6/22.
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Nursing Staff #42 documented that he/she provided PD treatment for Resident #130 on 4/2/22 and 4/3/22.
However, on 10/23/23 the staff development coordinator provided documentation that both staff #42 and staff #13 received their PD training on 4/19/22 after they already provided PD care to Resident # 130.
On 10/23/23 at 3:08 PM, during an interview with the Regional Director of Clinical Services, she reported that she was unable to provide any additional information or documentation regarding the PD training for the staff listed above.
On 11/03/23, the Director of Nursing provided the Peritoneal Dialysis policy implemented on 12/14/22. Review of the policy revealed that the facility will ensure that staff who perform peritoneal dialysis in the nursing home are trained and qualified and receive training and competency from a qualified dialysis trainer from a certified dialysis center. Further review of the policy revealed that the facility will maintain documentation of completion of competency/training for staff or other individuals providing the dialysis treatment.
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 F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
3) On 10/23/23 at 9:03 AM, during medication administration for Resident # 34, it was observed that two blood pressure medications were not administered by staff # 45, a licensed practical nurse (LPN)...
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3) On 10/23/23 at 9:03 AM, during medication administration for Resident # 34, it was observed that two blood pressure medications were not administered by staff # 45, a licensed practical nurse (LPN), who stated she held the blood pressure medications because Resident # 34's blood pressure reading was low.
Low blood pressure occurs when blood flows through your blood vessels at lower-than-normal pressures. Normal blood pressure is usually less than 120/80 mm Hg for most adults. Low blood pressure is blood pressure that is lower than 90/60 mm Hg for some.
Systolic blood pressure is the top blood pressure. It refers to the amount of pressure in the arteries during the heart muscle contraction.
On 10/23/23 at 12:21 PM, a review of Resident #34's medical record revealed the attending physician's orders dated 12/1/22 for two blood pressure medications to be given daily for high blood pressure. The physician's order did not state any parameters at which the medications were to be held.
A continued review of Resident #34's medical record showed a medication administration record for October 2023. The record documented that Resident # 34's blood pressure medications were not administered for twelve days in October. However, the review failed to show that the attending provider was notified of the change in condition on 10/2, 10/7/23, 10/16/23, 10/17/23, and 10/19/23 when the medications were held.
On 10/23/23 at 1.00 PM, during a review of the vital signs section of the facility's medical record, documented blood pressures were noted for Resident # 34. However, the blood pressure was not taken every day, and there was no correlation between when the blood pressure was taken and when the medication was administered.
On 10/23/23 at 1:39 PM, during an interview with staff #45, she checked the facility's electronic medical record in the presence of surveyor. She confirmed that no parameters for Resident # 34's blood pressure medications were entered with the attending provider's orders for the blood pressure medications. The orders did not state to hold the medications.
During continued interview, staff # 45 stated that she would usually hold blood pressure medications for all residents when the systolic blood pressure (SBP) was less than 110 mmHg (millimeters of mercury) per facility policy. Staff # 45 also stated she notified the attending provider every time Resident # 34's blood pressure was less than 110mmHg.
On 10/23/23 at 2:10 PM, during an interview with staff # 20 (LPN), she stated that she would use her nursing judgment to hold a blood pressure medication if a resident's SBP was less than 110mmHg. Staff # 20 said she would notify the attending provider about low SBP.
On 10/23/23 at 3:15 PM, during an interview with staff # 32, Regional Director of Clinical Services, she stated that the facility did not have a policy for blood pressure parameters but followed the attending provider's orders for blood pressure medications.
On 10/23/23 at 4:38 PM, staff # 32 stated that Resident # 34's attending provider was notified of concerns with Resident # 34's blood pressure medications, and adjustments were made after surveyor's intervention.
2) Resident #112's October Medication Administration Record (MAR) was reviewed on 10/23/23 at 2:36 PM. The October, 2023, MAR revealed that Resident #112 had an active order for Dilaudid, 4mg, to be given every 6 hours as needed for pain levels between 8-10 on a 10-point scale. The MAR showed that the resident received 10 doses of as-needed Dilaudid in October, 2023. 7 of the 10 doses were administered for documented pain scores of less than 8:
- 10/3/23, 12:50 PM: administered for a pain score of 2
- 10/5/23, 6:17 PM: administered for a pain score of 3
- 10/16/23, 4:27 AM: administered for a pain score of 5
- 10/23/23, 2:40 PM: administered for a pain score of 4
- 10/25/23, 1:32 PM: administered for a pain score of 5
- 10/26/23, 2:14 PM: administered for a pain score of 6
- 10/30/23, 1:32 PM: administered for a pain score of 0
Ongoing review of the medical record failed to reveal any progress notes or pain evaluations that documented pain scores between 8 - 10 around the time of any of these administrations.
On 11/2/23 at 2:00 PM, the Director of Nursing (DON) was shown the seven administrations of Dilaudid for Resident #112 that were given for pain scores lower than 8. The DON confirmed that all of these administrations had been given for documented pain scores outside of the parameters of the physician's order.
Based on medical record review and staff interview it was determined the facility staff failed to: 1) ensure that orders for medication included an accurate route of administration, 2) ensure orders had adequate parameters to indicate when to administer as needed medicationsfor constipation, 3) ensure that residents were not given as-needed pain medication outside of a medication's parameters, and 4) ensure a resident received medication according to an attending physician's orders. This was evident for 2 (#79, #112) of 7 residents reviewed for unnecessary medications and 1 (#34) out of 4 residents observed for medication administration.
The findings include:
1a) On 10/23/23 at 1:33 PM, a review of Resident #79's medical record was conducted. Review of Resident #79's October 2023 Medication Administration Record (MAR) revealed the resident had physician orders which indicated medications were to be administered enterally (delivered through a feeding tube directly into the stomach or small intestine) to the resident. There was an 11/6/21 order for Sennosides (laxative) Syrup, give enterally every 12 hours as needed for bowel regimen, a 11/5/21 order for Pancrelipase (enzymes), give enterally every 12 hours as needed for clogged feeding tube, a 11/5/21 order for Sodium Bicarbonate (antacid), give enterally every 12 hours as needed for metabolic acidosis (buildup of acid in the body), and a 5/22/23 order for Ibuprofen Suspension, give enterally every 8 hours as needed for pain.
Review of Resident #79's medical record revealed documentation that Resident #79 no longer had an enteral feeding tube. On 2/7/23 at 8:55 PM, in a progress note, the nurse documented the resident returned from a doctor's appointment and the resident's PEG (Percutaneous Endoscopic Gastrostomy) (procedure to place feeding tube) (g-tube) was removed. Review of Resident #79's February 2023 physician orders revealed the resident had enteral feeding orders which were discontinued on 2/8/23.
1b) Resident #79's October MAR documented an 11/5/21 order for Milk of Magnesia (MOM) by mouth every 72 hours as needed for bowel regimen, give on 7-3 shift after 72hr if no BM, an 11/5/21 Dulcolax (Bisacodyl) Suppository to insert 1 suppository rectally as needed for bowel regimen @ 6am on the 4th day of constipation if MOM administered and ineffective per protocol, and an 11/5/21 order for Fleet Enema, insert 1 application rectally as needed for bowel regimen at 10 am on the 4th day of constipation if Dulcolax was administered and ineffective per protocol. Also, there was an 11/6/21 order for Sennosides Syrup enterally every 12 hours as needed for bowel regimen with no clear indication when to give the Sennosides for constipation. The order failed to have clear parameters in place to indicate when to administer the as needed medication for constipation per the resident's bowel regimen.
On 10/24/23 at 3:04 PM, during an interview, Staff #34, RN, 3rd floor Unit Manager was made aware of Resident #79's orders with an enteral route of administration, and concerns related to the order for Sennosides as needed for bowel regimen, with no clear indication when to give the Sennosides for constipation. At that time, Staff #34 confirmed Resident #79 no longer had an enteral feeding tube, that the enteral route of administration was inaccurate, and the sennoside order was an unnecessary medication.
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 staff interview, it was determined that the facility staff 1) failed to ensure that a psychotropic medication prescribed as needed was limited to 14 days and failed ...
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Based on medical record review and staff interview, it was determined that the facility staff 1) failed to ensure that a psychotropic medication prescribed as needed was limited to 14 days and failed to ensure a resident who received psychotropic medication was monitored for behaviors and side effects. This was evident for 1 (#) of 1 residents reviewed for hospice, and 1 (#79) of 7 residents reviewed for unnecessary medications.
The findings include:
1) On 10/23/23 at 8:31 AM, a review of Resident #82's medical record revealed the resident was admitted to the facility at the end of July 2023 with diagnoses which included depression, anxiety, and Alzheimer's dementia and was receiving Hospice services. Review of Resident #82's October 2023 Medication Administration Record (MAR) revealed psychotropic medications prescribed to be administered as needed (PRN) had no discontinuation/end date, were not limited to 14 days duration, and had no documented rationale for continuing the orders beyond 14 days:
a 7/29/23 physician's order for Haloperidol (Haldol) (antipsychotic) Concentrate sublingually (SL) (applied under the tongue) every 6 hours as needed for agitation was not limited to 14 days and did not have a discontinuation date. There was no documentation in the MAR to indicate Resident #82 had received haloperidol as needed in October 2023.
a 7/29/23 physician's order for Lorazepam (Ativan) (antianxiety) by mouth every 6 hours as needed for anxiety was not limited to 14 days and did not have a discontinuation date. There was no documentation in the MAR to indicate Resident #82 had received lorazepam as needed in October 2023.
a 7/29/23 physician's order for Prochlorperazine Maleate (Compazine) (antipsychotic and antiemetic) by mouth every 6 hours as needed for nausea/vomiting. The as needed order for Prochlorperazine
There was no documentation in the MAR to indicate Resident #82 had received prochlorperazine as needed in October 2023.
In a Psychiatric Evaluation & Consultation note, the Psychiatric Nurse Practitioner indicated that, after assessment of patient and review of patient's medication, and in collaboration with the Director of Nurses, Social Worker and Manager, current medication benefits outweigh the risk of discontinuation or reduction of dose and for the resident to continue Haloperidol every 6 hours and Lorazepam every 6 hours to prevent the return of symptoms. There was no documentation to indicate the resident previously received Haloperidol or Lorazepam routinely or PRN (as needed), there was no documented rationale for extending the orders beyond 14 days, or a discontinue date for the haloperidol and lorazepam PRN orders. In addition, no documentation was found to indicate the rationale for the extending the as needed order for prochlorperazine beyond 14 days.
Continued review of the medical record failed to reveal documentation by the prescribing practitioner as to the duration of the as needed psychotropic medication orders or a rationale for extending the orders beyond 14 days.
On 10/23/23 at 8:31 AM, received a Physician's Telephone Order form, dated 10/18/23 at 11:55 AM, that documented to continue PRN Haldol and Lorazepam, and there was no end date while patient was on hospice.
On 10/23/23 at 10:08 AM, the above concerns related to psychotropic medications prescribed as needed with no rational for extending the orders beyond 14 days were discussed with the resident's physician, Staff #31. At that time, Staff #31 indicated the facility's visiting psychiatric NP reviewed resident's psychotropic medications, and the physician preferred the NP take the lead when it was not the physician's area of expertise. Staff #31 stated the psychiatric NP was very involved, along with pharmacy, and that decisions with prescribing psychotropic medications were made as a team.
On 10/23/23 at 10:35 AM, the Director of Nursing (DON) was made aware of the above findings and confirmed the findings at that time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined that the facility failed to prevent cross contamination of cookware and ensure that clean cookware was separated from dirty work areas and protect...
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Based on observation and interview, it was determined that the facility failed to prevent cross contamination of cookware and ensure that clean cookware was separated from dirty work areas and protected from splashes. This has the potential to affect all the residents.
The findings include:
On 10/19/23 at 12:40 PM, an observation of the kitchen was made. The observation revealed that the staff had washed dishes in a scullery sink that had three basins. One basin for washing, one for rinsing, and one for sanitizing. Further observation revealed that, following the sanitizing of 3 large cookie sheets and one large cutting board, all three of these items were then placed behind the faucets with about 1/3 of the cookware hanging above the washing basin and exposed to splash from the washing basin.
On 10/19/23 at 12:42 PM, The Kitchen Manager, Staff #51, was asked about this practice noted in the above observation. The Kitchen Manager immediately removed the cookware from behind the faucets and placed them among the items needed to be washed.
On 11/02/23 at 8:46 AM, during an interview with the kitchen manager, he reported that he educated his staff to dry the clean cookware away from the dirty washing basin to avoid contamination.
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 reviews and interviews, it was determined that the facility failed to maintain systematic and accurate medical r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that the facility failed to maintain systematic and accurate medical records for its residents. This was evident for 2 (Resident #50, #7) out of 47 residents reviewed during the survey. The findings include:
1) Resident #50 was a long-term care resident of the facility since 2022. On [DATE] at 12:14 PM, Resident #50's medical record was reviewed and revealed s/he was certified to have adequate decision-making capacity.
On [DATE] at 1:50 PM, the infection preventionist Nurse (IP/RN staff #6) was interviewed about one of Resident #50's vaccinations and the IP nurse reported that she had called the responsible party (RP) and left a message to call back so she can get the consent to administer the vaccination. When the IP nurse was asked specifically on how she determines who the consent should come from, she indicated that she uses the face sheet of the resident and obtains consent from whomever is listed as Responsible Party for resident contacts. A review of the resident' s face sheet revealed that a family member was listed as the responsible party.
On the same day at 2:09 PM, Unit Nurse Manager (UM/RN staff #3) was interviewed regarding
Resident #50. The UM was asked specifically who makes healthcare decisions about Resident #50 and the UM reported that they ask the family member. When asked who they would call for consents, the UM also indicated they would call the family member. While the surveyor was reviewing Resident #50 ' s hard chart in front of the UM, the UM stated the resident could make his/her own decisions and indicated that they still have to reach the family member to let them know what is happening with the resident. The concern was discussed with the UM that Resident #50 was certified to have adequate decision-making capacity by the medical director but the family member was listed under RP.
Further review of the resident's medical record on [DATE] at 12:34 PM revealed the facility had changed the facesheet and the resident was now listed as his/her own RP.
2) Resident #7 was a long-term care resident admitted in 2023. On [DATE] at 10:34 AM, the resident's medical records were reviewed and revealed the resident was certified on [DATE] by the medical director as lacking adequate decision-making capacity. No other certification was found by the surveyor regarding decision making capacity in the resident ' s records.
On [DATE] at 10:19 AM, the Director of Nursing (DON, staff #2) was asked to provide the surveyor with Resident #7's certification of incapacity. The DON was only able to provide the certification dated [DATE].
On [DATE] at 10:55 AM, the DON was interviewed about her understanding of certifying a resident as lacking adequate decision-making capacity. The DON reported that a resident can be certified as lacking the capacity by just one doctor.
On the same day at 11:39 AM, the Medical Director (staff #31) was interviewed about the process of certifying a resident's decision-making capacity. The medical director stated that when a resident is certified as not having adequate capacity, it is a requirement that 2 certifications are needed, and that the 2nd is done by another medical doctor or a Psych Nurse Practitioner. The certifications should be done as soon as possible and she usually gets an alert such as an email from social services (staff #19) if certifications need to be done for a resident.The concern was discussed with the medical director that, for Resident #7, there was no evidence of a 2nd certification. The medical director stated that ensuring two certifications are completed is the responsibility of the whole team. The medical director confirmed that if a second certification of incapacity was not done, then the certification process is incomplete, and that the understanding of their DON was incorrect. The medical director indicated that she had already educated the DON on what is required when certifying a resident as incapable.
Based on medical record review and staff interview, it was determined that the facility staff failed ensure that a resident's current wishes related to life-sustaining treatment were up to date by failing to void previous MOLST (Maryland Medical Order for Life Sustaining Treatment) forms when a new MOLST was created. This was evident for 1 (#104) of 5 residents reviewed for advanced directives.
The findings include:
Maryland MOLST (Maryland Orders for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. If an updated MOLST form is completed, all older forms shall be voided in accordance with the MOLST's instructions: Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician, NP, or PA to void the MOLST order form. Keep the voided order form in the patient's active or archived medical record.
On [DATE] at 1:23 PM, a review of Resident #104's medical record revealed that the resident had two active MOLST forms in his/her paper medical record (chart). One MOLST form was signed and dated [DATE], that documented Resident #104 elected, CPR resuscitation status, attempt CPR, indicating if cardiac and/pulmonary arrest occurs, CPR should be attempted, and an active MOLST signed and dated on [DATE], that documented Resident #104 elected, CPR resuscitation status, attempt CPR.
On [DATE] at 2:02 PM, during an interview, Staff #19, Social Services Designee, stated that when a resident was admitted to the facility from the hospital, h/she would come with a MOLST. When Staff #19 meets with the resident, h/she offers to go over the Health Care Decision Making Worksheet with the resident, and the physician will complete the MOLST. Staff #19 stated that the original MOLST goes in the resident's medical record and a copy would be kept in a binder in social services. Staff #19 stated that when a physician completes a new MOLST, the physician would void the previous MOLST and send it to medical records.
At that time, Staff #19 was made aware of that 2 active MOLSTs were seen in Resident #104's paper medical record. In response, Staff #19 indicated that when resident was transferred to the hospital, the nurse would sometimes make multiple copies of the resident's records. Staff #19 stated that h/she usually goes on the floor and audits the charts every week.
On [DATE] at 3:48 PM, Staff #19 confirmed that when the physician updated Resident #104's MOLST on [DATE], the physician failed to void the previous MOLST, and there were two active MOLST forms in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance progr...
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Based on surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement plans of action to correct quality deficiencies identified during the prior recertification survey. This was evident during the survey process and review of the Quality Assurance Program.
The findings include:
On 11/3/23 at 1:00 PM, the surveyor reviewed the results of the facility's last recertification survey, with a plan of correction date 10/25/19. It was determined that effective processes were not put in place regarding repeat deficiencies. The corrective actions implemented by the facility after the recertification surveys failed to effectively correct deficiencies related to the facility's failure to ensure a safe/clean/comfortable/homelike environment, notice requirements before transfer/discharge, development and implementation of care plans, and care plan timing and revision. These failures resulted in a continuation of the deficient practices as identified during the current recertification and complaint survey. Cross reference F584, F623, F656, and F657.
On 11/3/23 at 1:30 PM, the Quality Assessment and Improvement program was reviewed with the Nursing Home Administrator (NHA). The NHA was made aware that deficient practices cited during the last annual survey were again identified during the current survey, and that the corrective actions the facility implemented after the last annual survey failed to effectively correct these deficient practices. The NHA verbalized understanding at that time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/18/23 at 9:45 AM, during the tour of the facility's laundry rooms, the door in between the clean and soiled room for laund...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/18/23 at 9:45 AM, during the tour of the facility's laundry rooms, the door in between the clean and soiled room for laundry services remained open while laundry was being processed. The surveyor observed washable chucks and hoyer lift pads hanging over the door. The housekeeper (staff #12) who was folding laundry was interviewed about her process and reported that the door in between the two rooms stays open and that she uses it as an area to hang the washed hoyer lift pads for drying. Staff #12 further reported that the lift pads currently on the door were washed the day prior and hung there for drying.
On the same day at 3:22 PM, the surveyor observed the housekeeper (staff #12) loading clothes into the washer while the door between the clean and soiled room was open with the hoyer pads still draped over the door. The laundry supervisor (Staff #43) confirmed this observation and stated that the door should be shut when staff is dealing with the laundry. Surveyor discussed the concern with the supervisor of the earlier observation and conversation regarding drying the pads on the door. The Laundry supervisor (staff #43) indicated that he would address the issue.
On 11/03/23 at 12:30 PM, the surveyors discussed the concern identified in the laundry room with the Director of Nursing (DON staff #2) that the door was being used as a drying rack, preventing the door from being closed during processing of linens to prevent cross contamination.
Based on observation and interview, it was determined that staff failed to store resident care equipment and supplies in a sanitary manner as evidenced by failing to store linens so as to prevent the spread of infection
facility and failed to keep the door separating the clean from the soiled area of the laundry room closed to prevent cross contamination.This was evident in 22 resident rooms observed during the initial resident sample observations and evident in 2 out of 2 observations of the laundry area.
.The findings include:
On 10/11/23 at 9:21 AM, an observation was made of the bathroom in room [ROOM NUMBER]. In the middle of the bathroom there was a Geri-chair. On the seat of the Geri chair there was a white plastic bed pillow with multiple cracks in the plastic. On top of the pillow was a large, clear plastic bag that appeared to contain folded linen.
Along with Staff #35, RN, 3rd floor Unit Manager, a second observation was made of room [ROOM NUMBER]'s bathroom on 10/11/23 at 9:37 AM. At that time, Staff #35 confirmed that linens were in the large clear plastic bag. When asked if linens were stored in the resident's bathroom, Staff #35 replied that the linens shouldn't be stored in resident bathrooms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, it was determined that the facility failed to have the call device accessible to the residents while in their room. This was evident for 2 (Reside...
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Based on observations, interviews, and record review, it was determined that the facility failed to have the call device accessible to the residents while in their room. This was evident for 2 (Resident #7, #25) of 2 residents reviewed for call system functionality and accessibility.
Then findings include:
Resident #7 is a long-term care resident of the facility admitted in 2023. On 10/12/23 at 2:50 PM, in the initial tour of the resident's room, the surveyor observed the resident in bed, on the low position and the call device on the floor and not within reach of Resident #7.
On 10/18/23 at 12:44 PM, Resident #7 was observed eating his/her lunch on the bedside table and the resident asked the surveyor to turn up the heat in the room. Resident #7's call device was observed not within his/her reach. On the same day at 12:50 PM, the surveyor asked the nurse (LPN, staff #24) to assist Resident #7 with his/her request. Staff #24 moved the call device that was hanging from the wall to the bed.
The next day on 10/19/23 at 12:05 PM, the call device for Resident #7 was again observed on the floor and not within arm's reach. At 12:07 PM, the Speech Therapist (staff #25) was walking in the hallway where the resident's room was located and the surveyor informed the therapist that the call light was not within reach and the therapist proceeded to assist the resident.
On 10/27/23 at 10:47 AM, the door to Resident #7's room was closed. After knocking, the surveyor opened the door and observed the resident trying to change his/her diaper and was asking for the trashcan to be moved closer. The call device was not within arm's reach. The surveyor stepped out and informed the nurse (LPN, staff #45) that Resident #7 required some assistance.
On 10/27/23 at 11:01, Resident #7's medical records were reviewed and revealed the resident was at risk for falls with an intervention to encourage the resident to use the call bell when needing assistance.
On 10/30/23 at 1:57 PM, Resident #7 was observed in his/her room. The resident was awake, sitting on the side of her bed, the call device was on the floor and not within reach.
Resident #25 has been residing in the facility since 2017. On 10/11/23 at 11:44 AM, the residents medical records were reviewed and revealed that Resident #25 had limited mobility and was encouraged to use the call bell for assistance.
On 10/19/23 at 12:20 PM, Resident #25 was observed in his/her room asleep in a wheelchair located between the bed and the door. The call device was on the floor on the opposite side of the bed and not within the residents reach. On the same day at 12:23 PM, the Geriatric nursing assistant (GNA staff #26) was informed by the surveyor that Resident #25's call device was not within the residents reach. The GNA then went into the residents room and moved the call device.
On 11/03/23 at 12:30 PM, the Director of Nursing (DON staff #2) was interviewed and the surveyor addressed the concern that call devices were observed on multiple occasions of not being within the residents' reach.
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 pertinent document review and interviews, it was determined that the facility failed to ensure that all Geriatric Nursing Assistants (GNAs) working at the facility received 12 hours of contin...
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Based on pertinent document review and interviews, it was determined that the facility failed to ensure that all Geriatric Nursing Assistants (GNAs) working at the facility received 12 hours of continuing education annually. This was evident for 2 GNAs (GNA# 53, GNA # 54) out of 3 GNAs reviewed for staffing during a survey.
The findings include:
On 10/30/23 at 11:54 AM, the Director of Staff Development was interviewed. She stated that she scheduled staff competencies once a year, and the GNAs were provided with time off to complete the training. She stated that, in addition to the competencies, Human Resources (HR) enrolled each staff member in the online Healthcare Academy to complete their required annual training.
On 10/30/23 at 11:54 AM, the Director of Staff Development provided the competency training packages for the 2023 competencies. A review of the training documents failed to reveal that GNA Staff #53 (hire date 2/19/15) and GNA Staff #54 (hire date 9/11/17) completed their 2023 competencies.
On 10/30/23 at 12:24 PM, the Director of HR was interviewed. During the interview, she stated that that new employees received their new hire education through the Health Care Academy's online training program. In addition, on the anniversary of an employee's hire date, each employee was assigned at least 12 hours of continued education through the Health Care Academy's online training program. During the interview, the surveyor requested the training documents for GNA Staff #54 and #53.
On 10/30/23 at 2:10 PM, the Director of Human Resources provided the annual Health Care Academy's online training documents for GNA Staff #53 and GNA Staff #54. Review of the documents revealed that GNA Staff# 54 had not attempted to complete her annual training. GNA Staff # 53 completed his training on the evening of 10/30/23 after the surveyor requested the documents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined that the facility failed to provide a home-like environment for resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined that the facility failed to provide a home-like environment for residents. This was evident for 2 of 2 nursing units reviewed for the environment.
The findings include:
On 10/11/23 at 12:16 PM, during a tour of the second-floor unit, an observation was made in room [ROOM NUMBER]B that about a third portion of the paper blinds had been ripped off from the bottom.
On 10/12/23 at 1:13 PM, an observation was made of room [ROOM NUMBER], where surveyor observed stained ceiling tiles upon entry to the bathroom. One measured about 4 X4 inches to the right-hand corner of the ceiling and another, 6X6 inches to the left. Further observation was made of a missing ceiling tile, about 18x24 inches, in front of the toilet in the bathroom.
A continued observation was made on the second floor on 10/12/23 at 1:16 PM. The observation revealed chipped laminate about 3x2 inches to the left and 1x1 inches to the right sides of the counter at the nurses' station.
On 10/11/23 at 9:21 AM, during a tour of the third-floor unit, an observation was made of broken blinds to the window, and five slats of vertical blinds were noted to be missing in room [ROOM NUMBER]A. The overbed table was noted to have rust along the edges of the bottom U-shaped base. The closet door was noted to have scraped edges, and paint was missing along the bottom and around the door handle.
On 10/11/23 at 9:49 AM, during a tour of the third-floor unit, an observation was made in room [ROOM NUMBER] of a hole in the left wall upon entry to the room where the interior doorknob hits. The hole measured about 3x3 inches.
Further observation on the third-floor unit on 10/11/23 at 11:54 AM revealed a hole to the left side of the wall upon entry to the bathroom in room [ROOM NUMBER], which measured about 2 x1/4 inches. There was also an uncovered recessed night light to the wall under the window, which measured about 9x3 inches.
On 10/12/23 at 12:37 PM, an observation of room [ROOM NUMBER] revealed unpainted wood, which measured about 1 x 4 inches to the sides and across the top of the heating, ventilation, and air conditioning system.
On 10/12/23 at 12:59 PM, a subsequent observation was made of room [ROOM NUMBER]A, where about a third of the wall to the right-hand corner of the bathroom was unpainted. Upon entry, unpainted and chipped drywall was also observed to the right side of the door. Additionally,a baseboard under the sink was noted with paint peeled off.
Further observation was made on 10/12/23 at 1:48 PM, and it showed that room [ROOM NUMBER]-C had a scrape to the left wall upon entry to the room, which measured approximately 12 X 3 inches. The outlet next to the heating, ventilation, and air conditioning system was missing a cover. The drawer unit to the sink in the room had six drawers, with 3 to the right and 3 to the left. The first drawer to the left was missing a drawer pull. The three drawers to the left and one to the bottom right were noted with scrapes, missing paint, and also with exposed fiberboard. There was missing trim to the left side of the drawers. The nightstand was chipped on the front and had a broken door.
On 11/3/23 at 10:55 AM, an environmental tour was conducted with staff # 30, Maintenance Assistant. The tour included all of the above findings confirmed by Staff #30. Also, during the tour, an observation was made that there were no handrails between room [ROOM NUMBER] and the double doors. Continued observation on the third floor showed that the third handrail between rooms [ROOM NUMBERS] in the C-Hallway was loose. Another observation was made of a handrail on the left side of the hallway between room [ROOM NUMBER] and the exit door to be loose. Staff # 30 shook the handrails and confirmed they were loose.
11/3/23 at 11:09 AM, during an interview with staff # 30, he confirmed that the concerns that the surveyor brought to his attention were issues. He stated he would report all the concerns through the facility's communication system so the Maintenance Department could begin working on them.
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
3) Resident #96 is a long-term care resident admitted in 2022. On 10/13/23 at 9:35 AM, Resident #96's medical records were reviewed and revealed that the resident was transferred to the hospital in Ju...
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3) Resident #96 is a long-term care resident admitted in 2022. On 10/13/23 at 9:35 AM, Resident #96's medical records were reviewed and revealed that the resident was transferred to the hospital in July of 2023.
On 10/18/23 at 12:03 PM, the Licensed Practical Nurse (LPN staff#27) was interviewed about the process when a resident is ordered to be transferred to a community hospital for treatment. LPN staff #27 was able to name the different documents and notices that they are required to prepare to facilitate the resident's transfer. The nurse then documents these preparations in the facility's Change in condition/ Concurrent review evaluation form.
On 10/19/23 at 1:20 PM, a review of the change in condition/concurrent review form, with a reference date of 7/20/2023 signed by registered nurse (RN staff #46), revealed that section Pwas left unchecked, the area where the nurse would mark the documentation provided to residents or resident representatives for reasons for transfer. There was no evidence found In Resident #96's medical records for this document.
On 11/03/23 at 12:30 PM, in an interview with the Director of Nursing (DON staff #2), the concern was discussed that the surveyor found no evidence that the resident or resident representative was notified in writing, regarding the reason for transfer. The exit conference was conducted at 4:15 PM on the same day, and at that time, the facility had not provided documentation to contradict this finding.
2) On 10/16/23, a review of Intake #MD00183697 revealed a concern regarding the discharge of Resident #142, a resident admitted to the facility for rehabilitation.
On 10/25/23 at 11:24 AM, a review of Resident #142's hospital discharge summary revealed the
resident was discharged from the hospital on 9/14/22.
On 10/25/23 at 11:35 AM, a review of resident's medical record revealed that Resident #142 was
admitted to the hospital. Further review of Resident's #142 medical records revealed that the resident had not returned to the facility, but failed to reveal documentation that the resident was provided notice of discharge and that a discharge summary was documented in the medical record.
On 10/25/23 at 12:20 PM, the Director of Nursing reported that she was unable to provide any
documentation that Resident #142 had received a discharge notice and that a discharge summary was documented in the resident medical record.
On 10/25/23 at 2:59 PM, the Administrator was interviewed. During the interview he reported that he
was unsure sure who in his facility was responsible for transfer/discharge documentation.
On 10/26/23 at 10:20 PM, the Administrator reported that the facility does not have a
transfer/discharge policy and that he had been working on developing one.
Based on medical record review and staff interview, it was determined the facility failed to notify residents or their representatives in writing of the reason for transfer and document that notification in the medical record. This was evident for 3 (#104, #142, #96) of 3 residents reviewed for hospitalization.
The findings include:
On 10/25/23 at 8:21 AM, a review of the Resident #104's medical record revealed the resident was admitted to the facility in April 2023, and following his/her admission, had been transferred to the hospital on 9/15/23, returned to the facility on 9/19/23, then transferred to the hospital on 9/25/23 and returned to the facility on 9/29/23. Continued review of the medical record failed to reveal evidence that written notification of the resident's hospital transfer had been provided to Resident #104 and the resident's representative.
On 10/25/23 at 10:55 AM, during an interview, Staff # 35, RN, 3rd floor Unit Manager (UM), stated when a resident was transferred to the hospital, the nurses completed had a SNF (skilled nursing facility) to Hospital Transfer Form, which included a checklist of the documents the nurse was to send with the resident upon transfer to the hospital, and provided the surveyor with a copy of the form. Review of the form's transfer checklist revealed a notice of transfer was not included on the form. At that time, when asked if a written notification of transfer was provided to the resident and their representatives when the resident was transferred to the hospital, Staff #35 stated that a written transfer notice was not included with the documents nursing sent with the resident on transfer, and for the surveyor to check with social services.
On 10/25/23 at 10:55 AM, during an interview, Staff # 35, RN, 3rd floor Unit Manager (UM), stated when a resident was transferred to the hospital, the nurses completed had a SNF (skilled nursing facility) to Hospital Transfer Form, which included a checklist of the documents the nurse was to send with the resident upon transfer to the hospital, and provided the surveyor with a copy of the form. Review of the form's transfer checklist revealed a notice of transfer was not included on the form. At that time, when asked if a written notification of transfer was provided to the resident and their representatives when the resident was transferred to the hospital, Staff #35 stated that a written transfer notice was not included with the documents nursing sent with the resident on transfer, and for the surveyor to check with social services.
On 10/25/23 at 2:02 PM, during an interview, Staff #19, Social Services Designee stated that he/she was not responsible for providing residents and their representative with a written notice of transfer, that it was nursing's responsibility, and social services only got involved if nursing was unable to reach the resident's Power of Attorney (POA) or responsible party,
The nursing home administrator was made aware of the above concerns related to transfer notification on 10/25/23 at 3:01 PM, When asked who was responsible for notifying the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing when the resident was transferred to the hospital, the NHA indicated he was not sure the facility had a process in place and would let the surveyor know.
On 10/26/23 at 10:20 AM, the NHA reported to the surveyor that the facility and Corporate did not have a policy for notifying the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand, and stated that he was getting started on developing a policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
3) Resident #7 is a long-term care resident of the facility admitted in 2023. On 10/17/23 at 11:16 AM, a review of the residents MDS assessment, with a reference date of 9/5/23, revealed section F Pre...
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3) Resident #7 is a long-term care resident of the facility admitted in 2023. On 10/17/23 at 11:16 AM, a review of the residents MDS assessment, with a reference date of 9/5/23, revealed section F Preferences for customary routine and Activities was completed by a registered nurse (RN staff #52). Further review of Section F revealed dashes in the areas where assessment answers were to be documented.
On 10/19/23 at 8:55 AM, the Activities Director (AD staff# 21) was interviewed about her process and was asked specifically about the MDS assessment done for Resident #7 with a reference date of 9/5/23. The AD reported that she was responsible for the MDS assessments for all residents in the facility under activities and she didn't know who Staff #52 was. She also reported that she does not delegate this task and remembers doing it for Resident #7 but does not know why it was not in the resident's medical records. The concern was discussed with the AD that Resident #7 was not assessed for any of the questions in section F of the MDS assessment done on 9/5/23. The AD staff #21 acknowledged the concern of the surveyor and indicated that she was aware of the regulations.
On 11/03/23 at 12:30 PM, the identified concern was also discussed with the Director of Nursing and up until that time, no additional documentation or revision was provided by the AD staff #21.
Cross reference to F 679
2) On 10/30/23 at 11:20 AM, a medical record review for Resident # 24 revealed a Minimum Data Set (MDS) assessment, dated 9/26/23, that documented seven days of antibiotic use in section N.
A continued review of Resident #24's medical record showed a medication administration record for September 2023 with no documentation of antibiotic use for the observation period of the 9/26/23 MDS assessment. Further review of the record failed to show an attending provider's order for antibiotics in September 2023.
On 10/30/23 at 11:38 AM, an interview was conducted with staff # 40, MDS Coordinator. During the interview, she confirmed that seven days of antibiotic use recorded on Resident # 24's MDS assessment, dated 9/26/23, was documented in error and that she would modify the assessment.
Based on observation, medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 3 (Resident #79, #24, #7) of 47 residents reviewed during the survey.
The findings include:
The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need.
1) On 10/23/23 at 1:33 PM, a review of Resident #79's medical record revealed the resident was admitted to the facility in November 2021 for rehabilitation following an acute hospitalization for a traumatic brain injury, and multiple fractures resulting from a motor vehicle accident, and resided in the facility for long term care. In a History of Present Illness note on 11/8/21, the physician documented Resident #79 had a past medical history which included Hepatitis C (viral infection that attacks the liver). Continued review of the medical record failed to reveal any further documentation to indicate whether or not the resident's diagnosis was active. There was no documentation found to indicate that the resident was receiving treatment or being monitored for the disease.
Review of Resident #79's most recent quarterly MDS, with an ARD (assessment reference date) of 7/20/23. Section G, Cognitive Patterns, documented Resident #79's Brief Interview for Memory Status (BIMS) summary score was 6, indicating the resident had severe cognitive impairment. Section I, Active Diagnose coded Infections, I2400 Viral Hepatitis was an active diagnosis. Review of Resident #79's care plans failed to reveal that a comprehensive care plan had been developed to address the resident's hepatitis.
On 10/24/23 at 2:33 PM, during an interview, when asked whether Resident #79's diagnosis of Hepatitis C (Hep. C) was an active diagnosis, Staff #35, RN, 3rd floor Unit Manager, initially stated h/she was unaware of the resident having the diagnosis, then stated that h/she recalled that Resident #79's Hep. C was not an active diagnosis.
On 10/24/23 at 3:36 PM, during an interview, Staff #40, LPN, MDS Coordinator, indicated Resident #79 had the Hep. C since h/she was discharged from the hospital, and the diagnosis was documented in the physician's visit notes, Hepatitis was coded as an active diagnosis.
On 10/25/23 at 12:32 PM, during an interview, Staff #31, Attending Physician, confirmed the resident had a past history of Hepatitis C, and stated Resident #79 had never exhibited an symptoms of advanced liver disease. Staff #31 indicated that at the present time, the resident's Hepatitis was not active, or being treated, and if the physician suspected the disease was active, s/he would refer the resident to a specialist.
On 10/30/23 at 11:06 AM, the above concerns were again reviewed with the MDS coordinator, Staff #40, who agreed that though there was physician documentation that Resident #79 had a history of hepatis C, the diagnosis was inactive as the resident was not receiving any treatment or nursing monitoring for the diagnosis.
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 F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with residents, review of resident medical records, and interview with facility staff, it was determined that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with residents, review of resident medical records, and interview with facility staff, it was determined that the facility failed to ensure that residents were provided with summaries of their baseline care plans including a list of their medications. This was evident for 1 (Resident #112) of 3 residents reviewed for care planning.
The findings include:
Resident #112 was interviewed on 10/12/23 at 12:56 PM. During the interview, the resident stated that s/he had been admitted to the facility on [DATE]. The resident stated that a baseline care plan meeting had been held with the resident within 48 hours of admission. However, when asked if s/he had been provided with a summary of the baseline care plan or a list of his/her medications, Resident #112 stated no.
On 10/31/23 at 2:04 PM, Resident #112's electronic medical record was reviewed. The review included an admission care plan note dated 8/15/23, 11 days after the resident's admission, that stated the resident was provided with a copy of the comprehensive care plan. However, no note could be found that stated the resident had received a summary of his/her baseline care plan.
On 11/1/23 at 8:39 AM, Resident #112's paper medical record was reviewed. The review failed to reveal any evidence that Resident #112 had been provided with a copy of the baseline care plan, such as a photocopy of the document that the resident had signed.
On 11/1/23 at 9:26 AM, the Social Services Designee (Staff #19) was interviewed. During the interview, Staff #19 stated that patients should be given copies of their baseline care plans within 24 hours of when they were created. When asked who was responsible for providing the residents with these copies, she stated it was the nursing staff involved in their admission, including the Director of Nursing and the Unit Managers. She also stated that she expects a copy of the residents's baseline care plans to be signed and included in the resident's paper chart. However, she stated that she often does not see those in the charts of newly admitted residents even after the first 72 hours of their stay.
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
3) Resident #172 was admitted to the facility for rehabilitation. The resident was prescribed peritoneal dialysis (PD) prior to admission. Review of physician's orders on 10/18/23 04:20 PM revealed th...
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3) Resident #172 was admitted to the facility for rehabilitation. The resident was prescribed peritoneal dialysis (PD) prior to admission. Review of physician's orders on 10/18/23 04:20 PM revealed that the resident was to continue with PD during his/her admission.
Peritoneal dialysis is a treatment for kidney failure, a condition where the kidneys can't filter blood well enough any longer. Because peritoneal dialysis works inside the body, it's different from a more-common procedure to clean the blood called hemodialysis. That procedure filters blood outside the body in a machine. Peritoneal dialysis treatments can be done in a long-term care setting or at home.
On 10/19/23 at 3:13 PM, during an interview with the second-floor unit manager, Staff #41, he reported that his expectation was that a resident that received PD would have had this treatment documented in their care plan. He stated that he worked evenings and nights, when the PD treatments are administered, and the daytime 2nd floor unit supervisor would be the staff that completed the care plans.
A comprehensive care plan must be completed within 21 days after a resident is admitted .
On 10/30/23 at 9:00 AM, Resident #172's care plan was reviewed. Resident #172 had been admitted to the facility longer than 21 days. Review of the care plan failed to reveal a care plan for peritoneal dialysis.
On 11/01/23 at 11:04 AM, during an interview with the second-floor day shift Staff #3, he reported his expectation was that a resident that received PD treatment would have had this treatment included in their care plan. Staff #3 confirmed that the PD treatment for Resident #172 was not documented in the care plan.
On 11/02/23 at 1:34 PM, The Director of Nursing was interviewed. During the interview, she reported that there was a PD care plan for Resident #172. However, she confirmed that the PD care plans had been implemented after the resident has been at the facility more than 21 days and after the concern was brought to the attention of the second-floor unit manager on 11/01/23.
2) On 11/2/23 at 12:13 PM , a review of Resident #129's medical record revealed Resident #129 was admitted to the facility in February 2023 with diagnoses which included unspecified dementia, muscle weakness, and difficulty in walking.
A quarterly assessment with an assessment reference date (ARD) of 7/4/23 documented Resident #129 had a BIMS of 00, indicating the resident had severe cognitive impairment. The MDS also documented that Resident #129 was dependent for all ADLS and required extensive, 1 person support for bed mobility, and was totally dependent with 1 person support for all other ADLs including transfer, walking, dressing, eating, toilet use, personal hygiene and bathing. The assessment documented Resident #129 had functional limitation in range of motion with impairment with upper extremity on one side, and with lower extremity on one side.
Review of Resident #129's care plans failed to reveal evidence that a comprehensive care plan to address Resident #129's ADL status and mobility had been developed & implemented to address the resident's ADL care needs.
The above concerns were discussed with the Director of Nurses on 11/3/23 at 2:00 PM, and the DON offered no explanation or further comments at that time.
Based on medical record review and interview, it was determined the facility failed to ensure comprehensive care plans were developed and implemented. This was found to be evident for 3 (Resident #59, #129, #172) out of 47 residents reviewed during the survey.
The findings include:
The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
1) Review of Resident #59's medical record revealed the resident was admitted in June of 2023. A care plan was initiated for the resident in June 2023.
1a) During an interview with Resident #59 on 10/12/23 at 9:14 AM, when asked about activities, the resident reported that no one gets him/her up to go and they do not bring him/her things to do.
Review of the admission Minimum Data Set (MDS) assessment revealed the resident was cognitively intact with adequate hearing, clear speech and the ability to make self understood and to understand others. The resident was the primary respondant for the assessment questions about activities. The resident indicated it was very important to have books, newspapers and magazines to read, to listen to music s/he likes, to do things in groups, to go outside when the weather is nice and to participate in religious activities.
On 10/18/23, review of the resident's care plans failed to reveal a plan to address activities for the resident. No documentation was found in the care plan in regard to what kinds of activities the resident would enjoy or how those activities would be facilitated by staff.
On 10/19/23 at 9:20 AM when asked how she determines who gets a care plan for activities, the Activity Director (Staff #21) responded that everybody gets a care plan [for activities]. Surveyor then reviewed the concerns that there is no care plan to address activities for this resident.
On 10/20/23 at 2:15 PM surveyor informed the Director of Nursing of the concern regarding failure to develop a care plan for activities.
1b) Further review of Resident #59's care plan revealed a plan to address nutritional needs. This plan was initiated on 6/27/23 and included an intervention to Monitor weekly wts [weights].
Further review of the medical record revealed a 7/21/23 Dietitian Progress Note written by Registered Dietitian Eligible (Staff #38) which included: Weekly weights are already ordered to monitor for any significant changes /malnutrition.
On 8/28/23 Staff #38 documented that the scales have been re-calibrated in the facility and new weight is been used as the resident weight baseline.
Review of the MDS with an Assessment Reference Date of 9/29/23 revealed the resident had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a physician-prescribed weight loss regimen.
Further review of the medical record revealed a Weight Warning note dated 10/2/23 inwhich Staff #38 documented: Continue on weekly wts.
On 10/18/23 at 1:16 PM Staff #38 was interviewed about the resident's weight. She reported the resident started at 186 lbs and is now at 160 lbs and that they have the resident on weekly weights. After reviewing her last notes, she reported weight loss was due to variable in take and skin issues but could also be a result of the re-calibrating the scales and that is why [s/he] is on weekly weights.
On 10/19/23 further review of the medical record failed to reveal a current order for weekly weights. Review of the weights in the electronic health record revealed documentation of two weights in July, one weight in August, two weights in September and one weight in October on 10/10/23.
On 10/19/23 at 12:10 PM the unit nurse manager (Staff #3) was interviewed in regard to residents on weekly weights. The unit manager reported that the dietitian will send a report every week with a list of residents who are on weekly weights. The residents are weighed on Wednesday, the weights are put in the system [computer] on Thursday and the dietitian reviews on Friday. In regard to Resident #59, the unit manager reported the resident's weight is stable and the resident's name is not on the list for weekly weights. The Unit Manager confirmed that the 10/10/23 weight was the monthly weight. Surveyor then reviewed the concern with the Unit Manger that the care plan indicates weights are to be monitored weekly, the dietitian notes and her verbal report also indicate the resident is on weekly weights but there is no order or indication that weekly weights are being obtained.
On 10/20/23 at 2:15 PM surveyor reviewed the concern with the Director of Nursing regarding the failure to monitor weekly weights as indicated in the care plan and dietitian notes.
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) Resident #7 was admitted to the facility in August of 2023. On 10/11/23 at 11:32 AM, the resident's medical records were reviewed and revealed that Resident #7 was initially admitted for short term...
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2) Resident #7 was admitted to the facility in August of 2023. On 10/11/23 at 11:32 AM, the resident's medical records were reviewed and revealed that Resident #7 was initially admitted for short term rehabilitative care, and the resident's current care plan reflected goals and interventions for the resident to return to the community.
Minimum Data Set- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions.
On 10/17/23 at 8:07 AM, further review of Resident #7's medical records revealed a Minimum Data Set (MDS) assessment, with an assessment reference date of 9/5/23, which revealed the resident was expected to remain in the facility and no referrals were needed. Review of a care plan meeting note, dated 9/5/23 and completed by the Social Services Director (SSD Staff #19), also revealed that the resident was being placed for long-term care based on the resident's 24-hour supervised care needs.
No revision was made in Resident #7's care plan to reflect the new assessment and goals documented by the SSD related to the resident now being a long term care resident
On 11/03/23 at 12:30 PM, the Director of Nursing was interviewed and discussed the concern that Resident #7's care plan was not revised based on the changes made in the resident's assessment, and as discussed in the care plan meeting.
Based on observation, medical record review, and interviews, it was determined that the facility staff failed to evaluate and revise a resident's care plan to reflect accurate and current interventions. This was evident for 2 (#93, #7) of 47 residents reviewed during the survey.
The findings include:
A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
1) On 10/11/23 at 10:43 AM, an observation was made of Resident #93's room during a tour of the third-floor unit. The room was noted to have no curtains on the windows, no television in the room, no cables for the heating, ventilation, and air conditioning system, no baseboard to the walls, no nightstand, no furniture except the bed, and the bathroom door had a metal bar bolted across the upper left corner that prevented it from being opened.
On 10/18/23 at 2:45 PM, a medical record review for Resident # 93 revealed a care plan focus originally initiated on 3/24/23 that stated that Resident # 93 had a tendency to demonstrate physical behaviors, aggressive towards Staff, destruction of his/her room related to poor impulse control.
Although the care plan contained interventions related to managing Resident # 93's behaviors, no care plan intervention addressed Resident # 93's behaviors that resulted in the environmental alterations in the resident's room. Nor were there any interventions that specified how Resident #93's needs would be met, given that the alterations rendered the resident's bathroom inaccessible and the room's heating and cooling system nonfunctional.
On 10/19/23 at10:03 AM, during an interview with staff # 20, a licensed practical nurse, she indicated that the team had therapeutically removed most of the room's belongings and secured the bathroom door with a metal bar bolted across the upper left corner to keep Resident # 93 safe.
On 10/27/23 at 9:29 AM, an interview was conducted with staff # 29, maintenance director. During the interview, he stated that all the modifications made in Resident # 93's room were done in consultation with the nursing staff. Staff # 29 also said Resident # 29 removed those things by himself/herself.
On 10/19/23 at 11:34 AM, during an interview with the Director of Nursing (DON), she stated Resident # 29 had aggressive behaviors and removed all those fixtures by himself/herself.
On 11/02/23 at 12:37 PM, the Nursing Home Administrator (NHA) and the DON were made aware of the above concerns. Neither the NHA nor the DON provided a rationale for why the care plan was not updated or additional documentation
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
3) Resident #7 is a long-term care resident admitted in 2023. On 10/12/23 at 2:53 PM, the surveyor observed the resident in his/her room with no activities being provided. On 10/17/23 at 11:16 AM, the...
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3) Resident #7 is a long-term care resident admitted in 2023. On 10/12/23 at 2:53 PM, the surveyor observed the resident in his/her room with no activities being provided. On 10/17/23 at 11:16 AM, the minimum data set (MDS) section F, Preferences for customary routine and Activities with a reference date of 9/5/23, was reviewed and revealed it was completed by a registered nurse (RN Staff #52) and that the resident was not assessed for daily activity preference.
Also, on 10/17/23 at 11:16 AM, a review of the resident's care plan failed to reveal a plan to address the resident's activity preferences, goals, or resident specific interventions to be provided by staff.
On 10/19/23 at 8:55 AM, the Activities Director (AD staff #21) was interviewed about her process and involvement in resident assessments and care plans. The AD reported that, when a new resident comes in, she tries to conduct an interview as soon as possible with the resident or the family member if the resident is unable to say what their preferences are. The AD further reported that she is responsible for the MDS assessment for resident activities and preferences, and the care plan for activities, and that she does them for all the residents in the facility. She further stated that this was a task that was not delegated to another staff. On the same day, at 9:22 AM, the AD was shown a copy of the MDS section F, with the reference date of 9/5/23, for Resident #7. The surveyor raised the concern that all the questions in this section were not answered. The AD stated, I did not do that. I don't even know who that staff is. Surveyor then reviewed the concern that Resident #7 had no care plan for activities. The AD further stated that if they document and do the MDS, they should do the care plan as well. The AD also reported that she remembered doing an MDS assessment for Resident #7, but doesn't know why it's not there.
4) Resident #422 is a newly admitted resident of the facility and was observed on multiple occasions in the resident's room with no activities. On 10/12/23 at 12:25 PM, Resident #422 was interviewed, and the resident indicated that s/he had not been invited to attend activities.
On 10/17/23 at 10:30 AM, Resident #422 was again observed in the room with no activities being provided. On the same day at 10:45 AM, the resident's medical record was reviewed and revealed the MDS with a reference date of 9/26/23, where the assessment for section C (Cognitive patterns) revealed the resident was cognitively intact and section F (Preferences for customary routine and Activities) revealed it was very important for the resident to join group activities and to go outside for fresh air when the weather is good. A review of the resident's care plan failed to reveal a plan of care to address his/her activity preferences for the staff to provide.
On 10/19/23 at 8:55 AM, the Activities Director (AD staff #21) was interviewed about the activities being provided for Resident #422. The AD reported that the facility has been doing in-room activities with him/her and that activity assistants document what they do in the handwritten activities binder. The surveyors asked to get a copy of the documentation for activities done by the residents for the month of September. The surveyor also discussed the concern that when Resident #422's care plan was reviewed, it failed to show any resident specific goals or interventions related to activities for the resident. The AD stated she would provide a copy of the handwritten activities binder for the specific resident and review the resident's care plan to look for evidence for a plan of care regarding resident-specific activities. The AD (staff #21) also indicated that she knows the regulations and that she acknowledges the concerns of the surveyors.
On the same day at 10 AM, a review of the activities binder provided by the AD (staff #21) failed to show any evidence of Resident #422 attending any group activity or outdoor activities. Since admission to the end of September, the only activity written on the sheet for the resident is room visit. There was no other documentation or explanation as to what specific activity was done for the room visits.
On 10/19/23 at 10:45 AM, an activity assistant (staff #23) was interviewed about his process of providing activities for residents'. When staff #23 was asked specifically about the documentation in the activities binder stating room visit, he reported that he usually plays board games with the residents and that the only documentation they have is that form in the binder. Staff #23 further reported, We do pretty much the same activities for all residents.
On 11/03/23 at 12:30 PM, the Director of Nursing was interviewed and discussed the concerns identified regarding activities. Up until this time, no evidence was provided to the surveyors that the residents identified in this review had care plans to address the residents' goals and preferences for activities.
2) On 10/17/23 at 8:22 AM, a medical record review was done for Resident # 84. The review showed that Resident # 84 had a diagnosis of Dementia per the attending provider's note of 6/16/23. A continued review noted a Minimum Data Set (MDS) assessment, dated 6/20/23, which documented that Resident # 84 had severely impaired cognition.
A subsequent record review showed an admission and Annual Activities assessment completed on 6/26/23 for Resident # 84. The following answers were documented in section F:
- How important is it to you to do your favorite activities? Very important.
- How important is it to go outside to get fresh air when the weather is good? Very important.
- How important is it to you to participate in religious services or practices? Very important.
- How important is it to you to keep up with the news? Not very important.
On 10/17/23 at 8.30 AM, a review of Resident #84's activity care plan, dated 8/28/23, was completed. The review showed a focus that stated, Resident attends group activities on his unit. The goal of the care plan said, Resident provided Spanish activities, news, notes, reading material. The intervention recorded on the care plan stated, Activities will provide daily news, notes as necessary. However, the care plan failed to address the resident's needs for Dementia care and failed to show that Resident #84's activity care plan was updated with their activity preferences.
On 10/19/23 at 10:30 AM, June 2023 and September 2023 activity logs for Resident # 84 were reviewed. The logs recorded listening to music of interest, sensory stimulation, watching TV, and games/craft material. However, the logs failed to show that Resident # 84 was involved in activities that included going outside to get fresh air when the weather was good and participating in religious services or practices previously documented as their activity preferences during the Annual activity assessment.
On 10/19/23 at 8:55 AM, an interview was conducted with staff # 21, Activities Director. During the interview, she confirmed that the Activity care plan did not mention residents' preferences as identified on the activity assessment. She stated that the activity care plans were completed based on whether residents came out of their rooms. Staff #21 also confirmed that she would expect Resident# 84 to be taken outside to get fresh air when the weather was good if that was their preferred activity.
On 10/19/23 at 10:53 AM, during an interview with staff # 23, an activities aide, he stated he did not have access to residents' care plans. He said that when working with residents, he did not ask for their personal preferences for activities; instead, he offered standard activities to all residents.
Based on medical record review, staff interview, and observation, it was determined that the facility staff failed to provide an activities program to meet the needs and preferences of residents. This was evident for 4 (#59, #84, #7, #422) of 5 residents reviewed for activities.
The findings include:
The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the necessary care.
A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care.
1) Review of Resident #59's medical record revealed the resident was admitted in June of 2023.
During an interview with Resident #59 on 10/12/23 at 9:14 AM, when asked about activities, the resident reported that no one gets him/her up to go, and they do not bring him/her things to do.
Review of the admission Minimum Data Set (MDS) assessment revealed the resident was cognitively intact with adequate hearing, clear speech, and the ability to make self understood and to understand others. The resident was the primary respondent for the assessment questions about activities. The resident indicated it was very important to have books, newspapers, and magazines to read, to listen to music s/he likes, to do things in groups, to go outside when the weather is nice, and to participate in religious activities.
On 10/18/23, a review of the medical record failed to reveal a care plan addressing activities for the resident. The resident did have a care plan, established in June, for potential for impaired adjustment/anxiety/ineffective individual coping related to skilled nursing facility placement, which included an intervention of Activity referral as needed. No documentation was found in the care plan in regard to what kinds of activities the resident would enjoy or how those activities would be facilitated by staff. The care plan was updated on 10/16/23 with a newly initiated care plan related to the resident now being a long term care resident but no update regarding activities for the resident was found.
On 10/18/23 at 3:42 PM, the Social Service Director (Staff #19) reported they just had a care plan meeting for Resident #59 on 10/17/23, but she had not yet written the note about the meeting. Review of the sign in sheet for this meeting revealed the Activity Director had attended this meeting. The SSD confirmed that the resident was now a long term care resident.
On 10/19/23 at 9:20 AM, when asked how she determines who gets a care plan for activities, the Activity Director (Staff #21) responded that everybody gets a care plan [for activities]. In regard to Resident #59, the Activity Director reported they bring the resident out, but s/he doesn't do much and that the resident likes music. The Activity Director confirmed that she had attended the resident's care plan meeting. Surveyor then reviewed the concerns that although the Activity Director had attended the recent care plan meeting for the resident, there was no care plan to address activities for this resident. Surveyor also reviewed that the resident had reported that s/he does not get out of bed and denied that anyone brings him/her anything to do for activities. The Activity Director responded that she will need to check to see if any documentation regarding this resident and that the provision of services would be included in the activity book, which contains documentation for all of the residents.
After the interview, surveyor obtained a copy of the activity log for Resident #59 for the month of September 2023. Review of this documentation revealed everyday from September 1st through the 24th staff documented watching TV and listening to music and on the 1st and the 3rd staff also documented that the resident was talking to family and friends. For September 25- 30, Room Visit was documented, but no documentation was found to indicate what occurred during these room visits. No documentation was found to indicate the resident was offered or declined a group activity during the month of September.
On 10/19/23 at 10:55 AM, an interview with Activity Aide (Staff #23) confirmed they documented for Resident #59 for September. The Activity Aide confirmed that the documentation of watching TV and listening to music was for activity occurring in the resident's room. When asked about music for the resident, the Activity Aide reported he would put on classical music for the resident because that is what most of the residents here like, but denied ever having asked the resident what type of music s/he likes. The Activity Aide reported he does not have access to the residents' care plans or any resident specific information, and confirmed that he pretty much does the same thing for everyone.
On 10/20/23 at 2:15 PM, surveyor informed the Director of Nursing of the concern regarding failure to develop a care plan for activities, as well as failure to provide activities for Resident #59.
On 11/03/23 at 1:30 PM, the Nursing Home Administrator was informed of the concern regarding the facility's failure to assess for activity preferences, failure to develop care plans for activities as well as failure to provide activities for the residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 10/16/23 at 9:38 AM, a medical record review for Resident # 84 noted that a monthly pharmacy review was completed on 4/23/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 10/16/23 at 9:38 AM, a medical record review for Resident # 84 noted that a monthly pharmacy review was completed on 4/23/23 with a recommendation to review an antidepressant for dose reduction.
On 10/17/23 at 1:42 PM, a review of Resident #84's medical record showed that a consulting psychiatric Nurse Practitioner reviewed and signed the pharmacy recommendation on 6/6/23. The attending Physician saw resident # 84 on 4/30/23, 6/15/23, 6/16/23, 6/28/23, and 6/30/23. However, the review failed to show that the attending Physician for Resident # 84 had reviewed or responded to the pharmacy recommendation.
On 10/17/23 at 2:19 PM, during an interview with the Director of Nursing (DON), she stated that the psychiatric Nurse Practitioner reviewed and signed all the pharmacy recommendations for psychotropic medication use.
On 10/23 at 9:54 AM, an interview was conducted with the attending physician for Resident # 84 ( also the Medical Director). During the interview, she stated that she did not review pharmacy recommendations related to psychotropic medications but preferred the consulting Psychiatric Nurse Practitioner to review and respond to them. When asked if she reviewed the Psychiatric Nurse Practitioner's decisions prior to them being acted on, she said that she did not.
On 11/02/23 at 12:37 PM, the DON and Nursing Home Administrator were made aware of concerns. Neither the DON nor NHA provided a rationale for why the attending physician did not review all pharmacists' recommendations.
4) On 10/17/23 at 8:52 AM, a review of Resident #2's medical record revealed a pharmacy review completed on 9/18/23 with a recommendation to review and discontinue an anti-ulcer medication.
A continued medical record review revealed that a Physician Assistant-Certified (PA-C) reviewed and signed the pharmacy recommendation on 9/19/23. However, further review did not show evidence that the attending Physician had reviewed or responded to the pharmacy recommendation for Resident #2.
On 10/17/23 at 2:19 PM, during an interview with the DON, she stated that the pharmacy recommendations were reviewed and signed by the attending physician; however, if the attending physician were unavailable, the PA-C would review and sign it.
On 10/23 at 9:54 AM, during an interview with the attending physician, she stated that she was the one who reviewed the monthly pharmacy recommendations and signed them. When asked about the Pharmacy Recommendation for Resident #2 dated 9/18/23, she reported she did not review it. However, she expected the PAC not to have signed it. The attending Physician was made aware of the above concerns. She stated that she was unaware of the regulations she had to review all pharmacy recommendations and document her review and actions taken to address them.
2) On 10/11/23 at 1:31 PM, a review of Resident #82's electronic medical record EMR was conducted and revealed the resident was admitted to the facility at the end of July 2023. A brief review of Resident #82's October 2023 Medication Administration Record (MAR) revealed the resident had a 7/29/23 physician's order for Haloperidol (Haldol, antipsychotic) sublingually (SL, under the tongue) PRN for agitation, a 7/29/23 order for Lorazepam (Ativan, anxiolytic) by mouth PRN for anxiety, and a 7/29/23 physician's order for Prochlorperazine Maleate (Compazine) (antipsychotic and antiemetic) by mouth PRN for nausea/vomiting. The psychotropic medications prescribed to be administered as needed were not limited to 14 days duration and had no discontinue or stop date.
Further review of Resident #82's medical record revealed that following Medication Regimen Reviews (MRR), the consultant pharmacist wrote a Pharmacy Consultant note in the medical record. Review of the consultant pharmacists' notes for Resident #82 revealed that, on 7/31/23, 8/24/23, 9/18/23, the pharmacist documented that a recommendation was written and to see the report. Further review of the medical record failed to reveal written pharmacy reports in the resident's medical record.
On 10/17/23 at 10:35 AM, when asked where to find pharmacist's report Medication Regimen Reviews written by the consultant pharmacist for identified irregularities, the Director of Nurses (DON) stated that the pharmacist's letters were kept in a binder in the Unit Manager's office. At that time, the surveyor requested any pharmacy recommendation letters for Resident #82.
On 10/17/23 at 1:35 PM, the DON provided the surveyor with the MRR reports for Resident #82. On 7/31/23, in an MRR (Medication Regimen Review) Letter to the Attending Physician, the pharmacist wrote [Resident #82] was admitted on [DATE]. Please review the following: Haldol PRN and Lorazepam PRN need stop date review. Please review the orders for Haldol PRN and Lorazepam PRN for a stop date per CMS regulations for PRN. Handwritten on the form was Refer to Hospice Nurse, and T.O. (telephone order), the physician's name and the nurse's name was written on the signature line was and dated 8/1/23.
On 9/18/23, in an MRR Letter to Attending Physician dated 7/31/23, the pharmacist wrote: [Resident #82] is under the care of Hospice and has orders for the following psychotropic PRN medications, Lorazepam PRN for anxiety since 7/29/23, and Haldol PRN for agitation since 7/29/23. Per CMS regulations, all psychotropic PRN medications must be reviewed for a stop date. Antipsychotic PRN orders are limited to 14 days, with no exceptions. Antipsychotic PRN medications may be reordered for 14 days after full review of the resident and documentation of the rationale is noted in the resident chart. Residents under the care of Hospice are not exempt from this regulation. Please review the above psychotropic PRN medication orders for a stop date. If this resident is under the care of Hospice, have the Hospice clinician document the rationale in their progress notes. Following the pharmacist's recommendation, in the area for the physician to respond, there was a box that was checked Disagree, followed by the handwritten statement, the patient is stable on current medication regimen. No adverse effects with use of medication; continue medication. This was followed by an initial on the signature line and dated 8/2/23. The order was signed by Staff #55, Physician, who was not Resident #82's attending physician.
On 10/23/23 at 8:31 AM, the surveyor was provided with a MRR - Recommendation Summary, which included recommendations for Resident #82 created between 10/20/23 and 10/21/23 that stated, Unused PRN Medications - review for discontinuation. This resident has an order for the following PRN medication(s) which are not being used: Prochlorperazine PRN, Haldol PRN, Lorazepam PRN. Please review whether the above medications may be discontinued for this resident. There was no other documentation on the form. Also provided to the surveyor was a copy of physician's telephone order form, dated 10/18/23 at 11:55 AM, which documented Continue PRN Haldol and Lorazepam. There is no end date while patient is on [Name of Hospice].
On 10/23/23 at 9:54 AM, during an interview, Staff #31, Attending Physician and Medical Director stated that when the pharmacist wrote a report regarding a resident's medication irregularity or made a recommendation, the nurse supervisor on each floor usually gave him/her the report, unless s/he was unavailable. When asked about responding to the pharmacist's recommendations addressed psychotropic medication, Staff #31 stated that h/she preferred the visiting Psych NP take the lead, especially when a resident had diagnosis, such as Schizophrenia. At that time Staff #31 was made aware of the concerns related to psychotropic medications prescribed PRN for greater than 14 days with no stop date, with no clear rationale for continuing the medications documented in the resident's medical record. In addition, Staff #31 was made aware that there was no documentation in the resident's medical record to indicate the attending physician reviewed the irregularities identified by the pharmacist's or the physician's response. Staff #31 responded that s/he knew to document in the resident's medical record and would take notice of the concerns.
On 10/23/23 at 10:35 AM, the DON was made aware of the concerns related to the pharmacist's MRR recommendations not being in the resident's medical record, that the Pharmacist failed to identify Prochlorperazine was an antipsychotic and was ordered PRN for greater than 14 days, that Haldol PRN was ordered for greater that 14 days and Lorazepam was ordered for greater than 14 days, and there was no documented rationale for continuing the orders beyond 14 days. The DON was also made aware there was no documentation found to indicated attending physician reviewed the pharmacist's identified irregularities and/or failed to document the action taken or not taken to address the irregularities and the DON verbalized understanding of the concerns.
Review of the facility's MRR policy revealed the policy documented the steps and time frame the pharmacist must follow when no irregularities were identified, the steps and time frame the pharmacist must follow when an irregularity required immediate action, and the steps and time frame the facility would follow once informed an irregularity required immediate action. Continued review of the MRR policy failed to reveal documentation of the steps with appropriate time frames for the facility to respond when the pharmacist identified a non-urgent irregularity or recommendation.
On 10/24/23 at 12:55 PM, Staff #32, Regional Director of Clinical Services, was made aware of the concerns that the facility's MRR policy failed to include the steps with appropriate time frames for the facility and the physician to respond when the pharmacist identified an irregularity or made a recommendation. At that time, Staff #32 indicated that the steps with time frames were included in the policy. The concerns related to the facility's MRR policy and identify the appropriate time frames for the different steps in the MRR process were discussed with Staff #32 on 10/24/23 at 3:55 PM. At that time, Staff #32 verbalized understanding and indicated the facility's policy would be revised.
Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that irregularities identified by the pharmacist were reviewed and acted upon by the attending physician in a timely manner, and failed to develop, maintain, and implement policies and procedures that address the time frames for each step in the process. This was evident for 3 (#108, #84, #2) of 7 residents reviewed for unnecessary medications and 1 (#82) of 1 resident reviewed for hospice.
The findings include:
1) Review of Resident #108's medical record revealed the resident was originally admitted to the facility in April 2023.
On 11/1/23, a review of Resident #108's medical record revealed that monthly pharmacy reviews were being completed and that reports were generated for reviews conducted on 4/14/23, 6/26/23, and 8/30/23. Further review of the medical record, including both the electronic health record and the paper hard chart, failed to reveal documentation as to what these three pharmacy reviews had identified.
On 11/1/23 at 12:15 PM, the unit nurse manager reported that the pharmacy recommendations were kept in a binder in his office and proceeded to find the reports for April and June, which included documented responses. The unit nurse manager was unable to locate the report for the 8/30/23 review.
On 11/1/23 at 2:26 PM, the surveyor was provided a copy of the 8/30/23 pharmacy report for Resident #108. The report was in regard to a needed dose evaluation/adjustment. The section of the report for the Physician/Prescriber Response was noted to be blank. However, review of the medical record revealed an order for a dose adjustment, as indicated in the report, was put in place on 9/2/23.
On 11/1/23 at 2:58 PM, the Director of Nursing reported, in regard to the 8/30/23 pharmacy review, that she did not know why the review was not signed but that the order was changed.
CONCERN
(F)
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 interview of facility staff, it was determined the facility failed to ensure that a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operati...
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Based on interview of facility staff, it was determined the facility failed to ensure that a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operation and a certified Registered Dietician for nutrition management. This has the potential to affect all residents.
The findings include:
On 10/19/23 at 10:21 AM, an interview with the Kitchen Manager staff #51 revealed that he was not clinically qualified as per Federal and state regulations. During the interview, he reported that he had been in his position for two and a half years. He reported that he had completed his coursework, but had not yet passed the Certified Dietary Manager (CDM) exam. He stated he planned to take the exam in November 2023.
On 10/23/23 at 1:14 PM, an interview with Dietician (eligible) staff # 28, revealed that she was not clinically qualified as per Federal and state regulations. During the interview, she reported that she had been in her position since June 2023. She continued that she was eligible to take the registered dietitian exam, but had not taken it yet.
On 10/23/23 at 1:27 PM, the [NAME] President of Operations and the Administrator were interviewed. They reported the previous CDM left the facility around September 2021. They also were aware that the Dietitian was not currently certified as a registered dietician. They added that the dietitian does have a consulting dietician available when needed.
On 10/23/23 at 1:14 PM, during an interview with the facility Registered Dietitian (eligible) Staff # 28, reported that a registered dietitian consultant was available by phone from her company Nutraco. Staff #28 reported that the last time the consultant had been on site at the facility had been about 2 months ago.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on review of pertinent documentation, observation, and interviews with resident and staff, it was determined that the facility failed to ensure that residents were served meals according to a pr...
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Based on review of pertinent documentation, observation, and interviews with resident and staff, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated resident preferences. This was evident for 5 (Resident # 112, Resident # 49, Resident # 25, Resident #2, Resident #59) out of 6 residents on 5 of the 6 units at the facility reviewed for food during a survey. This has the potential to affect all residents.
The findings include:
1. Resident #112 was admitted to the facility for rehabilitation and wound care. An observation of resident's menu ticket and tray was made on 10/16/23 at 12:16 PM. The observation revealed that the resident had milk listed on his/her menu ticket; however, there was no milk on his/her tray.
On 10/18/23 at 12:38 PM, an additional observation of Resident #112's menu ticket and tray were made. This observation revealed that milk was included on the menu ticket; however, the observation failed to reveal that the resident was provided milk.
On 10/19/23 at 9:44 AM, a third observation of Resident #112's meal ticket was made. The observation revealed that the residents' menu ticket included milk and dry cereal and did not include orange juice. However, observation of the breakfast provided to the resident revealed dry cereal, and orange juice, but no milk. During a brief interview with Resident # 112, he/she reported that he/she had not requested any substitutes for his/her breakfast and that he/she did not drink orange juice because he/she was a diabetic.
On 10/19/23 at 10:30 AM, the Kitchen manager, staff #51, was interviewed. During the interview, he reported that, due to a traffic accident, the milk was not delivered today. He reported that the facility purchased milk from a local store but had run out before Resident # 112 room was served. He reported that he was not sure why the resident did not receive milk for the last three days.
On 10/20/23 at 9:12 AM, the Dietician (eligible) Staff # 38 was interviewed. She reported that she was unaware of any residents not receiving milk, as indicated on the menu ticket. She confirmed that increased protein was indicated for resident # 112 due to the resident having a wound. In addition, she confirmed that orange juice should be limited to a Liberalized Diabetic.
On 10/31/23 at 12:56 PM, the surveyor observed Resident #112 during lunch. The resident had been served meatloaf, peas, roasted potatoes, and mixed melon. The lunch ticket for the meal was still on the tray. The lunch ticket had today's date at the top and stated that the resident was supposed to be served harvest beets, mashed potatoes, oven fried chicken, and watermelon. None of the items on the ticket corresponded to the items in the meal that was served to the resident.
Furthermore, there was a list of preferences at the top of the lunch ticket that specified no melon. Neither the watermelon on the ticket nor the mixed melon that was served to the resident followed this preference.
Resident #112 was interviewed and that time and stated that the tickets are always wrong. And I'm served melon all the time even though I don't want it.
On 10/31/23 at 1:06 PM, Unit Manager (UM) #3 was interviewed in Resident #112's room. During the interview, UM #3 confirmed that the resident's meal ticket was different than the items that were served to the resident.
2. Resident # 49 was admitted to the facility for rehabilitation and received dialysis as an outpatient. During an interview on 10/24/23 at 12:13 PM, the resident reported that he/she often had received orange juice for breakfast, but that he was not supposed to because he/she was on dialysis. He/she stated that he/she did not drink orange juice.
An observation was made on 10/24/23 at 12:52 PM of Resident #49's menu ticket and breakfast tray. The observation of the menu ticket revealed that milk had been included on the menu ticket, and orange juice was not listed on the menu ticket. Observation of the resident's tray revealed that the resident received orange juice for breakfast and no milk. During the observation, the resident reported that the staff never asked him/her if he wanted orange juice; they just served it a couple of times a week.
On 10/26/23 at 8:39 AM, an additional observation of Resident #49's menu ticket and tray was made. The observation revealed that his/her menu ticket included garlic bread and did not include apple cranberry juice. Observation of his/her tray failed to reveal garlic bread but did include apple cranberry juice. During the observation, the resident reported that he/she did not request any alterations to his/her meal.
Review of Resident #49's diet orders on 10/24/23 revealed an order dated 2/23/22 for a liberalized renal diet.
On 10/23/23 at 01:14 PM, the Dietician (eligible) Staff # 38 was interviewed. During the interview, she was asked about special considerations that are included with a renal diet; she replied, that the diet would avoid high potassium diet. This would include orange juice, tomatoes, potatoes, and bananas.
3. Resident # 25 was a long-term resident of the facility with moderate cognitive decline. On 11/01/23 at 8:05 AM, an observation was made of Resident #25's menu ticket and tray. Observation of the menu ticket revealed oatmeal, chopped waffles, orange juice, whole milk, coffee, and diet sugar. Further review of the menu ticket revealed the resident was on a liberalized diabetic with no added salt (NAS)- chopped diet. However, observation of the tray provided to the resident served scrambled eggs, chopped meat, and a whole waffle.
On 11/1/23,a review of orders for Resident #25 revealed a diet order dated 1/27/23 for a diet of liberalized diabetic NAS- chopped.
4. On 11/01/23 at 8:40 AM, an observation was made of Resident # 2's menu ticket and breakfast tray. Observation revealed that the resident had oatmeal on his/her tray, however, the oatmeal was not on the menu ticket.
On 11/01/23 at 8:42 AM, GNA, Staff #49 was interviewed while serving Resident #2's breakfast. During the interview, she confirmed that the oatmeal was served but not on the menu ticket. She reported she knew the resident could eat the oatmeal because the resident was on a regular diet. GNA #49 did not know why the oatmeal was omitted from the menu ticket. She reported that the resident did not request any changes in breakfast.
0n 11/1/23 a review of the dietary orders for Resident #2 revealed an order dated 3/7/33 for a liberalized diabetic diet, regular texture.
On 11/01/23 at 1:00 PM, the Corporate Dietary Director, a Registered Dietitian, was interviewed. During the interview, the surveyor reviewed the discrepancies in what was written on the kitchen's menu, resident meal tickets, and the menus provided to the residents. She reported that that a liberalized diet has less restrictions and allows the resident to make more choices. In addition, a liberalized diet may increase the resident's caloric intake in situations where the resident needs to gain weight. She also reported that the facility follows the guidelines from Dietary Guidelines Maryland of Health and Mental Hygiene Diet. However, unless the resident has made a specific request, the expectation is that the resident should be provided with the food items that are written on the menu ticket.
5. Resident # 59 was admitted to the facility following a hospital stay. On 10/23/23 at 9:44 AM, an observation was made of the resident's breakfast tray and menu ticket. The observation of the menu ticket included oatmeal. Observation of the breakfast tray failed to reveal that oatmeal was provided.
Further observation of Resident #59's meal menu and tray on 10/24/23 at 12:34 PM revealed a menu ticket that included garlic bread; however, there was no garlic bread provided to the resident. During the observation, the resident reported that he/she did not request any changes to the above meals.
On 11/02/23 at 8:46 AM, the above concerns were discussed with the Kitchen Manager staff # 51. During the interview, he reported that the expectation was that the residents would receive all the food items that are on the menu tickets.
On 11/03/23 at 10:28 AM, the Dietician eligible staff #38 was interviewed. During the interview, she reported that she conducted monthly audits of the diet orders. The audits included reconciling the electronic record of the ordered diet and the menu tickets. Staff 38 provided documentation of the audits. She also reported that she does weekly observations of the residents to ensure the residents menu tickets matches what the residents are provided, and she had no concerns with the results of these observations. However, she reported that she does not document these observations.
Oct 2019
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on surveyor observations of dining service to residents and interview with facility staff, it was determined that the facility failed to ensure a homelike environment during meal services. This ...
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Based on surveyor observations of dining service to residents and interview with facility staff, it was determined that the facility failed to ensure a homelike environment during meal services. This finding was evident for 1 of 2 main dining rooms within the facility. The findings include:
On 10-21-19 at 12:29 PM, surveyor observation of the 3rd floor main dining room revealed facility staff serving lunch meals to residents seated at several dining tables. Staff placed the residents' trays in front of each resident at the table but removed only the plate covers and cup covers leaving the plate and utensils on the tray. Residents then proceeded to eat directly from the placed tray. Further observation revealed no evidence of music playing in the background nor other background stimulation. Staff were observed only directly communicating with one another and not with the dining room residents.
Additionally, surveyor observation at 10-22-19 at 9 AM and 12:40 PM of the 3rd floor main dining room, revealed no evidence again of background music or any stimulation provided to residents during the designated meal time. There was no evidence of any social communication with residents from staff while in the dining room. Meals were were directly served on the trays when placed in front of the resident from the meal cart.
On 10-23-19 at 9:30 AM and 10:30 AM, an interview with the Director of Nursing and the Director of Activities revealed no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on review of administrative documents and interviews with residents and staff, it was determined that the facility failed to assist a resident with filing a grievance and promptly follow up on t...
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Based on review of administrative documents and interviews with residents and staff, it was determined that the facility failed to assist a resident with filing a grievance and promptly follow up on the grievance. This finding was evident for 1 of 6 residents reviewed for personal property concerns during the survey.(#123) The findings include:
On 10-22-19 at 09:29 AM, surveyor interview with resident #123 revealed that he/she reported to the laundry personnel that 3 shirts and a gray blanket went missing approximately 3 weeks ago when they were taken to the laundry and no one had followed up on the missing items.
On 10-23-19 at 07:41 AM, surveyor interview with staff #4 confirmed that resident #123 reported the missing items to them over a week ago and they had not yet been found.
On 10-24-19 at 08:09 AM, surveyor interview with the Social Services Director/Facility Grievance Officer revealed that the facility's procedure for missing items was for the staff member (to whom the concern was reported) assist the resident with completing a written concern report and then submit it to the Grievance Officer. The Grievance Officer would investigate any concerns and follow up with the resident within 5 days. The Grievance Officer stated that he/she was not aware of resident #123's missing belongings and did not have any outstanding written concerns filed by the resident.
On 10-24-19 at 10:30 AM, surveyor interview with the laundry supervisor revealed that, when residents report missing items in the laundry, laundry staff are to search for the missing items immediately and file a report with the Social Services Director if they are not found.
On 10-24-19, surveyor review of the facility policy on resident grievances and concerns revealed staff members who overhear a complaint voiced by a resident should assist the resident with filing a written concern report to the facility grievance officer. The facility grievance officer is to initiate an investigation upon receipt of the concern report. Within 72 hours of notification of the concern, the grievance officer will report his/her findings to the appropriate manager, who would then follow up with the resident that filed the concern. There was no evidence that the facility assisted resident #123 with filing a grievance nor did the facility follow up with resident #123 after he/she voiced their concern.
On 10-24-19 at 03:01 PM, interview with the administrator revealed no new information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of clinical records and interviews with staff and residents, it was determined that the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of clinical records and interviews with staff and residents, it was determined that the facility failed to provide written notification of a resident's transfer or discharge to the resident or representative. This was evident for 2 of 5 residents selected for review of hospitalization during this survey. (#123 and #27) The findings include:
1. On 10-22-19, surveyor review of resident #123's clinical record revealed that he/she was transferred and admitted to the hospital on [DATE], 05-25-19, and 09-20-19 for medical emergencies. Further review of the record revealed that resident #123 was self-responsible. However, there was no evidence that resident #123 was given any written notice of transfer.
On 10-22-19 at 09:50 AM, interview with resident #123 revealed that he/she did not receive any written notification of the hospital transfers.
On 10-24-19 at 01:07 PM, interview with the Director of Nursing revealed no additional information.
2. On 10-25-19, surveyor review of the clinical record for resident #27 revealed a 07-26-19 change in condition that was completed by facility staff. Staff documented that the resident was transferred to the local hospital emergency room via 911 to rule out internal bleeding. Further review revealed tht staff notified the resident's responsible party of the hospital transfer via telephone.
However, further record review revealed no documented evidence that the facility staff had notified resident #27's responsible party in writing of the 07-26-19 hospital transfer.
On 10-25-19 at 4PM, surveyor interview with the Director of Nursing revealed no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews with facility staff and residents, it was determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews with facility staff and residents, it was determined that the facility failed to provide the facility bed hold policy for residents that were transferred to the hospital. This was evident for 2 of 5 residents selected for review of hospitalization during the survey. (#123 and #27) The findings include:
1. On 10-22-19, surveyor review of resident #123's clinical record revealed that he/she was transferred and admitted to the hospital on [DATE], 05-25-19, and 09-20-19 for medical emergencies. Further review of the record revealed resident #123 was self-responsible and there was no evidence that resident #123 was given the facility's bed hold policy upon transfer to the hospital.
On 10-22-19 at 09:50 AM, interview with resident #123 revealed he/she did not receive a bed hold policy during the hospital transfers.
On 10-24-19 at 01:07 PM, interview with the Director of Nursing revealed no additional information.
2. On 10-25-19, surveyor review of the clinical record for resident #27 revealed a 07-26-19 change in condition completed by facility staff. Staff documented that the resident was transferred to the local hospital emergency room via 911 to rule out internal bleeding. The attending physician was notified and ordered the resident to be transferred to the local hospital emergency room via 911 to rule out internal bleeding.
However, further record review revealed no documented evidence that the facility staff had notified resident #27's responsible party of the bed hold policy, either verbally or in writing at the time of the hospital transfer on 07-26-19.
On 10-25-19 at 4PM surveyor interview with the Director of Nursing revealed no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10-24-19, surveyor review of resident #68's clinical record revealed that he/she was admitted to the facility on [DATE] an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10-24-19, surveyor review of resident #68's clinical record revealed that he/she was admitted to the facility on [DATE] and was discharged to the community on 10-03-19. There was no evidence that a discharge plan was documented in the comprehensive care plan.
On 10-25-19 at 09:29 AM, interview with the Social Services Director revealed that he/she was responsible for completing discharge care plans, however, he/she did not have access to discharge care plans in the facility's electronic medical record system.
Based on surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to develop a comprehensive resident centered care plan to address residents' medical conditions. This finding was evident for 2 of 30 residents selected for review during the survey. (#51 and #68). The findings includes:
1.On 10-23-19 at 10:30 AM, surveyor review of the clinical record for resident #51 revealed that the resident was admitted to the facility's long-term care unit with multiple diagnoses including, but not limited to, unspecified pain. Further review of resident #51's medication administration record (MAR) revealed that Tylenol (medication for ache and pains) 1000 mg was given twice a day, Gabapentin (medication for nerve pain)200 mg three times a day for neuropathic pain, and Tramadol (opioid) 50 mg twice a day as needed for breakthrough pain.
However, there was no evidence in the clinical record to indicate that a comprehensive care plan was developed for resident #51 to address the administration of the multiple pain medications and the related side effects.
On 10-23-19 at 3:35 PM, surveyor interview with the Director of nursing revealed no new information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical records and interview of resident #115 and facility staff, it was determined that the facility staff failed to review a resident's plan of care quarterly. This...
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Based on surveyor review of the clinical records and interview of resident #115 and facility staff, it was determined that the facility staff failed to review a resident's plan of care quarterly. This finding was evident in 1 of 30 residents selected for review during the survey. (#115). The findings include:
On 10-21-19 at 1:30 PM, surveyor interview with resident #115 revealed that he/she had not participated in a care plan meeting in a while. Resident #115 was self-represented and occasionally a friend also participated in the meeting.
On 10-22-19 around 1 PM, surveyor review of the clinical record revealed that the last care plan meeting for resident #115 was in December 2018. Further record review revealed that resident #115 makes his/her own health care decisions.
There was no evidence that a quarterly review of resident #115's care plan was done by the interdisciplinary team as required. In addition, resident #115 was not given the opportunity to participate in the review of his/her plan of care.
On 10-22-19 at 2:10 PM, interview with the social worker revealed it was an oversite.
On 10-22-19 at 4:30 PM, surveyor interview with the director of nursing did not reveal any new information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on surveyor observations, record review, and interviews with facility staff, it was determined that the facility failed to assess resident #81 for risk of entrapment and obtain informed consent ...
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Based on surveyor observations, record review, and interviews with facility staff, it was determined that the facility failed to assess resident #81 for risk of entrapment and obtain informed consent from resident #81's responsible party prior to the installation of 1/2 length bed rails. This finding was evident for 1 of 2 (#81) residents reviewed for restraint use during the survey. The findings include:
On 10-21-19 at 01:46 PM, 10-22-19 at 09:01 AM, and 10-23-19 at 09:33 AM. surveyor observed half length bed rails that were on both sides of resident #81's bed.
On 10-21-19 at 01:46 PM, interview with resident #81 revealed that the facility installed the bed rails because he/she had a history of rolling out of bed while sleeping.
On 10-23-19, surveyor review of resident #81's clinical record revealed no evidence that the resident was assessed for risk of entrapment prior to the installation of the bed rails. Furthermore, there was no evidence that the facility reviewed the risks and benefits or obtained informed consent from resident #81's responsible party for the use of the 1/2 length bed rails.
On 10-23-19 at 10:55 AM, surveyor interview with the Director of Nursing revealed no new information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical record, review of facility's consultant psychiatric services contract/addendum and interview with facility staff, it was determined that the facility failed to...
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Based on surveyor review of the clinical record, review of facility's consultant psychiatric services contract/addendum and interview with facility staff, it was determined that the facility failed to ensure that necessary behavioral health services were in place for resident #104. This finding was evident for 1 of 8 residents selected for the Unnecessary Medication/Behavior/Mood review. The findings include:
On 10-24-19, surveyor review of the clinical record for resident # 104 revealed the following psychotropic medications ordered for administration: Zoloft 175 mg once daily for Major Depressive Disorder in September 2017, and in November 2018 Abilify 2 mg once nightly for Schizophrenia.
On 05-03-19, documentation by the facility's consultant pharmacist, on the monthly report, revealed the recommendation for the attending physician to evaluate if dosage reduction for the Abilify could be attempted for resident #104. Further review of the 05-03-19 report revealed documentation by the facility's psychologist on 05-14-19 that the resident was not covered for Counterpoint services and this is not an emergency so cant see for this. There was no evidence in the clinical record that the resident was receiving any psychiatric services since January 2019.
Additionally, review of the pharmacist's monthly report for 08-07-19 revealed that a request was made to resident #104's attending physician to evaluate if a dosage reduction for the resident's Zoloft medication could be attempted . Further review of the 08-07-19 report revealed documentation by the psychiatric NP that dosage reduction was not possible secondary to Past GDR (Gradual Dosage Reduction) resulted in patient withdrawing, depressed mood and mutism. There was no evidence of a date for the NP's documentation, only a date stamp of 10-15-19 by staff that the physician/NP was notified by staff of the report. At this time, the resident was still not being followed by the facility's consultant psychiatric services.
On 10-25-19 at 10:45AM, surveyor interview with resident #104's attending physician revealed that the physician was unaware that the resident was not being followed by psychiatric services within the facility. Further interview revealed that the attending physician felt that the responsibility to address the justification of the continued use and/or dosage reductions for the resident's psychotropic medications should be addressed by psychiatric services and not the attending physician. No additional information was provided.
On 10-25-19 at 3PM, interview with the facility administrator revealed that the facility had initiated an addendum to the contract with the consulting psychiatric services, which included a monthly stipend for services to be provided to residents that required psychiatric visits, even if the resident's payer source would not reimburse for the services.
Surveyor review on 10-25-19 of the facility's Addendum to Service Agreement revealed that the facility had agreed to pay the consultant psychiatric services $500.00 each month as of 05-01-19 to cover the non-reimbursable third party visits by the consultant. Further review of the Addendum revealed that this agreement would remain in force through the lifetime of the Service Agreement, unless amended by mutual written consent in the future. The Agreement included a list of residents whose payer source had been billed by the Consultant and was not reimbursed. The list of residents included resident #104 for a consultant psychiatric visit on 01-29-19 when there was no reimbursement.
On 10-25-19 at 4:30PM, interview with the Director of Nursing and the Assistant Director of Nursing revealed no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of the clinical record, observation, and facility staff interview, it was determined that the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of the clinical record, observation, and facility staff interview, it was determined that the facility staff failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. This finding was evident in 1 of 2 residents selected for review of infections not UTI related care area during the survey. (#227). The findings include:
On 10-21-19 at 08:30 AM, surveyor tour of resident #227's room revealed a wound vac machine (a device that drains seeping liquid from a wound by forming airtight cover and pumping the liquid out) hooked to resident #227's left foot.
On 10-24-19 at 9:12 AM, surveyor interviewed resident #227 who stated I have the wound vac because I have MRSA (Methicillin Resistant Staphylococcus Aureus) infection.
Surveyor review of resident #227's clinical record revealed a hospital Discharge summary, dated [DATE], that documented the resident had a MRSA infection in the left foot wound. Further record review revealed a physician order that stated contact isolation for MRSA in wound to left foot
On 10-24-19 at 10:15 AM, surveyor interviewed the wound nurse who stated that he/she was not aware that the resident had MRSA in the wound. The wound nurse indicated that he/she does not wear any protective gown when caring for resident #227's wound.
Additional interview with the facility's infection control preventionist revealed that, on a line listing of infections in the facility, resident #227 was identified as having MRSA in the left wound. The infection control nurse indicated that per facility policy, isolation precautions are instituted whenever a resident is positively identified as having MRSA. These precautions included gowning during wound care and dealing with soiled materials.
However, there was no evidence that isolation precautions were set up outside of the resident's room nor a sign to tell care givers and visitors that the resident was on isolation.
On 10-24-19 at 1:10 PM, surveyor interview with the Director of Nursing and infection control nurse revealed no new information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10-21-19 at 04:09 PM, surveyor observed that resident #44's bed contained two bed rails on each side that spanned the enti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10-21-19 at 04:09 PM, surveyor observed that resident #44's bed contained two bed rails on each side that spanned the entire length of the bed. On 10-22-19 at 07:30 AM, surveyor observed resident #44 lying in bed with 2 side rails up on each side of the bed that spanned the length of the bed preventing the resident from leaving the bed.
On 10-23-19, a surveyor review of resident #44's record revealed that a physician's order was written on 08-02-18 for 1/4 length bed side rails to assist the resident with bed mobility. There was no evidence of a physician's order authorizing the use of full length bed side rails. The resident's responsible party gave informed consent for the use of the 1/4 length side rails on 08-02-18 and again on 06-25-19. The facility reassessed the resident's risk for entrapment on 06-25-19.
On 10-23-19 at 10:59 AM, interview with the Director of Nursing revealed that the resident and family requested that the resident have the side rails due to the resident's history of falling and poor safety judgment.
However, there was no evidence that facility staff obtained physician's orders for full length side rails.
According to the Maryland Nurse Practice Act 10.27.09.03, the registered nurse will collaborate with other health care providers in providing care. In addition, according to CO[DATE].07.09.14A, physical restraints may be used only if prescribed by a physician or administered by another health care professional practicing within the scope of their license and if less restrictive alternatives were considered and appropriately ruled out by the physician
3. On 10-21-19 at 01:46 PM, 10-22-19 at 07:32 AM, and 10-23-19 at 09:33 AM, surveyor observed that resident #81's bed contained side rails on each side that spanned half the length of the bed.
On 10-23-19, surveyor review of resident #81's clinical record revealed no evidence of a physician's order authorizing the use of half length bed side rails.
On 10-23-19 at 10:55 AM, surveyor interview with the Director of Nursing revealed that they were not aware that resident #81's bed contained side rails.
According to the Maryland Nurse Practice Act 10.27.09.03, the registered nurse will collaborate with other health care providers in providing care. In addition, according to CO[DATE].07.09.14A, physical restraints may be used only if prescribed by a physician or administered by another health care professional practicing within the scope of their license and if less restrictive alternatives were considered and appropriately ruled out by the physician.
Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility failed to ensure standards of nursing practice. This finding was evident for 4 of 30 residents selected for review during the survey (#44, #51, #81, #88). The findings include:
1. On 10-23-19 at 10:30 AM, surveyor review of the clinical record for resident #51 revealed the resident was admitted to the facility's long-term care unit with multiple diagnoses including, but not limited to, unspecified pain. Further review of resident #51's medication administration record (MAR) for the months of August and September 2019, revealed that Tylenol (medication for normal ache and pain) 1000 mg was given twice a day, Gabapentin (medication for nerve pain) 200 mg three times a day for neuropathic pain, and Tramadol (an opioid analgesic) 50 mg twice a day as needed for breakthrough pain.
Additional record review revealed that resident #51 was administered the Tramadol on August 8th, 9th, 21, 26, and 29, 2019. In addition, the Tramadol was administered to resident #51 on September 3rd, 6th, 7th, 8th, 10th, 11th, 15th, 16th and 17th. Although there was evidence of pre administration pain level assessment, the assessment did not specify the location where resident #51 was experiencing pain. Additionally, there was no evidence that facility staff assessed and documented resident #51's pain level after administering the pain medication.
Furthermore, there was no evidence in the clinical record that the facility staff attempted non pharmacological (interventions that do not involve the use medications to treat pain) approaches to help relieve resident #51's pain prior to administering the pain medications.
On 10-24-19 at11:12 AM, during a surveyor interview with the second floor unit manager, he/she stated that per facility policy, whenever as needed pain medication are administered, the nurse who administered the medication is required to document on the MAR the pain score and location of the pain prior to administering the medication and also document the outcome of the pain medicine administered.
As a standard of nursing practice, a licensed nurse is required to document medication administered as indicated in section 10.27.10.03 B of the Nurse practice act under policies and procedures of the nurses' practice setting.
On 10-24-19 at 11:43 AM, surveyor interview with the Director of Nursing revealed no further information.
4. On 10-23-19, surveyor review of the clinical record for resident #88 revealed that, on 10-04-19, the resident was evaluated by the optometry consultant. An assessment concluded that the resident had conjunctivitis and the recommended treatment was Polytrim eye solution 4 times a day for 14 days. Conjunctivitis is an inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid.
Further review revealed that, on 10-04-19 at 4:30PM, the attending physician for resident #88 ordered the administration of Polytrim Solution eye drops 4 times a day in each eye for 14 days for Conjunctivitis.
Review of the October 2019 MAR (Medication Administration Record) revealed that the initial dose was scheduled to be administered at 8PM on 10-05-19, and the last completed administration dose was for 10-19-19 at 4PM.
However, further review of the October 2019 MAR for resident #88 revealed that the initial dose of the Polytrim Solution was not administered by staff until 4PM on 10-07-19, while the last dose administered was documented for 4PM on 10-19-19 at 4PM. Staff documented on the MAR from 8PM on 10-05-19 till 12PM on 10-07-19 that they were waiting for the medication to come from the pharmacy. There was no documented evidence that licensed staff had notified the attending physician that the medication was not available until 10-07-19, nor did staff obtain physician clarification for a change in the administration schedule to cover the initial 7 doses that had not been administered.
On 10-23-19 at 12:30PM, surveyor interview and observation of the 2nd floor C wing medication cart with LPN (Licensed Practical Nurse) #3 revealed an approximate 1/4 filled bottle of the remaining Polytrim solution with a label attached that the medication was delivered to the facility on [DATE] for administration to resident #88 Further interview with LPN #3 revealed that licensed staff would need to contact the attending physician for an order to change the medication's administration schedule due to a delay in the initiation of the medication.
Interview with the Director of Nursing and the assistant Director of Nursing on 10-23-19 at 5:30PM revealed no additional information.
According to the Maryland Nurse Practice Act 10.27.09.02D, the RN shall develop a plan of care that prescribes interventions to attain expected outcomes and (b) the plan shall (ii) provide for continuity of care and (iii) include identification, coordination, and utilization of available resources.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of the clinical record, surveyor observation and interview with facility staff, it was determined that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of the clinical record, surveyor observation and interview with facility staff, it was determined that the facility staff failed to follow physician orders in medication administration for resident #88. This finding was evident for 1 of 30 residents reviewed for the survey. The findings include:
On 10-23-19, surveyor review of the clinical record for resident #88 revealed that, on 10-04-19 the resident was evaluated by the optometry consultant. An assessment concluded the resident had conjunctivitis and the recommended treatment was Polytrim 4 times a day for 14 days.
Further review revealed on 10-04-19 at 4:30PM the attending physician for resident #88 ordered the administration of Polytrim Solution eye drops 4 times a day in each eye for 14 days for Conjunctivitis. Conjunctivitis is inflammation of the outermost layer of the white part of the eye and the inner surface of the eyelid.
Review of the October 2019 MAR (Medication Administration Record) revealed the initial dose was scheduled to be administered at 8PM on 10-05-19 and the last administration dose was for 10-19-19 at 4PM.
However, further review of the October 2019 MAR revealed that the initial dose of the Polytrim Solution was not administered to resident #88 by staff until 4PM on 10-07-19, while the last dose administered was documented for 4PM on 10-19-19 at 4PM. Therefore, staff failed to administer a total of 7 doses of the Polytrim and the resident did not receive the total ordered 56 doses. In addition, record review revealed no evidence that licensed staff had notified the attending physician that the medication was not made available until 10-07-19. (Refer to F658 for additional information)
On 10-23-19 at 12:30PM, surveyor interview and observation of the 2nd floor C wing medication cart with LPN (Licensed Practical Nurse) #3 revealed an approximate 1/4 filled bottle of the remaining Polytrim solution with a label attached that the medication was delivered to the facility on [DATE] for administration to resident #88 Further interview with LPN #3 revealed that licensed staff would need to contact the attending physician for an order to change the medication's administration schedule due to a delay in the start of the medication.
Interview with the Director of Nursing and the assistant Director of Nursing on 10-23-19 at 5:30PM revealed no additional information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. On 10-21-19 at 08:30 AM, during entrance conference meeting, the facility Director of Nursing revealed that the facility was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. On 10-21-19 at 08:30 AM, during entrance conference meeting, the facility Director of Nursing revealed that the facility was a smoke free or non-smoking facility.
On 10-21-19 at 09:32 AM, surveyor interview with resident #19 during initial tour revealed that he/she was a smoker and had been smoking for 45 years. Resident #19 stated he/she was aware of the facility non-smoking policy prior to admission but chose to smoke off the property whenever he/she wanted to smoke.
Record review revealed a signed copy of facility non-smoking policy by resident #19 on 04-19-19. Further review revealed the resident was alert and oriented to self, place time and situation. Resident #19 was self-represented.
On 10-22-19 surveyor reviewed the facility non-smoking policy. The policy indicated smoking is not permitted inside the facility or its grounds. The policy specified:
A. Upon admission/readmission residents will be assessed for smoking
B. If a resident is identified as a smoker or has a history of smoking, then 1. resident will be offered smoking cessation assistance such as nicotine patch and 2. will be informed that smoking materials such as cigarettes and lighters are not permitted at the facility.
C. If any smoking material is found on a resident, it will be confiscated, labeled and turned over to social worker for safe keeping till discharge.
D. If a resident is non-compliant with the facility smoking policy by smoking anywhere in the facility and has tobacco products and smoking materials on their person or room, regular checks of room will be instituted and if the behavior persist, a 30-day discharge notice will be given to the resident
Further record review revealed that on 08/19/19 at 08:44 AM, the facility social worker witnessed resident #19 smoking a cigarette in front of the facility building. The interdisciplinary team members met with the resident and explained the facility policy again to him/her and offered to transfer the resident to a sister facility that allows smoking. Resident #19 declined the offer.
On 10-23-19 at 08:40 AM, surveyor observed resident #19 propelling him/herself off the facility property. Surveyor followed the resident and observed the resident smoking off the facility property. The resident was observed returning to the facility and keeping his/her smoking material on his/her person.
On 10-22-19 at 09:45 AM, surveyor interview with resident #19 revealed that he/she did go outside in-front of the building to smoke a cigarette and has done these multiple times. Resident #19 revealed that he/she has kept his own cigarettes and lighter since admission on [DATE]. Resident stated that its his/her right to smoke and has done so for 45 years and no one will stop him/her.
On 10-22-19 at 10:10 AM, surveyor interview with the social worker revealed that resident was a non-compliant smoker who refused to give up smoking materials despite several counseling.
On 10-22-19 at 11:22 AM, a 30-day notice of discharge was issued to resident #19 for violating facility non-smoking policy.
Although the facility smoking policy indicated that smoking materials for residents who smoke were to be confiscated and kept by the social worker until discharge, surveyor observed resident #19 keeping his/her own smoking materials. In addition, resident #19 was not issued a 30-day discharge notice until 10-22-19 even though social worker observed resident smoking on August 19, 2019 the IDT team were aware resident #19 was keeping his/her own smoking material.
On 10-22-19 at 10:30 AM, interview with the director of nursing revealed no further information.
2. On 10-21-19 at 09:32 AM, surveyor interview with resident #51 during initial tour revealed that he/she was not a smoker and was aware of the facility non-smoking policy prior to admission on [DATE].
On 10-21-19 at 4:30 PM, follow up interview of resident #51 by another surveyor revealed that the resident was a smoker and usually signed him/herself out to go smoke off the facility property.
Record review revealed a signed copy of facility non-smoking policy by resident #51 on 06-26-19. The resident was alert and oriented to self, place and time. The resident was able to advocate for him/her self appropriately and was self-represented.
On 10-22-19 surveyor review of facility non-smoking policy. The policy indicated smoking is not permitted inside the facility or its grounds. The policy specified:
A. Upon admission/readmission residents will be assessed for smoking
B. If a resident is identified as a smoker or has a history of smoking, then A. resident will be offered smoking cessation assistance such as nicotine patch and B. will be informed that smoking materials such as cigarettes and lighters are not permitted at the facility.
C. If any smoking material is found on a resident, it will be confiscated, labeled and turned over to social worker for safe keeping till discharge.
D. If resident is non-compliant with the facility smoking policy by smoking anywhere in the facility and has tobacco products and smoking materials on their person or room, regular checks of room will be instituted and if the behavior persists, a 30-day discharge notice will be given to the resident.
Further record review revealed nursing documentation on 10-21-19 at 4:10 PM, that indicated the unit manager was called to the resident's room by the charge nurse. Per the unit manager documentation, there was a heavy smell of cigarette smoke in the resident ' s room.
On 10-22-19 at 09:12 AM, surveyor review of the clinical record revealed a plan of care, initiated on 09-06-19, that identified the resident as non-compliant with the facility's no smoking policy. Additional record review revealed that a smoking assessment was done on 10-21-19 at 4:30 PM. The smoking assessment identified resident #51 as a safe smoker.
On 10-22-19 at 4:30 PM, surveyor interview with resident #51 revealed that he/she did go outside in-front of the building to smoke a cigarette on 10-21-19 around 4 PM. The resident confirmed that he/she kept smoking materials on his/her person and showed surveyor a lighter, but denied smoking in his/her room.
On 10-22-19 at 10:10 AM, surveyor interview with the social worker revealed that the resident was non-compliant with the facility's smoking policy.
Although the facility smoking policy indicated that smoking materials for residents who smoke were to be confiscated and kept by the social worker until discharge, surveyor observed the resident keeping his/her own smoking materials. In addition, the smoking assessment was not done until 10-21-19.
On 10-22-19 at 10:30 AM, interview with the director of nursing revealed no further information.
Based on surveyor review of the clinical record, surveyor observations, review of the facility's policy and procedure, and interviews with residents and facility staff, it was determined that the facility failed to ensure that a systematic approach was identified with the hazards and/or risks consistently addressed for residents who smoke. This finding was evident for 4 of 4 residents reviewed for Smoking. (#86, #23, #19, and #51) The findings include:
On 10-21-19 at 7:56AM and 7:58AM, surveyor observed resident #19 and resident
#51 leaving the grounds of the facility in their wheelchairs. At 8:08AM and 08:12AM, both residents were observed returning to the front entrance of the facility.
Surveyor interviewed resident #19 at 8:12AM, as he/she approached the facility grounds, and the resident stated that h/she leaves the facility to go smoke down the hill away from the facility's entrance. During the interview,the resident stated that other residents also go down the hill to smoke.
Interview on 10-21-19 at 1PM with the Director of Nursing revealed that the facility has a smoking policy that smoking is not permitted at the facility, since the facility maintains a smoke free environment.
Review of the facility's current Smoking Policy revealed that, if a resident smokes or has recent history of smoking, the resident will be offered smoking cessation assistance or transfer to a facility where smoking is permitted. In addition, the resident will be informed that no cigarettes, lighters, matches or other smoking paraphernalia will be permitted while a resident resides at the facility. This policy included that no resident is permitted to retain in their possession any smoking materials and/or lighting paraphernalia.
Further review of the Smoking Policy revealed that a Non Compliant smoker is identified if one or more of the following behaviors have occurred: Smokes anywhere in the facility or on facility property; Has cigarettes other tobacco products or smoking paraphernalia on his/her person or in his/her room. The policy stated that facility staff will meet with all Non compliant smokers to review the facility's Smoke Free Policy and remove all smoking materials from the resident's person and room.
1. On 10-21-19, surveyor review of the clinical record for resident #86 revealed documentation on 09-11-19 at 2:31PM by RN (Registered Nurse) #5 that the resident was observed smoking on the facility premises. Further review revealed that the resident was then educated on the risk of smoking and the resident's family and responsible party were notified and made aware that any further violation would result in a 30 day notice to vacate.
Record review revealed a smoking evaluation completed by staff, with an effective date of 03-25-16 ,that had determined resident #86 was safe to smoke with supervision and with protective smoking equipment.
However, further record review revealed no evidence of any further smoking evaluations completed, until 10-21-19 at 4:49PM, that had identified that resident #86 had dexterity problems. There was no determination as to whether the resident was a safe smoker on this evaluation.
Additionally, review of the active comprehensive plans of care for resident #86 revealed a care plan initiated on 10-08-19 that documented the resident had been made aware that the facility is a smoke free environment. The only intervention documented that the resident will demonstrate the ability to smoke without assistance.
Surveyor interview with resident #86 on 10-22-19 at 10AM revealed the resident had been observed by staff outside in front of the facility smoking in September 2019. Further interview revealed that the resident denied possession of any cigarettes or lighting materials currently. However, the resident stated he/she has smoked since the incident in September 2019 with other residents, but is aware of the facility's policy.
On 10-22-19 at 3PM surveyor observation revealed resident #86 was found outside in front of facility sitting in his/her wheelchair, with no evidence of any type of smoking behavior. Further observation revealed there was no evidence of burn holes in the clothes and no smoke burns on the resident's hands/fingers.
Interview on 10-22-19 at 5:20PM with the Director of Nursing (DON) and the Director of Social Services revealed that the DON was unaware of the 09-11-19 incident with resident #86. The DON further revealed that she was unaware that the assessment or care plan re: the smoking behavior had not been addressed timely. Further interview with the Director of Social Services revealed that the facility currently possesses any residents' smoking paraphernalia as indicated in the policy except a lighter from resident #23, which was had been obtained on this day. No additional information provided.
2. On 10-23-19 at 10:25 AM surveyor interview with resident #23 revealed that the resident to smokes approximately 3-4 cigarettes, but not daily, since it depends on whether he/she has any cigarettes. The resident stated an extensive history as a smoker and does wear a smoking cessation patch that is applied by facility staff. Further interview revealed when he/she wants to smoke that the resident signs out LOA (Leave of Absence) to go away from the facility. The resident stated currently he/she has no cigarettes and handed his/her lighter to the Social Worker on 10-22-19 upon request. The resident stated that facility staff are aware of other residents who smoke.
Record review on 10-23-19 revealed Smoking evaluations completed on 03-13-19 and 06-13-19 that identified resident #23 does not smoke.
However, on 10-21-19 at 4:39PM facility staff completed a Smoking evaluation that had identified the resident was a smoker. In addition, the evaluation included that education of the facility's smoking policy was completed and a determination was made that the resident was safe to smoke with supervision.
Further review of the active comprehensive plans of care revealed that not until 10-06-19 was there a care plan that identified resident #23 was at risk for injury due to smoking with a decrease in dexterity. The only intervention documented was that the resident will demonstrate ability to smoking without assistance.
Interview on 10-22-19 at 5:20PM with the Director of Nursing (DON) and the Director of Social Services revealed that the facility has resident #23's lighter, which had been obtained on this day. No additional information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to adequately provide ongoing assessment of resident #5's condition and ...
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Based on surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to adequately provide ongoing assessment of resident #5's condition and monitoring for complications before and after dialysis treatments. This finding was evident in 1 of 4 residents selected for review of dialysis care during the survey. The findings include:
1. On 10-23-19 at 11:15 AM, surveyor review of the clinical record for resident #5 revealed that the resident was dependent on peritoneal dialysis (the process of removing excess water, solutes and toxins from the blood through the abdomen in people whose kidneys can no longer perform these functions naturally) due to his/her disease process.
Further review of the physician order sheet (POS) for October 2019 revealed physician orders to check resident #5's vital signs before dialysis and weigh resident #5 every evening before dialysis and every morning after each peritoneal dialysis.
Additional record review revealed that resident #5 received peritoneal dialysis from 9 PM through 7 AM daily.
However, there was no evidence in resident #5's clinical record to indicate that resident #5 was weighed or that vital signs were obtained before resident #5 began dialysis from April 8 through October 23, 2019.
On 10-24-19 at 3:32 PM, interview with second floor unit manager and the Director of nursing revealed no additional information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on record review and interviews with facility staff, it was determined that the facility failed to document a rational to continue an as needed anti anxiety medication beyond 14 days and documen...
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Based on record review and interviews with facility staff, it was determined that the facility failed to document a rational to continue an as needed anti anxiety medication beyond 14 days and document the justification for continued use of psychotropic medications. This finding was evident for 3 of 8 residents selected for the Unnecessary Medication/Behavior/Mood review. (#58, #92, #104) The findings include:
1. On 10-21-19, surveyor review of resident #58's clinical record revealed a physician's order was written on 04-04-16 for as needed Lorazepam (an anti-anxiety medication).
Further review of the clinical record revealed there was no duration specified by the physician for the use of the anti-anxiety medication and resident #58 has not received any doses of the medication since 04-04-16.
On 10-25-19 at 01:00 PM, interview with resident #58's attending physician revealed no new information.
On 10-25-19 at 01:44 PM, interview with the Director of Nursing revealed no additional information.
2. On 10-24-19, surveyor review of the clinical record revealed that the following psychotropic medications were ordered for resident #92: Bupropion 150 mg once daily for Major Depressive Disorder in September 2018, Zoloft 125 mg once daily for Major Depressive Disorder was increased in April 2019, while in June 2019 Risperidone 0.5 mg once nightly for Paranoia was ordered.
Review of resident #92's Behavior Monthly Flow Sheets, completed by staff daily on each shift, revealed that staff were monitoring for behaviors that included anger, depressed/ withdrawn and striking out/hitting while on the above psychotropic medications.
On 10-04-19, documentation by the facility's consultant pharmacist, on the monthly report, revealed the recommendation for the attending physician to evaluate if dosage reductions for the Risperidone and/or the Bupropion medications could be attempted . Further review of the 10-04-19 report revealed that the facility's consultant psychiatric nurse practitioner (NP) documented that the resident's Chronic mental illness with relapse risk a GDR (Gradual Dose Reduction) of Risperdone and Bupropion would likely impair the patient's (resident's) behavioral functioning.
However, on 10-24-19, surveyor review of the August, September and October 2019 Behavior Monthly Flow Sheets revealed no evidence that resident #92 had any episodes of the behaviors. In addition, on 07-16-19 and 09-18-19, documentation by the psychiatric NP revealed that GDR was not indicated as target symptoms are ongoing. There was no clear justification by the consultant psychiatric NP in whether dosage reduction attempts of the resident's psychotropic medications had been thoroughly evaluated .
On 10-24-19 at 5:30PM, interview with the Director of Nursing and the Assistant Director of Nursing revealed no additional information.
3. On 10-24-19, surveyor review of the clinical record for resident # 104 revealed the following psychotropic medications ordered for administration: Zoloft 175 mg once daily for Major Depressive Disorder in September 2017, and in November 2018 Abilify 2 mg once nightly for Schizophrenia.
Review of resident #104's Behavior Monthly Flow Sheets, completed daily on each shift by staff, revealed that staff were monitoring for behaviors that included anger, mood changes and depressed /withdrawn while on the above psychotropic medications.
On 05-03-19, documentation by the facility's consultant pharmacist, on the monthly report, revealed the recommendation for the attending physician to evaluate if dosage reduction for the Abilify could be attempted at this time for resident #104. Further review of the 05-03-19 report revealed documentation by the facility's psychologist on 05-14-19 that the resident was not covered for Counterpoint services and this is not an emergency so cant see for this. There was no evidence in the clinical record that the resident was receiving any psychiatric services since January 2019. ( Refer to F740 for additional information)
Additionally, review of the pharmacist's monthly report for 08-07-19 revealed a request was made to resident #104's attending physician to evaluate if a dosage reduction for the resident's Zoloft medication could be attempted . Further review of the 08-07-19 report revealed documentation by the psychiatric NP that dosage reduction was not possible secondary to Past GDR (Gradual Dosage Reduction) resulted in patient withdrawing, depressed mood and mutism. There was no evidence of a date for the NP's documentation, but only a date stamp of 10-15-19 by staff that the physician/NP was notified by staff of the report. At this time, the resident was still not being followed by the facility's consultant psychiatric services.
Further record review revealed that resident #104's attending physician documented on 10-02-19 that GDR of Abilify/Zoloft not indicated at this time. However, on 10-24-19, surveyor review of the August, September and October 2019 Behavior Monthly Flow Sheets revealed no evidence of any episodes of behaviors for resident #104. There was no clear justification by the attending physician that dosage reduction attempts of the resident's psychotropic medications had been thoroughly evaluated .
On 10-25-19 at 10:45AM, surveyor interview with resident #104's attending physician revealed that the physician was unaware that the resident was not being followed by psychiatric services within the facility. Further interview revealed that the attending physician felt that the responsibility to address the justification of the continued use and/or dosage reductions for the resident's psychotropic medications should be addressed by psychiatric services and not the attending physician. No additional information provided.
On 10-24-19 at 5:30PM and 10-25-19 at 1PM, interview with the Director of Nursing and the Assistant Director of Nursing revealed no additional information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Smoking Policies
(Tag F0926)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. On 10-21-19 at 09:32 AM, surveyor interview with resident #19 during initial tour revealed that he/she was a smoker and had b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. On 10-21-19 at 09:32 AM, surveyor interview with resident #19 during initial tour revealed that he/she was a smoker and had been smoking for 45 years. Resident #19 stated that he/she was aware of the facility non-smoking policy prior to admission, but chose to smoke off the property whenever he/she wanted to smoke.
On 10-22-19 surveyor reviewed the facility non-smoking policy. The policy indicated smoking is not permitted inside the facility or its grounds. The policy specified:
A. Upon admission/readmission residents will be assessed for smoking
B. If a resident is identified as a smoker or has a history of smoking, then
1. resident will be offered smoking cessation assistance such as nicotine patch and
2. will be informed that smoking materials such as cigarettes and lighters are not permitted at the facility.
C. If any smoking material is found on a resident, it will be confiscated, labeled and turned over to social worker for safe keeping till discharge.
D. If a resident is non-compliant with the facility smoking policy by smoking anywhere in the facility and had tobacco products and smoking materials on their person or room, regular checks of the room would be instituted and if the behavior persisted, a 30-day discharge notice would be given to the resident
Further record review revealed that, on 08/19/19 at 08:44 AM, the facility social worker witnessed resident #19 smoking a cigarette in front of the facility building.
Additional record review revealed resident # 19's non-compliance with the facility's smoking policy plan of care initiated on 08-06-19. Further record review revealed a smoking assessment done on 10-21-19 at PM that identified resident #19 as a safe smoker.
On 10-22-19 at 08:40 AM, surveyor observed resident #19 propelling him/herself off the facility property. Surveyor followed resident #19 and observed resident smoking off the facility property. Resident #19 was observed returning to the facility and keeping his/her smoking material on his/her person.
On 10-22-19 at 09:45 AM, surveyor interview with resident #19 revealed the resident had kept his own cigarettes and lighter since admission on [DATE].
On 10-22-19 at 10:10 AM, surveyor interview with the social worker revealed that resident was a non-compliant smoker. However, regular check in the resident room to look for smoking materials had not been instituted.
On 10-22-19 at 11:22 AM, a 30-day notice of discharge was issued to resident #19 for violating facility non-smoking policy.
Although the facility smoking policy indicated that smoking materials for residents who smoke were to be confiscated and kept by the social worker until discharge, surveyor observed resident #19 keeping his/her own smoking materials. Regular checks in resident's room to seek out smoking materials was not instituted as stated in the facility smoking policy. Smoking assessment was not done until 10-21-19. In addition, resident #19 was not issued a 30-day discharge notice until 10-22-19. The facility failed to implement their own policy.
On 10-22-19 at 10:30 AM, interview with the director of nursing revealed no further information.
2. On 10-21-19 at 09:32 AM, surveyor interview with resident #51 during initial tour revealed that he/she was not a smoker and was aware of the facility non-smoking policy prior to admission on [DATE].
On 10-21-19 at 4:30 PM, follow up interview of resident by another surveyor revealed that resident #51 was a smoker and usually signed him/herself out to go smoke off the facility property.
Record review revealed a copy of the facility's non-smoking policy signed by resident #51 on 06-26-19. Resident #51 was alert and oriented to self, place and time. The resident was able to advocate for him/her self appropriately and was self-represented.
Further record review revealed nursing documentation on 10-21-19 at 4:10 PM, that indicated the unit manager was called to resident's room by the charge nurse. Per the unit manager documentation, there was a heavy smell of cigarette smoke in resident's room. However, the resident denied smoking in the room.
On 10-22-19, surveyor reviewed of facility non-smoking policy. The policy indicated smoking is not permitted inside the facility or its grounds. The policy specified:
A. Upon admission/readmission residents will be assessed for smoking
B. If a resident is identified as a smoker or has a history of smoking, then A. resident will be offered smoking cessation assistance such as nicotine patch and B. will be informed that smoking materials such as cigarettes and lighters are not permitted at the facility.
C. If any smoking material is found on a resident, it will be confiscated, labeled and turned over to social worker for safe keeping till discharge.
D. If a resident is non-compliant with the facility smoking policy by smoking anywhere in the facility and has tobacco products and smoking materials on their person or room, regular checks of room will be instituted and if the behavior persists, a 30-day discharge notice will be given to the resident.
On 10-22-19 at 09:12 AM, surveyor review of the clinical record revealed a plan of care initiated on 09-06-19 that identified the resident as non-compliant with the facility's no smoking policy. Additional record review revealed a smoking assessment done on 10-21/19 at 4:30 PM that identified resident #51 as a safe smoker.
On 10-22-19 at 4:30 PM, surveyor interview with resident #51 revealed that he/she did go outside in-front of the building to smoke a cigarette on 10-21-19 around 4 PM. The resident confirmed that he/she keep his/her smoking material on his/her person and showed surveyor a lighter, but denied smoking in his/her room.
On 10-22-19 at 4:35 PM, surveyor notified the social worker that resident #51 had smoking materials on his/her person. The social worker confiscated the smoking material after surveyor intervention.
Although the facility was aware the resident was smoking despite the no smoking policy as evidenced by a smoking plan of care initiated on 09-06-19, there was no evidence that the smoking evaluation was done until 10-21-19. In addition, the facility failed to ensure that resident's smoking materials were not kept on his/her person. The facility also failed to institute regular checks in the resident's room to ensure the resident was not keeping smoking materials. The facility failed to implement their own policy.
On 10-22-19 at 10:30 AM, interview with the director of nursing revealed no further information.
Based on surveyor review of the clinical record, review of the facility's smoking policy and procedure, surveyor observations and interviews with residents and facility staff, it was determined that the facility failed to consistently implement their smoking policy for residents who smoke. This finding was evident for 4 of 4 residents reviewed for smoking. (#86, #23, #19, #51) The findings include:
Interview on 10-21-19 at 1PM with the Director of Nursing revealed that the facility had a smoking policy that smoking is not permitted at the facility, since the facility maintains a smoke free environment.
Review of the facility's current smoking policy revealed that, if a resident smokes or has recent history of smoking, the resident will be offered smoking cessation assistance or transfer to a facility where smoking is permitted. In addition, the resident will be informed that no cigarettes, lighters, matches or other smoking paraphernalia will be permitted while a resident resides at the facility. This policy included that no resident is permitted to retain in their possession any smoking materials and/or lighting paraphernalia.
Further review of the smoking policy revealed that a Non Compliant smoker is identified if one or more of the following behaviors have occurred: Smokes anywhere in the facility or on facility property; Has cigarettes other tobacco products or smoking paraphernalia on his/her person or in his/her room. The policy stated that facility staff will meet with all Non compliant smokers to review the facility's smoke free policy and remove all smoking materials from the resident's person and room.
1. On 10-21-19, surveyor review of the clinical record for resident #86 revealed documentation on 09-11-19 at 2:31PM by RN (Registered Nurse) #5 that the resident was observed smoking on the facility premises. Further review revealed that the resident was then educated on the risk of smoking and the resident's family and responsible party were notified that any further violation would result in a 30 day notice to vacate.
However, there was no documented evidence that the facility staff had removed all smoking materials from the resident's person and room as indicated in the facility's smoking policy. In addition, there was no evidence that the resident was offered smoking cessation interventions and/or assistance with the resident's discharge from the facility as also indicated in the facility's smoking policy.
Further record review revealed no evidence that smoking evaluations were updated until 10-21-19 at 4:49PM. This evaluation identified that resident #86 had dexterity problems. There was no determination as to wether the resident was a safe smoker on this evaluation. (Refer to F689 for additional evaluation)
Surveyor interview with resident #86 on 10-22-19 at 10AM revealed the resident had been observed by staff outside in front of the facility smoking in September 2019. Further interview revealed the resident denied possession of any cigarettes or lighting materials currently. However, the resident stated he/she has smoked since the incident in September 2019 with other residents, but was aware of the facility's policy.
Interview on 10-22-19 at 5:20PM with the Director of Nursing (DON) and the Director of Social Services revealed no additional information.
2. On 10-23-19 at 10:25 AM, surveyor interview with resident #23 revealed that the resident smoked approximately 3-4 cigarettes, but not daily, since it depends on whether he/she has any cigarettes. The resident reported an extensive history as a smoker and did wear a smoking cessation patch that was applied by facility staff. Further interview revealed that, when he/she wants to smoke, the resident signs out LOA (Leave of Absence) to go away from the facility. The resident stated that he/she had no cigarettes at the time, and handed his/her lighter to the Social Worker on 10-22-19 upon request. The resident stated that facility staff were aware of other residents who smoke.
However, not until 10-21-19 at 4:39PM, was there an updated smoking evaluation that identified resident #23 as a smoker. Further review of the evaluation revealed that staff had educated the resident on the facility's smoking policy, with a determination that the resident was safe to smoke with supervision, which was inconsistent with the facility's smoking policy. Further record review revealed previous smoking evaluations that indicated that the resident was not a smoker, even though the resident stated that staff was aware of his/her smoking. (Refer to F689 for additional information)
Interview on 10-22-19 at 5:20PM with the Director of Nursing (DON) and the Director of Social Services revealed that the facility had resident #23's lighter, which had been obtained on that day. No additional information was provided.
MINOR
(B)
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
4. On 10-22-19, surveyor review of the clinical record for resident #70 revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) dated 11-12-18. The MOLST is a portable and enduring me...
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4. On 10-22-19, surveyor review of the clinical record for resident #70 revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) dated 11-12-18. The MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on the resident's wishes about medical treatments. The attending physician documented certification for the MOLST was based on the patient's health care agent as named in the patient's advance directive.
However, further review revealed no evidence of a advanced directive in the clinical record. The MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on the resident's wishes about medical treatments.
On 10-23-19 at 3:00 PM, surveyor interview with the resident's representative stated that the only paperwork that was submitted to the facility was the financial power of attorney documents.
On 10-24-18 at 8:30 AM, surveyor interview with the Director of Nursing revealed no additional information.
Based on surveyor review of the clinical record and interviews with residents, the resident's responsible party and facility staff, it was determined that the facility failed to ensure accurate documentation in residents' clinical records. This finding was evident for 4 of 30 residents reviewed during the survey. (#100, #79, #23, #70) The findings include:
1. On 10-23-19, surveyor review of the clinical record for resident #100 revealed a completed Maryland Medical Orders for Life-Sustaining Treatment (MOLST) signed by the attending practitioner on 05-19-19. The MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on the resident's wishes about medical treatments.
Further review of the 05-19-19 MOLST revealed that certification for the basis of the orders on the MOLST were the result of a discussion with and the informed consent of resident #100's health care agent as named in the resident's advance directive.
However, record review revealed no documented evidence of an advance directive in the clinical record for resident #100. Further review revealed a completed Maryland Person Financial Power Attorney document that indicated who was designated to make decisions regarding only for financial matters re: resident #100.
On 10-23-19 at 5PM, surveyor interview with the Director of Social Services and the Director of Nursing revealed no additional information.
Interview on 10-25-19 at 4PM with the attending physician revealed no additional information.
2. On 10-23-19, surveyor review of the clinical record for resident #79 revealed a completed Maryland Medical Orders for Life-Sustaining Treatment (MOLST) signed by the attending practitioner on 03-22-19. The MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on the resident's wishes about medical treatments.
Further review of the 03-22-19 MOLST revealed that certification for the basis of the orders on the MOLST were the result of a discussion with and the informed consent of resident #79's health care agent as named in the resident's advance directive.
However, record review revealed there was no documented evidence of an advance directive in the clinical record for resident #79.
On 10-23-19 at 5PM, surveyor interview with the Director of Social Services and the Director of Nursing revealed no additional information.
Interview on 10-25-19 at 4PM with the attending physician revealed no additional information.
3. On 10-24-19 at 10:30AM, surveyor interview with resident #23 revealed the resident had not received the annual influenza injection from facility staff.
Record review for resident resident #23 revealed documentation in the electronic record that the resident had refused the influenza immunization. However, there was no documented evidence in the clinical record of the resident's refusal.
Further review revealed nursing documentation on 10-13-19 that resident #23 was status post day 2 with no reaction from the flu shot. In addition, on 10-14-19 LPN (License Practical Nurse) # 2 documented status post day 3 for the flu shot received, and that the resident had no reaction and the resident's temperature was 97.4 degree Fahrenheit.
On 10-24-19 at 11:15AM, interview with the facility's Infection Control Coordinator revealed that resident #23 had refused the flu injection previously on 10-12-19 and there would have been documentation on the Change in Condition 24 Hour report if the flu injection had been administered. Therefore the nursing documentation on
10-13-19 and 10-14-19 were in error.
Interview on 10-24-19 at 11:30AM with LPN #2 revealed that documentation on the Change in Condition 24 Hour report was a request to F/U (follow up) on a report for resident #23 but had been misread as the flu shot had been administered.
On 10-24-19 at 11:45AM, interview with the attending physician for resident #23 revealed that the resident had previously refused the flu shot, but had now agreed to receive the shot.
On 10-24-19 at 4PM, interview with the Director of Nursing revealed no additional information.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0838
(Tag F0838)
Minor procedural issue · This affected most or all residents
Based on surveyor review of facility-wide assessment record and interview with facility staff, it was determined that the facility failed to review and update the assessment when there was a personnel...
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Based on surveyor review of facility-wide assessment record and interview with facility staff, it was determined that the facility failed to review and update the assessment when there was a personnel change. This finding was evident for 1 of 1 facility assessment record reviewed during the annual survey.
On 10-25-19 at 2:30 PM, surveyor review of the facility assessment record revealed names of personnel in the following positions: Administrator, Director of nursing and Medical Director. Upon further review, surveyor could not identify these personnel as part of current facility staff.
On 10-25-19 at 2:36 PM, surveyor interview with the administrator revealed that the identified personnel were previous staff who no longer worked with the facility.
There was no evidence that the administrator reviewed and updated the facility assessment when there was a change in personnel as required. No additional information was provided.
Nov 2018
12 deficiencies
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 surveyor review of the closed clinical records and interview with the facility staff, it was determined that the facility failed to notify resident #70's responsible party in writing of a hos...
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Based on surveyor review of the closed clinical records and interview with the facility staff, it was determined that the facility failed to notify resident #70's responsible party in writing of a hospital transfer. In addition, the facility failed to send a copy of the hospital transfer notice to a representative of the Office of the State Long -Term Care Ombudsman. This finding was evident for 1 of 3 residents selected for review of the Hospitalization Care Area during the survey. The findings include:
On 11-13-18, surveyor review of the closed clinical record for resident #70 revealed that the resident was transferred to the hospital in March 2018, however, there was no documented evidence that the facility had notified resident #70's responsible party in writing of the transfer to the hospital.
Additionally, there was no documented evidence that the facility sent a copy of the notice for the resident #70's hospital transfer to a representative of the Office of the State Long-Term Care Ombudsman.
On 11-13-18 at 1:45PM, surveyor interview with the facility's Long-Term Care Ombudsman revealed there was no notification, either verbally or in writing, received from the facility of a hospital transfer for resident
#70.
On 11-13-18 at 4PM, surveyor interview with the Director of Nursing revealed no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical records, surveyor observation and interview with facility staff, it was determined that the facility staff failed to a comprehensive plan of care for resident ...
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Based on surveyor review of the clinical records, surveyor observation and interview with facility staff, it was determined that the facility staff failed to a comprehensive plan of care for resident #53. This finding was evident for 1 of 32 residents selected for review during the survey. The findings include:
On 11-13-18 at 10:30 AM, surveyor review of the clinical record for resident #53 revealed Eliquis 5mg
(a blood thinner used to prevent stroke and blood clots) was to be administered twice daily.
However, there was no evidence that a comprehensive care plan was developed for resident #53 to address the administration of the blood thinner and its related possible side effects.
On 11-13-18 at 3:35 PM, surveyor interview with the Director of Nursing revealed no new information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical records, interview with resident #53's family and the facility staff , it was determined that the facility staff failed to provide the necessary services to re...
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Based on surveyor review of the clinical records, interview with resident #53's family and the facility staff , it was determined that the facility staff failed to provide the necessary services to resident #53, who was unable to carry out Activities of Daily Living (ADL) This finding was evident for 1 (#53) of 4 residents selected for the ADL review during the survey. The findings include:
On 11-06-18 at 09:15 AM, observation during initial tour revealed resident #53 in bed, disheveled and in need of mouth care. The resident had a long beard and long finger nails with a brownish substance underneath the nails.
On 11-06-18 at 12:20 PM, observation revealed resident #53 in a wheelchair self propelling around the unit and drooling a thick sputum on his/her clothing and chest.
Surveyor review of the clinical record revealed resident #53 was dependent on facility staff to provide all of his/her ADLs and was nonverbal, but able to answer simple yes or no questions with either nodding for yes or shaking his/her head for no.
On 11-07-18 at 2:15 PM, surveyor interview with resident #53 revealed that he/she would like his/her finger nails to be trimmed and beard to be shaved.
On 11-07-18 at 2:20 PM, surveyor interview with staff #4 revealed that I forgot to shave him/her and did not pay attention to the nails. After surveyor intervention on 11-07-18, resident #53 was shaved and the resident's fingernails were trimmed and cleaned.
On 11-07-18 at 2:30 PM, surveyor interview with resident #53's responsible party revealed they don't shave him/her when they get him/her out of bed although I have told them to shave him/her every day. Additionally, they don't brush his/her teeth which results in the drooling.
On 11-13-18 at 2:40 PM, surveyor interview with the Director of Nursing revealed no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical records and interview with facility staff, it was determined that the facility staff failed to follow physician's orders for residents receiving peritoneal dia...
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Based on surveyor review of the clinical records and interview with facility staff, it was determined that the facility staff failed to follow physician's orders for residents receiving peritoneal dialysis. This finding was evident for 2 of 3 residents selected for review during the survey for the dialysis care area. (#106 #281). The findings include:
Peritoneal dialysis is the process of removing excess water, solutes and toxins from the blood through the abdomen in people whose kidneys no longer perform these functions naturally due to a disease process.
1. On 11-13-18 at 11:15 AM, surveyor review of the clinical record for resident #106 revealed the resident received peritoneal dialysis from 9 PM through 6 AM daily. Further review of the October and November 2018 Physician Order Sheet (POS) revealed orders for staff to obtain vital signs before dialysis, and weights before and after each peritoneal dialysis treatment.
However, there was no evidence in the clinical record to indicate that resident #106 was weighed and or vital signs were obtained daily prior to dialysis from 10-11-18 through 11-13-18.
On 11-13-18 at 3:32 PM, interview with the 2nd floor unit manager and the Director of Nursing revealed no additional information.
2. On 11-13-18 at 1:15 PM, surveyor review of the clinical record for resident #281 revealed the resident received peritoneal dialysis from 9 PM through 6 AM daily. Further review of the October and November 2018 Physician Order Sheet (POS) revealed an order for staff to obtain vital signs before dialysis, and weights before and after each peritoneal dialysis treatment.
However, there was no evidence in the clinical record to indicate that resident #281 was weighed and or vital signs were obtained daily prior to dialysis from 10-22-18 through 11-13-18.
On 11-13-18 at 3:32 PM, interview with the 2nd floor unit manager and the Director of Nursing revealed no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical records and interview with facility staff, it was determined that the facility failed to ensure that resident #7 received timely behavioral health care and ser...
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Based on surveyor review of the clinical records and interview with facility staff, it was determined that the facility failed to ensure that resident #7 received timely behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well being, in accordance with the comprehensive assessment and plan of care. This finding was evident for 1 of 6 residents selected for review during the survey for the Mood/Behavior Care Area. The findings include:
On 11-08-18, surveyor review of the clinical record revealed that, on 11-27-17, the facility's pharmacist recommended that resident #7's Abilify be evaluated for a possible attempt to decrease the dosage. The resident's attending physician documented that the facility's psychiatric services should evaluate this recommendation.
On 12-08-17, documentation by the facility's psychiatric service nurse practitioner revealed the following psychiatric medications for resident #7: Abilify 5 mg once nightly, Trazadone 50 mg once nightly and Zoloft 175 mg once daily. Further review revealed that the resident currently did not exhibit any signs and symptoms of anxiety and or depression. Staff did report that, at times the resident became easily irritable and tried to throw self onto the floor. Therefore, a gradual dose reduction of medications was not indicated at the time.
Further review of the pharmacist monthly medication review for May 2018 revealed that the pharmacist recommended an evaluation for a decrease in the dosage of Abilify for resident #7. In addition, the monthly medication review for August 2018 revealed a recommendation for an evaluation for a dosage reduction for Zoloft.
On 11-13-18, review of the comprehensive plans of care for resident #8 revealed a plan of care addressing the risk of adverse effects related to the use of antipsychotic medication and the use of antidepressant medication. Interventions included the evaluation of the effectiveness and the side effects of the medication use with the possible decrease/.elimination of psychotropic drugs.
Surveyor review of the Monthly Behavior Flow Sheets from April 2018 thru October 2018, revealed staff documentation of 0 episodes of depressed/ withdrawn and mood changes noted by staff every shift daily.
However, review of the attending physician documentation revealed no evidence that the attending physician addressed the dosage reduction for either the Abilify and the Zoloft in May 2018 and August 2018.
In addition, there was no evidence of any further psychiatric service visits to resident #7 to address the dosage reduction of Abilify and Zoloft since December 2017.
On 11-09-18 at 2PM, and 11-13-18 at 11AM, interview with the 3rd floor unit manager revealed that no further visits were made by psychiatric services to resident #7 since 12-08-17. After surveyor intervention, psychiatric services arranged to assess the resident as soon as possible. No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical records, surveyor observation and interview with facility staff, it was determined that the facility staff failed to provide a safe, sanitary and comfortable e...
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Based on surveyor review of the clinical records, surveyor observation and interview with facility staff, it was determined that the facility staff failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. This finding was evident for 5 of 32 residents identified during the survey for the infection control area (#53, #95, #106, #117, #280). The findings include:
1. On 11-07-18 at 08:30 AM, observation of resident #53's room revealed a suction machine (medical device used for respiratory care to remove fluid from the airways) sitting on the resident's bedside table.
Further observation revealed the suction tubing was connected to a Yankauer (an oral suctioning tool designed to allow effective suction of fluid without damaging the surrounding tissue), which was connected to the suction machine. The Yankauer tool was observed on the floor underneath the resident's bed.
Further review revealed that resident #53 had a physician order to Change and date suction tubing every week and as needed when in use. However, there was no date on the tubing as to when it was last changed.
On 11-07-18 at 09:12 AM, surveyor interview with the facility's Infection Control coordinator revealed that, per facility protocol, all tubing must be labeled with date and initials. Additionally, oxygen, nebulizer and Yankauer tubing were to be stored in a plastic bag when not in use.
On 11-07-18 at 1:10 PM, surveyor interview with the Director of Nursing revealed no new information.
2. On 11-06-18 at 10:30 AM, observation of resident #95's room revealed oxygen tubing connected to an oxygen concentrator (a device which concentrates the oxygen from the surrounding air). The tubing was connected and used by the resident. Further observation revealed that, neither the tubing or the humidifier bottle was dated as to when they were last changed. The air filter was observed dirty with dust and cobwebs.
Surveyor review of the clinical records for resident #95 revealed an order to Change and date oxygen tubing every week and as needed. Rinse oxygen concentrator filter with water pat dry and reapply to concentrator weekly. Change oxygen humidifier bottle weekly. However, there was no evidence that the facility staff changed and labeled the oxygen tubing, humidifier bottle and rinsed the oxygen concentrator filter as indicated in the physician orders.
On 11-06-18 at 10:42 AM, surveyor interview with the Director of Nursing (DON) revealed that, per facility policy, the oxygen tubing and humidifier bottle must be labeled and changed weekly.
3. On 11-13-18 at 11:15 AM, review of the clinical record for resident #106 revealed that the resident received peritoneal dialysis. Further review of the physician order sheet (POS) for October 2018 and November 2018 revealed an order to clean the receptacle for resident #106's dialysis tubing with a solution of bleach daily at the end of the day, after each dialysis treatment, as a minimum practice.
However, there was no evidence to indicate that the facility staff had cleaned the receptacle with bleach as indicated.
On 11-13-18 at 1:10 PM, surveyor interview with staff #6 revealed that resident #106's receptacle was only cleansed with an alcohol swab.
On 11-13-18 at 3:32 PM, interview with the 2nd floor unit manager and the Director of Nursing revealed no additional information.
4. On 11-06-18 at 09:33 AM, observation revealed that resident #117's nebulizer treatment set was on the resident's bedside table. The tubing and the canister (plastic container that holds the medication) had been left on the bare table with the tubing still attached to the canister.
Further observation revealed a dried crusted substance in the nebulizer mask, while the tubing and the canister had no date as to when they were last changed.
Surveyor review of the clinical record for resident #117 revealed a physician order to Change and date the oxygen and nebulizer tubing every week and as needed.
On 11-06-17 at 09:42 AM, surveyor interview with the Director of Nursing (DON) revealed that the oxygen and nebulizer tubing, as well as the mouth piece and mask were to be stored in a plastic bag when not in use.
However, there was no evidence that staff had stored the oxygen tubing in a plastic bag. In addition, there was no evidence that the tubing had been changed.
5. On 11-06-18 at 10:30 AM, observation of resident #280's room revealed oxygen tubing connected to an oxygen concentrator. The tubing was observed on the floor with the nostril section (the tip that goes into the nose) under the resident's bed. Further observation revealed that the tubing had no date to indicate when it was last changed.
Surveyor review of the clinical record for resident #280 revealed a physician order to Change and date oxygen tubing every week and as needed.
On 11-06-18 at 11:12 AM, surveyor interview with the facility's Assistant Director of Nursing (ADON) revealed that the oxygen and nebulizer tubing, including the mouth piece and mask, were to be stored in a plastic bag when not in use, however, there was no evidence that staff had stored the oxygen tubing in a plastic bag when not in use. In addition, there was no evidence that the tubing had been changed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on surveyor observations and interview of facility staff, it was determined that facility staff failed to ensure the safe, clean and comfortable condition of residents' furniture. This finding w...
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Based on surveyor observations and interview of facility staff, it was determined that facility staff failed to ensure the safe, clean and comfortable condition of residents' furniture. This finding was evident for 2 of 32 residents observed during the survey. (#50, #119) In addition, the facility staff failed to maintain the cleanliness of resident furnishings in the facility's dining areas. This finding was evident for 1 of the 2 facility's main dining areas. The findings include:
1. On 11-06-18 at 8:30 AM, observation revealed resident #50's overbed table to be in disrepair. There were several rips/tears observed on the laminated surface of the table top as well as the sides, with a large sections of the laminated surface missing and exposing the material underneath.
On 11-13-18 at 11:36 AM, further observation revealed that the overbed table for resident #50 had torn edges on the side that were sharp. After surveyor intervention, the 2nd floor unit manager immediately removed the overbed table.
2. On 11-06-18 at 9:20 AM, observation revealed resident #119 sitting up in a geri-chair (recliner). Both arms of the geri-chair were observed ripped with large sections of the vinyl missing and exposed foam material. Additionally, there was dried food, and liquid noted on the sides and rear of the geri-chair.
On 11-13-18 at 12:28 PM, interview with the Director of the housekeeping department revealed that housekeeping staff maintain a schedule for the cleaning of residents' wheelchairs, However, there was no schedule for the routine cleaning of residents' geri-chairs.
3. Additionally, on 11-13-18 at 12:30PM, observation of the 3rd floor dining room revealed 6 dining chairs soiled with food and/or dried liquids on the arms and seats of the chairs, as well as some chairs with tears in the vinyl seat.
Surveyor identified these findings to the facility's housekeeping director at the time of the observation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
2. On 11-07-18 at 12:30 PM, observation during tour of resident #280's room, revealed that about 50 ml of the IV (intravenous) antibiotic, Docycycline, remained in the IV bag which was connected via a...
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2. On 11-07-18 at 12:30 PM, observation during tour of resident #280's room, revealed that about 50 ml of the IV (intravenous) antibiotic, Docycycline, remained in the IV bag which was connected via an IV pump. Further observation revealed that the IV tubing was not connected to resident #280's midline catheter. A midline catheter is a soft IV catheter placed in a vein in the arm and ends in a larger vein near the heart. The IV is used for patients requiring more than five days of infusion therapy.
On 11-07-18 at 12:32 PM, surveyor interview with resident #280 revealed that the nurse came in and turned the IV pump off and disconnected the IV tubing from the midline IV site.
On 11-07-18 at 12:35 PM, surveyor review of the November 2018 Medication Administration Record (MAR) for resident #280 revealed a physician order for Doxycycline Hyclate solution Reconstituted 100 mg/100 ml. Use 100 ml/hour every 12 hours for 21 days.
Further review of the MAR revealed documentation that the entire 100 ml of Doxycycline had been administered at 9am, despite 50 ml remaining in the bag at the time of surveyor observation.
On 11-07-18 at 12:40 PM, surveyor interview with staff #5 who documented the administration of the medication revealed that he/she had not turned off the IV pump or disconnected the IV tubing. This had been done by the 2nd floor unit manager. However, staff #5 documented the administration of the medication before the actual administration.
Interview with the 2nd floor unit manager revealed that he/she had turned off the pump when the alarm came on and thought the medication was completely administered, but did not check the contents of the IV bag.
On 11-07-18 at 1:10 PM, surveyor interview with the Director of Nursing revealed it's the facility policy to implement all required care before documenting.
As standard of nursing practice as stated in section 10.27.09.02 E(iv) of the Nurse Practice Act, under documentation, RN document after implementing in a safe and appropriate manner consistent with scientific principles. Based on surveyor review of the clinical records, surveyor observation and interview with facility staff, resident and resident's family member, it was determined that the facility staff failed to ensure standards of nursing practice for residents. This finding was evident for 5 of 32 residents selected for review during the survey.(#17, #280, #180, #18, #123) The findings include:
1. On 11-08-18 at 5:08PM, observation of medication administration to resident #17 revealed that LPN (Licensed Practical Nurse) #3 administered Clonazepam 0.25mg tablet to the resident. Clonazepam is a scheduled controlled IV substance. A controlled substance is government regulated whether for manufacture, possession or for use. Licensed staff are required to sign at the time of the removal of the controlled medication prior to its administration on a controlled drug administration record to maintain the accountability for the quantity.
However, further observation on 11-08-18 at 5:20PM, after medication administration was completed to resident
#75, LPN #3 never signed for the removal of the Clonazepam on the Controlled Drug Administration Record for resident #17, until surveyor intervention.
On 11-08-18 at 5:40PM, surveyor interview with the 3rd floor unit manager, LPN #3 and the Director of Nursing revealed no additional information.
Per the Nurse Practice Act 10.27.09.03 F (2) (a) (b) collaborate with the client (resident), family, significant others and other health care providers in the formulation of overall goals, the plan of care and decisions related to care and the delivery of services; and consult with health care providers for client care. 3. On 11-06-18 at 2:30 PM, resident #180 was observed lying in bed. The resident was non-verbal and could not engage in a conversation. Due to physical limitation, resident #180 required total assistance with all activities of daily living.
On 11-07-18 at 10 AM, interview of resident #180's family member revealed the resident had left sided paralysis due to a stroke. Further interview revealed staff #1 had informed the family member that the resident should wear a multipodus boot for the right foot due to a deformity.
On 11-07-18 at 10:30 AM, the resident was observed wearing the multipodus boot to the right foot and a soft boot to the left foot as per the family interview.
On 11-08-18 at 8 AM, surveyor observation during medication pass to resident #180, revealed the resident wore the multipodus boot to the left foot and the soft boot to the right foot, which is inconsistent with the family interview and observation on 11-07-18.
On 11-09-18 at 2 PM, the resident was observed wearing the multipodus boot to the right foot and the soft boot for the left foot.
On 11-09-18, review of the physician's order, dated 11-06-18, revealed instructions were given to apply a multipodus boot to the left foot for pressure relief and foot drop. There was no order for the soft boot to the right foot.
Further review of November 2018 TAR revealed that the nursing staff signed off that the resident wore the multipodus for the left foot every shift between 11-06-18 and 11-09-19, which was inconsistent with surveyor observations on 11-07-18 and 11-09-18.
On 11-09-18 at 4:30 PM, interview of the rehabilitation manager and review of staff #1's progress note revealed the resident was provided with bilateral multipodus boots, which was inconsistent with the physician's order.
On 11-09-18 at 4:45 PM, the resident was observed wearing the multipodus boot to the right foot in presence of the rehabilitation manager and the Director of Nursing.
On 11-09-18 at 5:30 PM, interview of the Director of Nursing revealed no additional information.
On 11-14-18 at 9 AM, telephone interview of staff #1 revealed he/she instructed a nursing staff member to assist resident #180 in wearing the multipodus boot for the right foot and the soft boot for the left foot on 11-06-18.
Following surveyor's intervention on 11-13-18, a clarification physician order was written.
Code of Maryland Regulations 10.27.10.02C(3), The plan of nursing care shall be communicated on records to other members of the health care team.
4. On 11-07-18 at 9 AM, interview of resident #18 revealed the resident was alert and oriented.
Review of the ophthalmologist's recommendation, dated 10-12-18, revealed that resident #18 was to start Travatan, at night for glaucoma. However, there was no evidence that the resident received the eye drop in October and November 2018 per review of the MAR.
On 11-09-18 at 4:51 PM, interview of resident #18 revealed that the resident received an eye drop for each eye every night, but he/she did not know the name of the eye drop.
On 11-09-18 at 5 PM, interview of staff #2 and observation of a medication cart, revealed a bottle of Latanoprost 0.0005 % labeled for resident #18. In addition, staff #2 stated the resident received 1 drop of Latanoprost to each eye every night. However, there was no physician's order to administer Latanoprost or Travatan for resident nightly. In addition, there was no documented evidence that resident #18 received an eye drop every night starting on 10-13-18.
As per the Code of Maryland Regulations 10.27.10.02C(3), The plan of nursing care shall be communicated on records to other members of the health care team.
5. On 11-07-18 at 9 AM, interview of resident #123 revealed the resident was alert and oriented. He/she was observed wearing a soft boot while in bed. The resident stated he/she had a pressure ulcer on the left heel, but could not recall when and how it developed.
a. On 11-07-18, review of the clinical record and TAR, revealed the treatment was to cleanse the left heel wound with normal saline solution, apply calcium alginate and cover with a dry dressing Mondays, Wednesdays and Fridays. In addition, Tylenol 650 mg, was scheduled to be administered 30 minutes prior to the dressing change.
On 11-07-18 at 12 noon, interview of staff #9 revealed that staff #10 was responsible to do dressing changes for resident #123.
However, interview of staff #10 on 11-07-18 at 12:15 PM revealed that the treatment completed earlier was the application of skin prep daily on the resident's left heel, which was inconsistent with the current physician's order.
Staff #10 stated that the provided treatment to resident #123 was based on the wound team's paperwork, not the physician's order or the TAR. Review of the wound team's paperwork dated 11-05-18 revealed the wound team assessed the resident's left heel and determined the treatment was to apply skin prep daily.
b. On 11-09-18, review of the November 2018 MAR revealed that there was no evidence that Tylenol 650 mg was given to resident #123 prior to the dressing change on 11-08-18.
On 11-09-18 at 4 PM, interview of the Director of Nursing revealed no additional information.
As per the Code of Maryland Regulations 10.27.10.02C(3), The plan of nursing care shall be communicated on records to other members of the health care team.
MINOR
(B)
Minor Issue - procedural, no safety impact
Comprehensive Assessments
(Tag F0636)
Minor procedural issue · This affected multiple residents
Based on surveyor review of the clinical records and interview with facility staff, it was determined that the facility failed to ensure that annual MDS's (Minimum Data Set) were completed in a timely...
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Based on surveyor review of the clinical records and interview with facility staff, it was determined that the facility failed to ensure that annual MDS's (Minimum Data Set) were completed in a timely manner. This finding was evident for 3 of 32 residents selected for review during the survey. (#4, #1, #10) The findings include:
The Minimum Data Set (MDS) is a mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive and accurate assessment of each resident's functional capacity and health status to assist nursing home staff in identifying health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. The MDS is to be completed no later than 14 days after the Assessment Reference Date (ARD).
1. On 11-09-18 surveyor review of the clinical record for resident #4 revealed an annual MDS with an ARD of
10-02-18. Staff was required to complete the annual MDS by 10-16-18. However, facility staff had not completed the annual MDS until 11-06-18, which was 21 days later than the required date of 10-16-18. Review of the CMS Submission Report/ Final Validation Report revealed that the annual MDS was considered completed late on 11-06-18.
On 11-13-18 at 11:30AM, surveyor interview with the MDS coordinator revealed that there were staffing issues that contributed to the late MDS assessments.
2. On 11-13-18, surveyor review of the clinical record for resident #1 revealed an annual MDS with an ARD of
09-13-18. Staff was required to complete the annual MDS by 09-27-18. However, facility staff had not completed the annual MDS until 11-06-18, which was 40 days later than the date required of 09-27-18. Review of the CMS Submission Report/ Final Validation Report revealed that the annual MDS was considered completed late on 11-06-18.
On 11-13-18 at 11:30AM, surveyor interview with the MDS coordinator revealed that there were staffing issues that contributed to the late MDS assessments.
3. On 11-13-18, surveyor review of the clinical record for resident #10 revealed an annual MDS with an ARD of 10-02-18. Staff was required to complete the annual MDS by 10-16-18. However, as of 11-13-18 there was still no evidence that facility staff has completed and submitted the annual MDS as rquired.
On 11-13-18 at 11:30AM, surveyor interview with the MDS coordinator revealed that there were staffing issues that contributed to the late MDS assessments. As of 11-13-18, the assessment is still in progress. No additional information provided.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0638
(Tag F0638)
Minor procedural issue · This affected multiple residents
3. On 11-13-18 at 2:30 PM, surveyor review of the MDS section A for resident #2 revealed a quarterly assessment with an ARD of 06-28-18. The next quarterly review assessment was due (to be completed) ...
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3. On 11-13-18 at 2:30 PM, surveyor review of the MDS section A for resident #2 revealed a quarterly assessment with an ARD of 06-28-18. The next quarterly review assessment was due (to be completed) on 09-28-18. However, there was no evidence that the quarterly MDS had been completed as of 11-13-18, which was 43 days after the required completion date. Further review revealed the overdue quarterly MDS was still in progress to be completed as of 11-13-18.
On 11-13-18 at 3:10 PM, surveyor interview with the MDS coordinator and the Director of Nursing revealed no additional information.
Based on surveyor review of the clinical records and interview with facility staff, it was determined that the facility failed to ensure that quarterly MDS's (Minimum Data Set) were completed in a timely manner. This finding was evident for 3 of 32 residents selected for review during the survey. (#3, #10, #2) The findings include:
The Minimum Data Set (MDS) is a mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive and accurate assessment of each resident's functional capacity and health status to assist nursing home staff in identifying health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. The MDS is to be completed no later than 14 days after the Assessment Reference Date (ARD).
1. a. On 11-13-18, surveyor review of the clinical record for resident #3 revealed that the quarterly MDS had an ARD of 10-02-18. Staff was required to complete the annual MDS by 10-16-18. However, as of 11-13-18, there was still no evidence that the facility staff had completed and submitted the annual MDS for resident #3.
On 11-13-18 at 11:30AM, surveyor interview with the MDS coordinator revealed that there were staffing issues that contributed to the late MDS assessments. As of 11-13-18, the assessment was in progress.
b. Additionally, review of the quarterly MDS, with an ARD of 01-02-18, for resident #3 revealed it was to be completed by 01-16-18. However, staff had completed the quarterly MDS on 02-11-18, which was 26 days later than the required date of 01-16-18. Review of the CMS Submission Report/ Final Validation Report revealed that the quarterly MDS was considered completed late on 02-11-18.
On 11-13-18 at 11:30AM, interview with the MDS coordinator revealed no additional information.
2. On 11-13-18, surveyor review of the clinical record for resident #10 revealed a quarterly MDS with an ARD of 01-03-18. Staff was required to complete the quarterly MDS by 01-17-18. However, staff had completed the quarterly MDS on 02-13-18, which was 27 days later than the required date of 01-17-18.
On 11-13-18 at 11:30AM, surveyor interview with the MDS coordinator revealed there were staffing issues that contributed to the late MDS assessments.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
Based on surveyor observation, review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to accurately document the use of physical restraints...
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Based on surveyor observation, review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to accurately document the use of physical restraints for resident #128. This finding was evident for 1 of 32 residents selected for review during the survey. The finding include:
On 11-08-18, review of resident #128's clinical record revealed a physician's order in January 2018 to apply an abdominal binder to the resident every shift to protect the gastrostomy tube. In April 2018, another order was written to remove the abdominal binder every shift in order to assess the resident's skin area.
A gastrostomy tube is a plastic tube that is inserted through the abdomen into the stomach to deliver fluid and nutrition to someone who cannot swallow safely by mouth.
On 11-08-18 at 12:30 PM, resident #128 was observed lying in bed in their room. The abdominal binder was in place. Interview of staff #7 and staff #8 at that time, revealed that the purpose of the abdominal binder was to protect the gastrostomy tube because the resident attempts to pull the tube out.
Further review of resident #128's care plans revealed a care plan for the abdominal binder, which was noted as a physical restraint. The care plan was initiated in April 2018 and revised in July and August 2018.
Review of the monthly Treatment Administration Records (TAR) revealed that the nursing staff had signed off that the abdominal binder was in place on every shift since January 2018. However, review of the quarterly Minimum Data Set (MDS) assessment section P0100 physical restraint, dated 07-16-18 and 10-16-18, revealed no indication that a physical restraint was in use for resident #123, which was inconsistent with the record review, observation and staff interview.
The Minimum Data Set (MDS) is an assessment to reflect an individual's mental, physical and functional status.
On 11-09-18 at 5:30 PM, interview of the Director of Nursing revealed the facility determined that the abdominal binder was a physical restraint, but did not accurately code the above MDS assessments.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0657
(Tag F0657)
Minor procedural issue · This affected multiple residents
Based on surveyor review of the clinical records and interview with facility staff, it was determined that the facility failed to revise a comprehensive plan of care for resident #128 as indicated on ...
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Based on surveyor review of the clinical records and interview with facility staff, it was determined that the facility failed to revise a comprehensive plan of care for resident #128 as indicated on the resident assessment. This finding was evident for 1 of 32 residents selected for review during the survey. The findings include:
On 11-09-18, review of resident #128's activity care plan, dated 01-16-18, revealed that the resident preferred not to attend group activities due to a preference to stay in his/her room. The facility staff would allow the resident to familiarize himself/herself with the center environment and activity programs on a regular basis.
Two days later on 01-18-18, a recreation evaluation was completed, which indicated that resident #128 was interested in cards/other games, crafts/art and exercise/sports.
Further record review revealed documentation on 07-17-18 by the Activities Director that the resident received one on one room visits including music stimulation and hand massages.
On 11-08-18, review of the November 2018 Therapeutic Recreation Resident Participation Record revealed that resident #128 received daily room visits that included music of interest, spiritual visits and sensory stimulation, which were not indicated in the assessment of interests for the resident. However, there was no evidence that the 01-16-18 activities care plan had been revised and implemented by staff as based on the resident's assessment.
On 11-09-18 at 5:30 PM, interview of the Director of Nursing and the administrator revealed no additional information.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Maryland facilities.
- • 30% turnover. Below Maryland's 48% average. Good staff retention means consistent care.
Concerns
- • 63 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Autumn Lake Healthcare At Oakview's CMS Rating?
CMS assigns AUTUMN LAKE HEALTHCARE AT OAKVIEW an overall rating of 2 out of 5 stars, which is considered 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 Autumn Lake Healthcare At Oakview Staffed?
CMS rates AUTUMN LAKE HEALTHCARE AT OAKVIEW's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 30%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Autumn Lake Healthcare At Oakview?
State health inspectors documented 63 deficiencies at AUTUMN LAKE HEALTHCARE AT OAKVIEW during 2018 to 2025. These included: 57 with potential for harm and 6 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Autumn Lake Healthcare At Oakview?
AUTUMN LAKE HEALTHCARE AT OAKVIEW 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 AUTUMN LAKE HEALTHCARE, a chain that manages multiple nursing homes. With 138 certified beds and approximately 122 residents (about 88% occupancy), it is a mid-sized facility located in SILVER SPRING, Maryland.
How Does Autumn Lake Healthcare At Oakview Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, AUTUMN LAKE HEALTHCARE AT OAKVIEW's overall rating (2 stars) is below the state average of 3.0, staff turnover (30%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Autumn Lake Healthcare At Oakview?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Autumn Lake Healthcare At Oakview Safe?
Based on CMS inspection data, AUTUMN LAKE HEALTHCARE AT OAKVIEW has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Autumn Lake Healthcare At Oakview Stick Around?
AUTUMN LAKE HEALTHCARE AT OAKVIEW has a staff turnover rate of 30%, 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 Autumn Lake Healthcare At Oakview Ever Fined?
AUTUMN LAKE HEALTHCARE AT OAKVIEW has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Autumn Lake Healthcare At Oakview on Any Federal Watch List?
AUTUMN LAKE HEALTHCARE AT OAKVIEW 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.