LAYHILL NURSING AND REHABILITATION CENTER
For profit - Limited Liability company
129 Beds
LIFEWORKS REHAB
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#207 of 219 in MD
Photo by Rob Mig
Photo by Rob Mig
Photo by Rob Mig
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Layhill Nursing and Rehabilitation Center has received a Trust Grade of F, indicating poor performance and significant concerns about care quality. They rank #207 out of 219 facilities in Maryland, placing them in the bottom half, and #34 out of 34 in Montgomery County, meaning there are no local options that perform worse. The facility's issues have worsened dramatically, jumping from 7 problems in 2019 to 70 in 2024, highlighting a troubling trend. While staffing is relatively stable with a 45% turnover rate, which is average, the facility has concerning fines totaling $153,596, higher than 96% of Maryland facilities. There is good RN coverage, exceeding that of 76% of state facilities, which is a positive aspect as RNs can catch issues that CNAs might overlook. However, there have been serious incidents, including a failure to document residents' wishes regarding CPR and a violation of privacy when a male staff member entered a shower room while a resident was bathing. Overall, families should weigh these strengths and weaknesses carefully when considering this facility.
- Trust Score
- F
- In Maryland
- #207/219
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 45% turnover. Near Maryland's 48% average. Typical for the industry.
- Penalties ✓ Good
- $153,596 in fines. Lower than most Maryland facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 49 minutes of Registered Nurse (RN) attention daily — more than average for Maryland. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 93 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 6%
Review needed
7 → 70 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2019: 7 issues
2024: 70 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (45%)
3 points below Maryland average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Maryland average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 45%
Near Maryland avg (46%)
Typical for the industry
Federal Fines: $153,596
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: LIFEWORKS REHAB
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 93 deficiencies on record
1 life-threatening 2 actual harm
Sept 2024
46 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to have an effective system in place to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to have an effective system in place to correctly identify the appropriate decision maker regarding health care decisions and that the resident/health care decision maker's wishes regarding CPR were clearly documented in the medical record to ensure CPR was performed if needed. This was evident for 4 out 51 Residents, (Resident #328, #30, # 97 #55), reviewed for advanced directives during a survey.
The facility's failure to ensure that each resident had only one active MOLST, led to the determination that immediate jeopardy existed. The facility was notified of this determination on [DATE] at 6:25 PM. Surveyors accepted the facility's plan to remove the immediacy on [DATE] at 11:00PM. The plan was validated, and the immediate jeopardy was removed on [DATE] at 5:05 PM.
The findings include:
A Maryland MOLST, (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. The orders on a MOLST are commonly referred to as code status.
1) On [DATE] at 8:02 AM, a review of medical records revealed Resident # 328, was admitted to the facility for rehabilitation following a hospital stay. Further review revealed a MOLST( MOLST #1) order, dated [DATE].
A review of MOLST #1 revealed that Resident #328 was not to receive CPR ( Do not resuscitate) if the resident experienced cardiac arrest. Continued review revealed the physician obtained the information, not by speaking to the Resident but by communicating with the resident's representative or surrogate.
On [DATE] at 1:45 PM, the Regional Social Worker (Staff # 17) provided an additional MOLST order, (MOLST #2) for Resident #328. Further review of MOLST #2 revealed the MOLST was dated [DATE] and was still active. Further review of the MOLST #2 revealed that Resident #328 was to receive CPR ( full code ) in the event the resident experienced cardiac arrest. Continued review revealed the physician obtained this information by speaking directly to the resident.
Further review of Resident #328's medical record revealed the following orders for the resident's code status:
On [DATE] at 10:28 PM order for full code
On [DATE] at 5:74 PM order for Do Not Resuscitate (DNR)
On [DATE] at 11:29 AM order for Full Code
On 9//13/24 at 5:02 PM DNR/DNI active for one day
On [DATE] at 5:47 PM order for DNR
On [DATE] at 10:14 AM, a review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE] section C indicated that the resident did not have any cognitive decline as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15.
On [DATE] at 10:15 AM, Resident # 328's medical records were reviewed and there was no documentation that the resident was incapable of making health care decisions.
On [DATE] at 1:43 PM, Nurse Staff #18 was interviewed regarding what actions she would take if Resident #328 became unresponsive and was not breathing. During the interview, staff #18 reported she would call for help and request another nurse to verify the code status of resident #328. Staff # 18 reported that the resident's profile page documented full code (perform CPR). Staff # 18 then showed the surveyor a MOLST form on the computer screen. The MOLST form indicated the resident was a DNR. The nurse reported she would follow the MOLST and would not perform CPR. She reported that to further verify the code status of a resident she would refer to the MOLST Binder. Staff #18 reported that the MOLST binder contains all the resident's most current MOLST orders and is kept at the nurse's station.
On [DATE] at 2:29 PM, the Director of Nursing (DON) was interviewed regarding Resident #328 having 2 active MOLSTs with orders that contradicted each other in the medical record. During the interview, she reported that MOLST #1 was completed at the hospital, and sent with the resident to the facility. Additionally, MOLST #2 was completed at the facility. The DON reported that staff should follow the most recent MOLST as indicated by the date on the MOLST. She reported, that a voided MOLST should have a line through it. The DON reported that MOLST #2 was the correct order because it was completed at the facility and therefore more recent than MOLST# 1 which was completed at the hospital.
On [DATE] at 3:13 PM, an interview was conducted in Resident # 328 room with the resident and the resident's family, which included the resident's power of attorney (POA). During the interview, Resident #328 and Resident # 328's POA (Resident's daughter) clearly communicated that the resident did not want CPR if s/he suffered a cardiac arrest.
On [DATE] at 3:17 PM, resident# 328's family member (not POA) reported that he was with Resident # 328 when the resident was admitted to the facility. He reported that he and the resident agreed to receive CPR if s/he suffered cardiac arrest. The next day he realized they made a mistake. He reported he had spoken to a nurse at the nurse's station and told her that Resident # 328's true wishes were to not have CPR performed if s/he suffered a cardiac arrest. He reported that the nurse told him that it was not a problem, and they had the paperwork from the Resident's primary physician indicating that the resident's code status was Do not resuscitate, DNR.
On [DATE] at 2:56 PM, Social Services personnel (Staff #11) were interviewed. During the interview, she reported, that before a care plan meeting for Resident #328, she obtained Resident #328's code status under the profile section in the medical records. Staff #18 reported that she did not actually review the MOLST, and at the time, she did not discuss the code status of Resident #328 with the resident or the resident's family during the meeting.
2) On [DATE] at 10:05 AM, Resident #97 's MOLST order dated [DATE] was reviewed. The review revealed that the residents' wishes were communicated to the physician through the resident's surrogate, per the authority granted by the Health Care Decisions Act. Further review revealed that the resuscitation status chosen was No CPR, DNR option B.
On [DATE] at 10:10 AM, a review of progress notes revealed a social services note, dated [DATE] at 12:39, A review of the note revealed that the Regional Social Worker (Staff #17) contacted resident #97's emergency contact representative to confirm the DNR status on file.
On [DATE] at 10:15 AM, further review of electronic health records failed to reveal certifications of incapacity for Resident #97. The resident's BIMS score was 15/15 indicating the resident was cognitively intact.
On [DATE] at 11:45 AM, During an interview with the medical director, he reported that he is familiar with resident # 97 and his opinion was that the resident has capacity.
On [DATE] at 11:00 AM, the above concerns were discussed with the administrator. He reported that he would reeducate the staff involved and re-audit the residents.
On [DATE] at 4:00 PM, a review of 8 percent of the facility residents failed to reveal any additional issues with residents' MOLST orders.
On [DATE] at 4:48 PM, The administrator reported that the 2 outstanding concerns were corrected.
On [DATE] at 4:50 PM. a review of Resident #97 medical record revealed a new MOLST dated [DATE]. A review of the MOLST revealed that the Medical Director communicated with Resident #97 regarding their wishes. Further review revealed that the residents' wishes were not the same as the resident's representative. The resident wished to receive resuscitative treatment (CPR) if s/he would suffer cardiac arrest.
On [DATE] at 4:50 PM, a review of resident # 97's MOLST revealed that the MOLST certification for the basis of these orders, was the resident and the order was for CPR.
On [DATE] at 4:51 PM, review of the Residents code status listed in the resident profile was a full code.
4) On [DATE] at 1:00 PM, a review Resident #55's electronic medical record (EMR) revealed the resident resided in the facility for long term care since 2020, and, following a brief hospitalization in [DATE], the resident was readmitted into the facility. Review of Resident #55's 5-day assessment with an assessment reference date (ARD) of [DATE] documented Resident #55's BIMS (brief interview for mental status) summary score was 15, indicating the resident was cognitively intact.
Continued review of Resident #55's EMR revealed 3 active MOLST forms; none of the MOLST forms had been voided when a new MOLST had been completed. In the EMR, under the document tab, Resident #55 had 1) an active MOLST signed and dated [DATE] that documented Resident #55 elected, CPR (resuscitation) status, 2) an active MOLST form that was signed and dated [DATE] that documented Resident #55 elected No CPR, Option A-2, Do not intubate (DNI): Comprehensive efforts may include limited ventilatory support by CPAP or BiPAP, but do not intubate, and, 3) Resident #55 had an active MOLST signed and dated [DATE] that documented Resident #55's elected CPR (resuscitation) status was Attempt CPR. None of the scanned MOLST forms had been voided by the practitioner when a new MOLST had been created, indicating the resident's MOLSTs were active. A copy of Resident #55's MOLST forms was requested and provided on [DATE].
Further review of Resident #55's EMR, revealed, on [DATE], at 12:45 PM, in a medical progress note, the physician documented s/he was asked to evaluate advance care planning and MOLST with Resident #55, advance care planning was reviewed, the MOLST reviewed and completed. There was no other documentation in the progress note to indicate the discussion the physician had with Resident #55 which led to the resident's DNR order.
In a medical progress note on [DATE] at 12:49 PM, the physician documented s/he was asked to evaluate advance care planning and MOLST with Resident #55, and advance care planning was reviewed, MOLST reviewed and completed. There was no other documentation in the progress note to indicate the discussion the physician and Resident #55 had which resulted in a change in the resident's wishes for life sustaining treatment, and a new MOLST.
The presence of more than one active conflicting MOLST in Resident #55's medical record, put the staff at risk of failing to accurately confirm the resident's wishes regarding cardiopulmonary resuscitation (CPR) and implement medical treatment based on the resident's wishes.
On [DATE] at 10:51 PM, Staff #20, Licensed Practical Nurse (LPN), Regional Director of Clinical
Reimbursement was made aware of the finding that Resident #55 had more than one unvoided MOLST in his/her medical record and the concern with the resident having more than one conflicting MOLST. Staff #20 acknowledged the concerns at that time, and indicated the administration was aware of the concern with active, conflicting MOLSTS in resident records.
Failures to identify residents that have the capacity (maintain the ability to make their healthcare decisions), failure to honor residents' wishes for life-sustaining treatments, and failure to maintain one accurate MOLST in a resident's medical record, put the resident at risk of not receiving the correct orders for life-sustaining treatments. Immediate action was needed to ensure that residents who wished life-sustaining treatment would receive that treatment if needed and were not just left to die and/or that residents who did not want life-sustaining treatments, did not endure those treatments unnecessarily. As a result of these findings, an Immediate Jeopardy situation was identified on [DATE] at 6:30 PM, and the facility was provided with the Immediate Jeopardy Template at that time.
The facility's failure to ensure each resident had only one active MOLST, led to the determination that immediate jeopardy existed. The facility was notified of this determination on [DATE] at 6:25 PM. Surveyors accepted the facility's plan to remove the immediacy on [DATE] at 11:00PM. The plan was validated, and the immediate jeopardy was removed on [DATE] at 5:05 PM.
The facility submitted a removal plan on [DATE] at 7:43 PM and again on [DATE] at 9:18 PM, which was not accepted. The facility submitted another plan to remove the immediacy on [DATE] at 9:52 PM, which again was not accepted. On [DATE] at 10:40 PM, the administrator provided an additional plan that was accepted by the survey team and OHCQ (The Office of Healthcare Quality) on [DATE] at 11:00 PM.
The following corrective measures were established on [DATE] at 8:50 AM
Social workers will complete a 100% audit of all alert and oriented residents and all non-alert and oriented resident's representative(s) via conversation to ensure they have an active and correct MOLST uploaded in their chart. All old MOLST forms will be voided and uploaded to ensure that the correct MOLST form is followed.
ADON will educate weekend supervisors and 3-11 & 11-7 weekday supervisors on the process of uploading new residents ' MOLST into the electronic healthcare record upon admission.
The Regional Director of Admissions will educate the admissions director and admissions coordinator on the process of uploading new residents' MOLST into PCC upon admission.
The Regional Director of social services will educate social workers to discuss MOLST and code status with residents and/or representative(s) during care plans, that all residents are to have an active and completed and uploaded in their chart, that CPR/DNR status are found in the residents ' chart under the document section and titled active MOLST that any changed MOLST will be voided and reflected on the chart, and that the order for code status matches the MOLST.
ADON will educate licensed nurses and physicians that all residents are to have an active and correct MOLST completed and uploaded in the chart, that CPR/DNR status ' are found in the residents; chart under the document section titled active MOLST, that any changed MOLST will be voided and reflected on the chart, and that the order for code status matches the active MOLST.
On [DATE], the facility provided an audit list of the MOLST forms which was to include all the residents in the facility. An initial review of the audit list failed to reveal 2 current residents (Resident #84, #13).
On [DATE] at 8:50 AM the Administrator was interviewed regarding the audit. During the interview, he confirmed that the audit was not acceptable, since it was incomplete.
On [DATE] at 9:50 am - an updated MOLST Audit list was provided to the survey team from the NHA.
On [DATE] at 10:10 AM, the NHA was interviewed to ask about any additional evidence to be provided, and he said this was the current evidence, and confirmed the previous evidence of education to staff regarding MOLST documentation.
On [DATE] at 10:00 AM, the facility audits were completed as part of their correction plan and were reviewed. A random 10 percent of the facility's residents were reviewed for accurate MOLST forms.
3) On [DATE], a review of Resident #30's medical record revealed a Minimum Data Set assessment, with a reference date of [DATE], that revealed the resident has a BIMS (Brief Interview for Mental Status) of 4/15 indicating the resident had severe cognitive impairment.
On [DATE] at approximately 5:00 PM, review of the electronic health record revealed 4 active current MOLST forms. Three of the MOLSTs, (dated [DATE], [DATE], and [DATE]) included orders for No CPR (DNR) and one (dated [DATE]) included orders to perform CPR (full code).
Further review of the MOLST, dated [DATE] and signed by Physician #31, revealed in the section for Certification for the Basis of these Orders the physician had initialed the section Mark this line if the patient or authorized decision maker declines to discuss or is unable to make a decision about these treatments. This section of the MOLST also included the following: The patient's or authorized decision maker's participation in the preparation of the MOLST form is always voluntary. If the patient or authorized decision maker has not limited care, except as otherwise provided by law, CPR will be attempted and other treatments will be given. The [DATE] MOLST included an order to perform CPR (full code).
Review of the progress note completed by Physician #31 for a visit conducted on [DATE] revealed an acknowledgement that the resident was previously a long term care resident at the facility prior to a recent hospitalization. The progress note also included: Code Status: I reviewed/completed the MOLST form with [name of Resident #30] on [DATE] and the patient is Full Code. Further review of this progress note revealed the resident was alert and oriented x1 and had AMS (altered mental status) -- baseline.
Further review of the medical record revealed a Physician Certification Related to Medical Condition, Decision Making, and Treatment Limitations, dated and signed by Physician #31 on [DATE], which indicated the resident lacks adequate decision making capacity (including decisions about life-sustaining treatments). Further review of the medical record failed to reveal a second certification that the resident lacked decision making capacity, since the [DATE] certification indicating the resident had capacity.
Review of the resident's Advance Directive included the identification of a Health Care Agent and an Alternative Health Care Agent. Both of these agent's contact information was found in the Contacts section of the resident Profile in the electronic health record.
Further review of the medical record failed to reveal documentation to indicate that an attempt was made to consult the resident's healthcare agent prior to establishing the full code MOLST on [DATE].
An interview was conducted with Physician #31 on [DATE] at 2:31 PM. She reported she sees new admissions and follows the resident while at the facility short term, and confirmed she does not see the residents when they are in long term care. When asked about completing a MOLST when a resident is re-admitted , the physician reported in this facility she has to fill out a brand new MOLST everytime the resident is admitted . She reported if the resident obviously has dementia and can't complete the form and no poa [health care agent] is available then the resident would have to be a full code by default. When asked if she looks to see if there is a valid MOLST she responded: if one is available to me. When asked about Resident #30, Physician #31 indicated she did not recall the resident. After surveyor reviewed the concerns related to Resident #30's MOLST, the physician reiterated that this facility requires a new MOLST be completed regardless of the old MOLST.
During the [DATE] interview, when asked about the process of putting the order into the EHR system, the Physician #31 reported there is a binder that we put the signed MOLST into and then the nursing staff put the order into the EHR.
Further review of the electronic health record for Resident #30 revealed an order, dated [DATE] for DNR. This order was signed by Physician #31 on [DATE]. The physician signed the DNR order two days after completing a MOLST which included orders for CPR (Full Code).
Further review of the medical record revealed a Multidisciplinary Care Conference note for a meeting held on [DATE]. Review of this note revealed the resident and the Health Care Agent participated in the meeting. The following was found in the Social Work Summary section: .Resident is alert and oriented x 3. MOLST updated reviewed and on file; Code Status; full code In the last section of this note, labeled Resident/Family Care Level Review, revealed Do Not Resuscitate was checked.
Further review of the EHR revealed an order, dated [DATE] for FULL CODE. This was signed by Physician # 33 on [DATE]. This was two weeks after Physician #31 completed the MOLST with orders for CPR (full code).
On [DATE] at 10:54 PM, surveyor reviewed with the corporate Social Worker #17 the findings that the resident had DNR orders in place until [DATE] despite the MOLST on [DATE] indicating full code, also reviewed the discrepancy in the [DATE] care plan note which indicated the social worker discussed with family and resident that resident was a full code, but at the end of the note DNR was marked. Surveyor also reviewed the concern that there was only one certification of incapacity for the resident with a BIMS of 4. The SW #17 acknowledged the need to re-evaluate the resident's code status.
On [DATE] at approximately 8:30 AM, review of the EHR revealed a note dated and signed by SSD #19 on [DATE] at 3:30 PM that stated: SW [social worker] followed up with [Health Care Agent] from the previous call on [DATE] regarding current code status and [Health Care Agent] requested code status be changed to DNR. Further review revealed a new MOLST, dated [DATE], which indicated that the orders were based on instructions in the patient's advance directive and included orders for No CPR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the faciltiy failed to have an effective system in place to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the faciltiy failed to have an effective system in place to ensure code status was discussed with residents and or their responsible party when new MOLSTs were created. This was found to be evident for 3 (Resident #30, #23. #97) out of 17 residents reviewed for code status during the survey. The findings include:
1). A Maryland MOLST, (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. The orders on a MOLST are commonly referred to as code status.
On [DATE] at 10:05 AM, Resident #97's MOSLT order, dated [DATE], was reviewed. The review revealed an order for Resident #97 not to receive CPR (DNR) if s/he should suffer cardiac arrest. Further review revealed the physician did not speak to Resident #97 about their wishes regarding CPR, but only communicated with the resident representative.
On [DATE] at 10:10 AM, review of progress notes revealed a social services note, dated [DATE] at 12:39 PM, that revealed Regional Social worker (Staff # 18) contacted Resident #97 personal representative to confirm the residents DNR status on file. Further review failed to reveal that Resident #97 was consulted.
On [DATE] at 10:15 AM, further review of medical records failed to reveal certifications of incapacity for Resident #97. In addition, the resident's BIMS score was 15/15 indicating s/he was cognitively intact.
On [DATE] at 10:20 PM, during a brief interview with the Administrator, he reported that he would review the Residents MOLST form and code status with the Medical Director.
On [DATE] at 11:45 AM, during an interview with the medical director he reported that he was familiar with resident # 97 and his opinion was that the resident had capacity.
On [DATE] at 4:50 PM,. review of Resident #97 medical record revealed a new MOLST, dated [DATE]. Review of the MOLST revealed that the Medical Director communicated with the Resident #97 regarding his wishes. Further review revealed that the residents' wishes were not the same as the resident's representative and that the resident wished to receive resuscitative treatment (CPR) if s/he would suffer cardia arrest.
2) Review of Resident #30's medical record revealed the resident has resided at the facility for several years and whose diagnoses included, but was not limited to, high blood pressure, kidney disease, major depressive disorder and dementia. Review of the Minimum Data Set assessment, with a reference date of [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment. The resident had a brief hospitalization in [DATE] and was then re-admitted to the facility.
Review of the electronic health record revealed that, prior to the hospitalization in [DATE], the resident had orders for No CPR. The most recent MOLST (Maryland Orders for Life Sustaining Treatment) found for the resident prior to [DATE] was documented as having been discussed with the resident and included orders for No CPR (DNR). The resident also had previous MOLSTs from 2020, which were also for No CPR and indicated they were the result of discussion with the residents health care agent as named in the advance directives.
On [DATE], a new MOLST was completed that included orders for CPR (full code). Review of this MOLST revealed it was completed because the patient or authorized decision maker declined to discuss or was unable to make a decision about these treatments. This MOLST was completed by Physician #31.
An interview was conducted with Physician #31 on [DATE] at 2:31 PM . She reported that she sees new admissions and follows the resident while here short term, and confirmed she does not see the residents when they are long term care. When asked about completing a MOLST when a resident is re-admitted , the physician reported that, in this facility she has to fill out a brand new MOLST everytime the resident is readmitted . She reported thst, if the resident obviously has dementia and can't complete the form and no POA [power of attorny/health care agent] is available then the resident would have to be a full code by default. When asked if she looks to see if there is a valid MOLST she responded: if one is available to me. When asked about Resident #30, Physician #31 indicated she did not recall the resident.
Review of the resident's Advance Directive included the identification of a Health Care Agent and an Alternative Health Care Agent. Both of these agents' contact information was found in the Contacts section of the resident Profile in the electronic health record.
No documentation was found to indicate that attempts were made to contact the Health Care Agent prior to changing the resident's code status from No CPR (DNR) to CPR (full code).
Further review of the medical record revealed a Multidisciplinary Care Conference note for a meeting held on [DATE]. Review of this note revealed that the resident and the Health Care Agent participated in the meeting. The following was found in the Social Work Summary section: .Resident is alert and oriented x 3. MOLST updated reviewed and on file; Code Status; full code In the last section of this note, labeled Resident/Family Care Level Review, it was revealed that Do Not Resuscitate (No CPR) was checked.
No documentation was found for the week between the establishment of the full code MOLST on [DATE] and the care plan meeting on [DATE] to indicate the Health Care Agent was informed of the change in code status. Review of the care conference note revealed conflicting documentation regarding the resident's code status.
On [DATE] at 10:01 AM, interview with the current Social Service Director (SSD #19) reported that the resident had dementia and a psychiatric diagnosis and confirmed that she would consult with the Health Care Agent if permission was needed for anything. SSD #19 also reported she had addressed code status with the Health Care Agent in the past and that the resident was a full code.
Further review of the medical record on [DATE] revealed a Discharge Planning Progress Note, written and signed by SSD #19 on [DATE] which stated: Resident has an advance directive of FULL CODE. Resident/family aware. This was more than two weeks after the code status was changed.
3) Review of Resident #23's medical record revealed the resident was admitted in [DATE] after a hospitalization. Review of the [DATE] Minimum Data Set (MDS) assessment revealed the resident was rarely or never understood, had functional limitations in range of motion on both sides for upper extremities (arms) and impairment on one side for lower extremities (legs). The resident was dependent on staff for activities of daily living and for eating. The resident was receiving occupational, speech and physical therapy.
During an interview with the resident's Health Care Power of Attorney (HCPOA) on [DATE] at 1:22 PM revealed concerns regarding not being informed about the resident's care.
On [DATE], further review of the medical record revealed two cerifications that the resident lacked adequate decision making capacity (including decisions about life-sustaining treatments). These incapacity certifications were completed on [DATE] by Physician #56 and on [DATE] by Nurse Practitioner #57.
Further review of the medical record revealed that a MOLST was completed on [DATE] by Physician # 31. In the section for Certification for the Basis of these Orders the physician had initialed the section Mark this line if the patient or authorized decision maker declines to discuss or is unable to make a decision about these treatments.
On [DATE] at approximately 3:10 PM, the Director of Nursing reported that when a resident comes from the hospital, the MOLST from the hospital remains in place until the practitioner updates the MOLST. The practitioner has to re-assess the MOLST, if the resident is not capable they have to review it with the family member.
Further review of the medical record failed to reveal documentation to indicate the resident's medical POA was contacted to discuss the code status when the MOLST was completed on [DATE]. No physician progress note was found to indicate Physician #31 examined or assessed the resident in June, July or August.
Review of the resident's profile section of the electronic health record revealed the name and contact information for the the residents Medical Power of Attorney.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on interview, and observation, it was determined that the facility failed to ensure that a resident received services with dignity. This was evident for 1 (Resident #42), out of 132 residents ob...
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Based on interview, and observation, it was determined that the facility failed to ensure that a resident received services with dignity. This was evident for 1 (Resident #42), out of 132 residents observed during a survey. The findings include:
On 9/13/24 at 8:33 AM, Resident # 42 was interviewed. During the interview, he reported that sometimes the facility staff entered his room without knocking.
On 9/13/24 at 840 AM, during an interview with Resident #42, a certified nursing assistant (CNA) (Staff #10) entered the room and delivered a lunch tray.
An observation during the interview with Resident #42 on 9/13/24 at 840 AM, failed to reveal that Staff #10 knocked before entering the room.
On 9/13/24 at 9:01 AM, Staff # 10 was interviewed. During the interview, Staff #10 reported that she introduced herself to the resident earlier in the morning, but she confirmed she did not knock when bringing the resident his/her lunch tray. Staff #10 reported that she just found out she had to knock prior to entering a room.
On 9/20/24 10:50 AM, the above concern was discussed with the Administrator and Director of nursing. No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
2) Resident #24 was admitted to the facility in August of 2024. A review on 9/11/24 at 12:29 PM of the resident's medical records failed to reveal an advance directive.
Subsequent review of Resident ...
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2) Resident #24 was admitted to the facility in August of 2024. A review on 9/11/24 at 12:29 PM of the resident's medical records failed to reveal an advance directive.
Subsequent review of Resident #24's medical records revealed that s/he was certified by the attending physician as having adequate decision-making capacity on 8/29/24. Furthermore, a review of the resident's care plan indicated that s/he had an advance directive.
On 9/12/24 at 1:37 PM, the Social Services Coordinator (Staff #11) was interviewed. Staff #11 explained the social services department's process with advance directive when a resident is admitted to the facility. Staff #11 reported that she had not handled the advance directives with the residents and that it was the Director of Social Services (Staff #19) who would usually go over the mater with the resident when they are admitted . However, Staff #11 indicated that Staff #19 was currently out on vacation.
Shortly after and during the interview with Staff #11, Staff #19 joined the conversation through telephone conference. Staff #19 reported that the advance directives are discussed with residents within 24 to 48 hours upon admission and documented in assessments under the Discharge planning psychosocial assessment category. She further reported that if a resident had a care plan that indicated that they have an advance directive, then that meant that we were able to obtain one from them.
On 9/13/24 at 9:07 AM, Resident #24's medical records for assessments were reviewed and revealed the Discharge Planning Psychosocial Assessment was highlighted in red and indicated that it was 14 days overdue.
On 9/13/24 at 10:01 AM, Staff #11 was asked to produce a copy of Resident #24's advance directive.
Later on, at 12:57 PM, Staff #11 was approached by the surveyor and was asked about the earlier request for documentation. Staff #11 reported that she reviewed the resident's medical records and was not able to find his/her advance directive. Staff #11 indicated that she spoke with Resident #24's family member who was at the facility and reported that the resident had one and would give the facility a copy.
In another interview with Staff #11 accompanied by the Regional Social Worker and Discharge Planning Specialist (Staff #17) on 9/13/24 at 2:31 PM, both staff were asked, prior to today, do you have documentation that the advance directive was discussed with the resident? Staff #17 provided the surveyor a copy of the Discharge Planning Psychosocial Assessment that was dated 9/13/24 at 1:34 PM. Both Staff #11 and #17 confirmed that the advance directive had not been discussed with the resident prior to today.
On 9/20/24 at 1:29 PM, the concern was discussed with the Director of Nursing (DON) that the facility failed to ensure the resident's right to formulate an advanced directive by failing to provide information to a capable resident. The DON acknowledged the concern.
Based on records review and interviews, it was determined that the facility failed to provide residents with information to formulate an advance directive. This was evident in 3 (Resident #24, #37, #55) of 17 residents reviewed for advance directives.
The findings include:
1). An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity.
On 9/17/24 at 2:27 PM, a review of Resident #37's clinical record revealed that there was no documentation related to advance directives. Further review revealed a document written by the facility's Medical Director on 7/18/24 that indicated the resident had capacity to make decisions.
On 9/20/24 at 11:23 AM, another record review revealed a care plan meeting note dated 4/11/24, which contained a discussion regarding Resident #37's code status but did not mention any review of advance directives or offer for the resident to complete an advance directive. A review of the progress notes and Assessments sections of the medical record revealed no additional documentation by social services staff regarding advance directives.
On 9/20/24 at 11:39 AM, an interview with the Director of Social Work (SW #19) was conducted. She said that advance directive information was normally offered and asked for at the time a resident was admitted , but not usually discussed during care plan meetings. When asked if Resident #37 had been asked about Advance Directive information or been offered the information, she replied that the resident preferred that their family was asked about any decisions. When SW #19 was asked to show evidence of this in the clinical record, she could find none, and further confirmed that SW #19 had not had any discussions with Resident #37's family regarding advance directives.
On 9/20/24 at 1:14 PM, an interview with the Director of Nursing (DON) was conducted to review that Resident #37 had not received information regarding advance directives. The DON acknowledged the finding.
3). A review of Resident #55's electronic medical record (EMR) on 9/10/24 at 1:38 PM failed to reveal to reveal evidence that Resident #55 had an advanced directive in place.
On 9/12/24 at 10:20 AM, further review of the EMR revealed Resident #55 resided in the facility for long term care since 2020, and, following a brief hospitalization in the beginning of August 2024, the resident was readmitted into the facility. Review of Resident #55's 5-day assessment with an assessment reference date (ARD) of 8/13/24 documented Resident #55's BIMS (brief interview for mental status) summary score was 15, indicating the resident was cognitively intact.
Continued review of Resident #55's medical record failed to reveal documentation to indicate Resident #55 had an advanced directive, that the resident's right to formulate an advanced directive had been discussed with the resident, or that advanced directives and its provisions were periodically addressed with the resident, as preferences may change over time.
On 9/16/24 at 12:25 PM, the above concerns were discussed with Staff #19, Director of Social Services. At that time, Staff #19 confirmed the above findings, and offered no further comments at that time
The Director of Nurses (DON) was made aware of the above concerns on 9/20/24 at 3:30 PM, and the DON acknowledged the concerns 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined that the facility failed to notify a resident's representative of changes in the resident's treatment. This was found to be evident for ...
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Based on medical record review and interview, it was determined that the facility failed to notify a resident's representative of changes in the resident's treatment. This was found to be evident for 1 out of (Resident #23) one resident reviewed for notification of change.
The findings include:
During an interview with the resident's Health Care Power of Attorney (HCPOA) on 9/11/24 at 1:22 PM concerns were revealed regarding the HCPOA not being informed about the resident's care.
On 9/17/24, review of Resident #23's medical record revealed the resident was admitted in June 2024 after a hospitalization. Review of the 6/11/24 Minimum Data Set (MDS) assessment revealed the resident was rarely or never understood, had functional limitations in range of motion on both sides for upper extremities (arms) and impairment on one side for lower extremities (legs). The resident was dependent on staff for activities of daily living and for eating. The resident was receiving occupational, speech and physical therapy.
On 9/17/24, further review of the medical record revealed two cerifications that the resident lacked adequate decision making capacity.
On 9/17/24 at 4:02 PM, further review of the medical record revealed a new medication was started on 6/26/24, Metoprolol 12.5 mg two times a day for high blood pressure. No documentation was found to indicate the HCPOA was notified of the start of this new medication.
Further review of the medical record revealed the attending physician changed on 7/1/24. A Medical Discharge Summary progress note was completed by Physician #56 on 7/1/24. No documentation was found to indicate the HCPOA was notified that the attending physician was changing.
On 9/17/24 at approximately 3:10 PM, the Director of Nursing reported that, when there is a change in the primary care provider to a different primary care provider for the health organization who is responsible for initial short term skilled care at the facility, the healthcare organization should contact the other provider. She also reported the prior primary care provider should inform the family of the change.
On 9/18/24 at approximately noon, surveyor reviewed the concerns with the DON regarding the lack of documentation to indicate the HCPOA was notified of the medication change or the change in the primary care provider.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined that the facility administered an intramuscular injection of an antipsychotic medication without adequate indication. This was found to ...
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Based on medical record review and interview, it was determined that the facility administered an intramuscular injection of an antipsychotic medication without adequate indication. This was found to be evident for one (Resident #30) out of five residents reviewed for unnecessary medication.
The findings include:
1) Review of Resident #30's medical record revealed that the resident had resided at the facility for several years and whose diagnoses included, but were not limited to: high blood pressure, kidney disease, major depressive disorder and dementia. Review of the Minimum Data Set assessment, with a reference date of 6/5/24, revealed the resident had a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment.
Review of the medical record revealed that the resident was seen about once a month by either the Psychiatrist #37 or the Psychiatric Nurse Practitioner (NP) #36.
Review of the June 2024 Medication Administration Record (MAR) revealed that the resdient received IM injections of haloperidol (Haldol) and diphenhydramine (Benedryl) on 6/9/24 for aggressive behaviors.
Haldol is an antipsychotic medication. Benedryl is an antihistamine medication.
Review of the Medication Administration Record (MAR) revealed areas for nursing staff to document resident behaviors on the day, evening and night shifts. Review of the MAR revealed staff can document based on the following coding: 1 - compulsive; 2 - pacing continuously; 3 - Continuously screaming and yelling; 4 - danger to others; 5 - danger to self; 6- false beliefs; 7 - finger painting feces; 8 - spitting; 9 - other. On 9/16/24, review of the documentation for this monitoring for June, July, August and September thru the 16th, 2024 revealed only a check mark for each shift.
On 9/16/23 at 3:52 PM, interview with Nurse #8 revealed a check on the behavior monitoring sheets meant that the resident did not display any of those behaviors.
On 9/16/24 at 3:58 PM, interview with the unit nurse manager #12 revealed that, when the nurses see this item on the computer they have to answer yes or no. The unit nurse manager confirmed that the checks indicated the resident was not displaying those behaviors.
Further review of the MAR revealed there was another section to document other psychiatric symptoms: 1- mood swings; 2 - sad; 3 - continuous crying; 4 - withdrawn; 5 - depressed; 6 - angry; 7 - poor eye contact; 8 - other. Review of the nursing documentation from June, July, August and September thru the 16th, 2024 revealed that staff documented every shift either a 0 or an N, thus indicating the resident was not experiencing these symptoms.
During the 9/16/24 interview with the unit nurse manager #12, surveyor reviewed the concern that the documentation did not support the administration of two IM medications in June. At 4:39 PM, the unit nurse manager presented the surveyor with a 6/8/24 change in condition note.
Review of the Change in Condition Evaluation note, with an effective date of 6/8/24 at 7:21 PM, revealed it was signed by Nurse #43. The note indicated it was about behavioral symptoms that had started in the afternoon and that since the change in condition occurred the symptoms had gotten better. The nurse documented the following in the section to summarize: [name of resident #30] was observed verbally abusive and throwing personal items towards [his/her] roommate in their shared room. [Name of resident #30] was highly agitated, and the roommate appeared distressed but physically unharmed. The writer calmly approached [resident #30] maintained a safe distance and used a soft reassuring tone to ask [him/her] step outside from the room and immediately called additional staff support to de-escalate the situation. Successfully separate the resident by escorting [Resident #30] to quiet and secure area. Further review of this note revealed the psychiatrist #37 was notified at 6:40 PM and ordered to transfer the resident out to the hospital, however the resident refused to go to the hospital; psychiatrist #37 was contacted again and gave a STAT order for Haloperidol (Haldol) 2 mg IM (intramuscular injection) and Benedryl 25 mg IM; and additional orders for lab work to be obtained the following day.
STAT orders are to be given right away.
On 9/16/24 at 4:41 PM surveyor reveiwed the concern with the Director of Nursing (DON) that the 6/8/24 change in condition note does not support the need for IM HALDOL and IM Benedryl. The DON indicated she would investigate.
Further review of the medical record revealed a Health Status Note with an effective time of 6/8/24 at 8:14 PM and written by Nurse #29. This note states: Resident exhibited aggressive behavior towards [his/her] roommate, throwing things and using inappropriate words as well. Further review of the note revealed the DON contacted the psychiatrist who gave the order to transfer resident via 911, the Health Care Agent (HCA) was notified and the psychiatrist spoke with the HCA who agreed to the transfer, when 911 arrived the resident refused to go. When the HCA was notified that the resident declined to be transfered the .[name of HCA] stated if my [relationship] decline to go to hospital I cannot forced [him/her]. [Name of Psychiatrist #37] notified and new orders given. Haldol 2 mg IM x 1, Benedryl 25 mg IM X 1 .
Further review of the medical record failed to reveal documentation to indicate the resident was continuing to exhibit aggressive behavior after the resident was seperated from roommate.
On 9/17/24 at 11:31 AM surveyor reviewed the concern with the Director of Nursing that the IM Haldol and the IM Benedryl were administereed without adequate indicate for use. Surveyor requested any additional documentation the facility may have regarding this concern.
On 9/23/24 at 10:40 AM an interview was conducted with the psychiatrist #37, in the presence of the Director of Nursing regarding the orders for the IM medications. The psychiatrist confirmed he would offer a by mouth medication prior to ordering an IM but that it was an emergency call, they had to do something, the psychosis was getting worse and the resident was out of control. He confirmed that he was told at the time the resident was attacking staff. The psychiatrist reports he ordered the Benedryl with the Haldol to avoid side effects of the Haldol. Surveyor reviewed the concern that the note that accompanied the orders failed to include documentation to indicate the resident was attacking staff, or others, after initially being removed from the room with the roommate.
Review of the orders revealed the order for the IM Haldol was put in by Nurse #29 on 6/8/24 at 7:52 PM and included the following instructions: Inject 2 mg intramuscularly one time only for aggressive behavior until 6/8/24 23:59 [11:59 PM]. The order for the IM Benedryl was put in by Nurse #29 at 7:32 PM and included the following instructions: Inject 25 mg intramuscularly one time only for aggressive behavior until 6/8/24 23:59.
Further review of the MAR revealed Nurse #43 administered that the resident's regularly scheduled 9:00 PM oral medications, which included atorvastatin for high cholesterol; depakote for mood stabilization; iron for anemia; and seroquel for psychosis. No documentation was found to indicate the resident refused to take these oral medications on the evening of 6/8/24. No documentation was found to indicate that Nurse #43 administered the IM Haldol or the IM Benedryl.
Further review of the MAR failed to reveal documentation to indicate that the IM Haldol or the IM Benedryl were administered on 6/8/24. The MAR did reveal documentation that both these injections were administered by Nurse #46 at 1:51 AM on 6/9/24. Review of the behavior monitoring documentation on the MAR revealed that Nurse #46 documented that the resident was not displaying behavioral issues during the night shift that started on 6/8/24.
On 9/23/24 at 11:30 AM, surveyor reviewed with Psychiatrist #37 the concern that the order was put in around 7:30 PM on 6/8/24, but the IM injections were not documented as administered until 1:50 AM on 6/9/24 by a different nurse. Psychiatrist #37 indicated that the injections should have been given STAT and questioned if this was just late documentation.
On 9/23/24 at 11:36 AM, review of Nurse #46 punch card information revealed that the nurse was off on 6/7/24. Nurse #46 punched in at 11:40 PM on 6/8/24 and punched out at 7:44 AM on 6/9/24.
On 9/23/24 at 11:44 AM, surveyor reviewed with the DON that the nurses who documented the behaviors on 6/8/24 and obtained the orders did not administer the IM injections and the that the nurse that did administer the injections was not in the facility when the STAT order was given.
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 records review and interviews, it was determined that the facility failed to prevent further potential abuse while an investigation was in progress as evidenced by an inaccurate immediate ass...
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Based on records review and interviews, it was determined that the facility failed to prevent further potential abuse while an investigation was in progress as evidenced by an inaccurate immediate assessment of the alleged victim. This was evident in 1 (Resident #232) of 5 residents reviewed for abuse.
The findings include:
Resident #232 resided in the facility for 20 days. An allegation of abuse on behalf of the resident was reported, related to a facility reported incident (FRI) with intake number MD00208964.
A review of the investigation packet for the FRI was conducted on 9/20/24 at 9:09 AM. The review revealed the different steps the facility took to prevent further potential abuse of an alleged victim including a pain assessment conducted by the Director of Nursing (DON).
The pain assessment with an effective date of 8/20/24 at 4:57 PM indicated the following:
Pain presence: No pain in the last 5 days
Pain frequency: Rarely or not at all
Pain Interference with Therapy activities: Does not apply- have not received rehab in past 5 days
Pain management: On a scheduled pain medication
Comments: Resident denies any pain at this time
A review of Resident #232's electronic Medication Administration Record (eMAR) on 9/20/24 at 9:32 AM, revealed that s/he was on and received an as needed pain medication at least once every day, each time with a pain score ranging from 4/10 to 10/10, since it was prescribed from over 5 days from when the pain assessment was conducted by the DON.
On the same day at 10:06 PM, the Director of Rehab (Staff #27) was interviewed about Resident #232. Staff #27 reported that the resident was receiving rehabilitation services when s/he was in the facility. Staff #27 provided documentation that confirmed Resident #232 was on their case load for 4 weeks from 8/10/24.
On 9/20/24 at 10:59 AM, the DON and the Nursing Home Administrator (NHA) was interviewed regarding the concerns with the pain assessment. The DON reported that she documented that the resident had no pain in the last five days because she focused on the resident's shoulder. When asked about her documentation regarding the resident not receiving therapy in the past 5 days, both staff agreed that the documentation was inaccurate. Also, the pain management was documented inaccurately as the resident was only on an as needed medication regimen, and in the comment section of the assessment, the DON did not indicate that she was only referring to the resident's shoulder. The concern was discussed that an immediate assessment of an alleged victim was done inaccurately to prevent further potential abuse. Both the NHA and DON acknowledged the concern.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that the facility failed to ensure that essential information was provided to emergency department staff when a resident went to the hospital. T...
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Based on record review and interview, it was determined that the facility failed to ensure that essential information was provided to emergency department staff when a resident went to the hospital. This was evident for 1 resident (Resident #10) of 2 residents reviewed for hospitalization during the recertification survey.
The findings include:
On 9/10/24 at 12:37 PM, a review of Resident #10's medical record revealed a physician's order for an emergency room transfer for abdominal pain on 9/04/24. Further record review revealed a transfer form completed by Licensed Practical Nurse (LPN #34) dated 9/04/24, that contained clinical information regarding the resident's status.
On 9/12/24 at 9:50 AM, Resident #10 was observed in bed but did not respond to the surveyor's spoken greeting. A sign on the wall above the resident's bed indicated that the resident had a device for ASL [American Sign Language] Interpreter. The device was not present in the room, and the resident refused further interaction at that time.
On 9/12/24 at 11:10 AM, a review of Resident #10's clinical record revealed a hospital discharge summary that documented Resident #10 was deaf. A review of the transfer form, dated 9/04/24 and completed by Staff #34, revealed that the section regarding the resident's communication needs was blank. There was no indication on the document that the resident was deaf or used any communication devices.
On 9/17/24 at 11:47 AM, Licensed Practical Nurse (LPN #34) was interviewed and when she was asked to review Resident #10's transfer form documentation, she confirmed that there was no information regarding the resident's deafness or need for communication device on the transfer form.
On 9/17/24 at 1:03 PM, an interview with the Director of Nursing (DON) was conducted. She was informed that Resident #10's transfer form, dated 9/04/24, lacked any information regarding the resident's need for a communication device or ASL interpreter. She was asked to provide any additional evidence that the hospital staff were informed of the resident's communication needs, but none was provided by the end of the survey.
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 record review and interview, it was determined that the facility failed to provide a resident with a notice of transfer when the resident transferred to the hospital. This was evident for 1 r...
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Based on record review and interview, it was determined that the facility failed to provide a resident with a notice of transfer when the resident transferred to the hospital. This was evident for 1 resident (Resident #10) of 2 residents reviewed for hospitalization. The findings include:
On 9/10/24 at 12:37 PM, a review of Resident #10's medical record revealed a physician order for an emergency room transfer for abdominal pain on 9/04/24. Further record review revealed no Notice of Transfer documents were present.
On 9/17/24 at 11:47 AM, an interview with Licensed Practical Nurse (LPN #34) was conducted. During the interview, Staff #34 reviewed Resident #10's documents and confirmed that there was no transfer notice in the resident's record.
On 9/17/24 at 1:03 PM, an interview with the Director of Nursing (DON) was conducted. She was informed that there was no evidence that a transfer notice was provided to the resident when the resident was transferred to the hospital on 9/04/24. She was asked to provide any additional evidence, but none was provided by the end of the survey.
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 a resident a bed hold notice when the resident transferred to the hospital. This was evident for 1 resident ...
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Based on record review and interview, it was determined that the facility failed to provide a resident a bed hold notice when the resident transferred to the hospital. This was evident for 1 resident (Resident #10) of 2 residents reviewed for hospitalization.
The findings include:
On 9/10/24 at 12:37 PM, a review of Resident #10's medical record revealed a physician's order for an emergency room transfer for abdominal pain on 9/04/24. Further record review revealed no bed hold notice in the resident's chart.
On 9/17/24 at 11:47 AM, an interview with Licensed Practical Nurse (LPN #34) was conducted. During the interview, Staff #34 reviewed Resident #10's documents related to the hospital transfer on 9/04/24 and Staff #34 confirmed that there was no bed hold notice in the resident's record.
On 9/17/24 at 1:03 PM, an interview with the Director of Nursing (DON) was conducted. She was informed that there was no evidence that a bed hold notice was provided to the resident when the resident was transferred to the hospital on 9/04/24. She was asked to provide any additional evidence, but none was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on medical record review, observation, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident f...
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Based on medical record review, observation, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 1 (#107) of 1 resident reviewed for behavior.
The findings include:
The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility with the information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status.
A record review on 9/16/24 at 11:13 AM found that Resident #107 was admitted to the facility in April 2024. The continued review contained four MDS assessments, dated 4/24/24, 5/23/24, 6/3/24, and 9/3/24, for Resident #107. All the MDS assessments documented in section GG that Resident #107 had an impairment in range of motion (ROM) to both sides of his/her lower extremities.
Observation of Resident #107 on 9/16/24 at 1:16 PM showed the Resident lying supine in bed with knees bent. Staff #8, a licensed practical nurse, was at the Resident's bedside. She reported that the Resident was ambulatory when asked if he/she had any contractions to his/her extremities. Staff #8 then asked the Resident if s/he wanted to walk. The Resident got up from bed and began to walk around by the bedside.
In an interview on 9/16/24 at 1:46 PM, staff #4, the MDS nurse, said that typically, the MDS would be documented with impairment to a resident's ROM after assessing that a resident was unable to his/her limbs. Staff also added that, if a resident were able to ambulate, then impaired ROM to the lower extremities would not be coded on the MDS. Staff #4 confirmed that Resident #107's MDS assessments dated 4/24/24, 5/23/24, 6/3/24, and 9/3/24 were all documented in error.
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 records review and interviews, it was determined that the facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) form was completed for a newly admitted residen...
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Based on records review and interviews, it was determined that the facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) form was completed for a newly admitted resident. This was evident for 1 (Resident #50) of 2 residents reviewed for PASRR.
The findings include:
Preadmission Screening and Resident Review is federally mandated and must be completed for all applicants in nursing facilities which participate in the Maryland Medical Assistance Program regardless of an applicant's payment source. The purpose of the screening is to help ensure that residents are not inappropriately placed in nursing homes for long term care. Everyone who applies for admission to a nursing facility must be screened for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions.
Resident #50 was admitted in the facility in late 2024. A brief review of the resident's medical record on 9/11/24 at 12:41 PM revealed an incomplete PASRR form, dated 8/22/24.
A subsequent review of the PASRR form of Resident #50 was conducted on 9/13/24 at 10:38 AM. The review revealed that the form had 4 parts:
A. Exempted hospital discharge - indicated that the remainder of the form must be completed as directed.
B. Intellectual disabilities and related conditions - indicated that the resident was not considered to have ID or related conditions.
C. Serious mental illness- this part had 4 questions that were unanswered.
D. Categorical advance group determination- this part had instructions above that stated, if the individual is considered to have MI or ID or a related condition, complete part D of this form. Otherwise, skip part D and sign below; this part was skipped.
The Social Services Director (Staff #19) was interviewed regarding PASRR on 9/16/24 at 10:43 AM. Staff #19 reported that residents who are transferred from hospitals come with a form and indicated that a new one was done in the facility within the 1st week of admission when there was a change in status or if the forms were incomplete.
A review of Resident #50's medical record was conducted with Staff #19, and she confirmed that the PASRR form was incomplete and came from the hospital, and that the facility did not complete a new one during admission. Staff #19 stated, We have a lot of residents that are in and out, but it should have been done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on review of the medical record and interview with staff, it was determined that the facility staff 1) failed to provide residents/representatives with a copy of their baseline care plan that in...
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Based on review of the medical record and interview with staff, it was determined that the facility staff 1) failed to provide residents/representatives with a copy of their baseline care plan that included a summary of the resident's medication. This was evident for 1 (#380) of 4 residents reviewed for pain management.
The findings include:
On 9/11/24 at 10:24 AM, during an interview, when asked if the resident or his/her representative received a written summary of the resident's initial care plan along with a summary of the resident's medications since s/he was admitted to the facility, Resident #380 indicated s/he had not, and deferred to his/her family member representative who was present during the interview. At that time, Resident #380's representative stated they had not been given a copy of the baseline care plan, however after requesting a copy of the resident's medications, a copy of the resident's medication list was given to the representative. In addition, the resident and his/her representative stated that the resident's baseline care plan and medications had not been reviewed with them.
On 9/13/24 at 9:00 AM, per the resident representative's request, the surveyor again met with the resident and his/her representative. At that time, the resident and his/her representative expressed concerns about the residents stay and reported that they had not yet spoken to the social worker or anyone else about the Resident #380's plan of care while in the facility, and again reported that they had not been provided with a copy of the resident's baseline care plan.
On 9/19/24 at 10:29 AM, a review of Resident #380's electronic medical record (EMR) revealed that, on 9/5/24 at 8:20 PM, in an Admission/readmission Nursing Collection assessment tool, baseline care plans for Resident #380 had been initiated. Continued review of the medical record revealed a Baseline Care Plan Initiation form, dated 9/6/24 at 5:58 AM, which stated, Baseline Care Plan, 1. Initiation of Baseline Care Plan, which was followed by 3 statements: 1. I have initiated the care plan items included on the admission assessment and completed the baseline care plan, 2. Baseline care plan has been reviewed with the resident/and or responsible party, and 3. Copy of baseline care plan and copy of medications have been given to the resident and or responsible party. Each of the statements were checked, indicating the care plan had been initiated, reviewed with the resident or responsible party, and the resident. There was no other documentation found in the medical record to indicate the baseline care plan and the resident's medications had been discussed with the resident or the resident's responsible party.
The documentation in the Baseline Care Plan Initiation form, contradicted Resident #380's and his/her representative's statement that the facility staff had not reviewed the baseline care plan with them, and that they had not been provided with a copy of the baseline care plan.
On 9/19/24 at 3:40 PM, during an interview, the Director of Nurses (DON) stated the Unit Manager (UM) was responsible for following up with the resident or the resident's representative regarding the baseline care plan, and if the resident was capable, the UM provided him/her with a copy of the baseline care plan and a copy of his/her medications. At that time, the DON was made aware of the above concerns with Resident #380 and his/her responsible party report that baseline care plans were not reviewed with the resident and that the resident had not been provided a copy of his/her care plans. The DON acknowledged the concerns and offered no further comments at that time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 nursing staff did not document administration of g-tube feedings that they had not actually prov...
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Based on medical record review and interview, it was determined that the facility failed to ensure that nursing staff did not document administration of g-tube feedings that they had not actually provided. This was found to be evident for one (Resident #23) out of one resident reviewed for g-tube feeding.
The findings include:
Review of Resident #23's medical record revealed that the resident was admitted in June 2024 after a hospitalization. The resident's diagnosis included dysphagia which is difficulty swallowing and the resident had a g-tube for the administration of nutrition. The resident was admitted with orders that nothing was to be given by mouth, and a g-tube with orders for bolus feedings of Jevity 1.5 four times a day.
A bolus is when a large amount of feeding is given at one time.
Further review of the medical record revealed there were two different enteral feed (g-tube) orders in effect from 6/6/24 until they were both discontinued on 7/26/24.
The first order, placed on 6/6/24 at 4:22 AM, was for Jevity 1.5 425 ml bolus four times a day every 6 hours per protocol. Review of the Medication Administration Record (MAR) revealed these feedings were scheduled for midnight, 6:00 AM, noon and 6:00 PM. Review of the MAR revealed a check mark to indicate that the 425 ml bolus feed was administered as ordered four times a day from 6/6/24 until the order was discontined on 7/26/24, except for one dose on 7/4/24 at 6 am that was noted to be blank.
The Jevity 1.5 provides 1.5 calories per ml, thus a 425 ml bolus provides 638 calories per bolus and four bolus per day would provide 2550 calories per day.
The second g-tube feeding order was placed on 6/6/24 at 12:51 PM and was for Jevity 1.5 one carton 4 times a day.
Review of the MAR revealed documentation that staff administered one carton of the Jevity 1.5 four times a day at 9:00 AM; 1:00 PM, 5:00 PM and 9:00 PM every day from 6/6/24 until the order was discontinued on 7/26/24.
Further review of the medical record revealed a 7/26/24 registered dietitian (Staff #30) note which documented that the resident's weight on 6/7/24 was 132 lbs and on 7/8/24 the weight was 125 lbs which was considered a significant weight loss. The tube feeding was providing 1420 calories per day and the resident was receiving an additional 180 calories from a supplement which totaled 1600 calories per day. Needs do not appear to be met with current rate as evidenced by wt loss. Recommend changing TF regimen Jevity 1.5 1 carton q3hour [every 3 hours], 6 times a day. The new regimen would provide 2130 calories per day.
Further review of the medical record revealed that a new g-tube order was put in place on 7/26/24 at 2:35 PM for one carton Jevity 1.5 bolus 6x/day. There was a notation that this feeding would provide 2130 cals per day. This order was discontinued on 9/18/24.
On 9/17/24 at 1:10 PM, review of the medical record revealed an order, dated 8/28/24 to hold the 10 AM bolus feed. There was also an order for dysphagia advanced texture diet for lunch only on 8/28/24.
Review of the MAR revealed staff documented the Jevity bolus feeds were administered 6 times a day as ordered every day from 7/27/24 thru 9/17/24, except for two feedings that were due scheduled to be administered on 9/5/24 at 10:00 AM and 1:00 PM. The area to document these feedings were noted to be blank, no documentation to see nurse's note or that these two feedings were held.
Further review of the medical record on 9/18/24 revealed the RD #30 had seen the resident on 9/17/24 and entered a note at 5:31 PM. This note acknowledged that the resident was now receiving lunch only and tube feeding for all other meals. It documented the current tube feeding as being Jevity 1.5 bolus 6 x/day. The note failed to include a notation that there was a current order to hold the 10 AM feeding.
On 9/18/24 10:01 AM, surveyor asked Nurse #59, who was assigned to care for the resident, when the next bolus feed would occur. The nurse reported that the resident was eating now, that s/he gets a bolus at 6 AM the next was not until the evening. She then confirmed that she was not administering the 10 AM or the 1 PM bolus feeds.
Review of the September 2024 MAR revealed that Nurse #59 had documented the 10 AM and 1:00 PM feedings on September 2, 3, 4, 6, 7, 8, 9, 11, 12, 13, 14, 16, and 17. Three other nurses also documented administering the 10 AM dose after the order to hold the 10 dose was in effect.
On 9/18/24 at 10:08 AM, the unit nurse manager #12 reported the resident received bolus feeds and proceeded to check the documentation in the computer. She went on to report the resident gets lunch only and bolus of Jevity 1.5 six times a day. When asked if the 10 oclock feeding was held, the unit nurse manager responded: yes for lunch and then she clarified that the resident was getting 5 bolus. After reviewing the MAR, the unit nurse manager stated: they were signing for it but not giving it and confirmed the order in August to hold the 10 AM feed.
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 F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, it was determined that the facility failed to ensure that residents' communication needs were met. This was evident for 1 complaint (#MD00209021) of ...
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Based on observation, interview and record review, it was determined that the facility failed to ensure that residents' communication needs were met. This was evident for 1 complaint (#MD00209021) of 5 complaints reviewed during the recertification survey. This had the potential to affect all deaf residents.
The findings include:
On 9/10/24 at 12:14 PM Resident #10 was observed in bed with their eyes closed and appeared to be asleep. A sign above the resident's bed indicated to use an interpreter line IVR instructions and included a company name - o, which indicated to call a phone number and say the language and the call would be connected to an interpreter. A second sign on the wall indicated that to communicate using ASL [American Sign Language] to request a tablet from Admissions, go to the interpreter app, choose the video button, hit the call button and the app would search for a live interpreter. The bottom of the sign stated Staff, tablet must be returned to Admissions once patient discharges. No such tablet was observed in the resident's room.
On 9/12/24 at 8:03 AM, a review of complaint # MD00209021 revealed multiple concerns regarding Resident #10's care that related to the resident's inability to communicate with staff.
On 9/12/24 at 8:07 AM, in an interview with the complainant via deaf relay service, the complainant reported that Resident #10 had multiple needs that were not met due to the lack of communication with the facility staff.
On 9/12/24 at 9:50 AM an interview was attempted with Resident #10 who was sitting in bed eating. The surveyor showed the resident their state surveyor identification badge and the resident made a writing gesture in the air. The surveyor pointed to the sign regarding the tablet for a video interpreter, and the resident shook their head to indicate no. There was no paper in the resident's room to write a note.
On 9/12/24 at 10:40 AM in another attempt to interview Resident #10, the surveyor provided a pad of paper and pen, and the resident wrote need interpreter and law. The surveyor wrote a note that the surveyor nurse was investigating the communications concerns and other issues. A Licensed Practical Nurse (LPN #8) was in the room and when asked she said that the resident's IVR device was downstairs because it was not working. LPN #8 left the room and came back with a piece of paper, but the resident refused further interview. LPN #8 was interviewed in the hallway and said the IVR tablet was in the admissions office since the device was not charging properly.
On 9/12/24 at 11:10 AM, a review of Resident #10's care plan revealed a problem for risk for complications related to impairment of communication. The associated interventions lacked any information regarding the use of a live video interpreter using a tablet device, the use of a white board, or the use of pen and paper to communicate with the resident.
On 9/12/24 at 2:06 PM, an interview with the Director of Nursing (DON) was conducted. The DON said Resident #10 was non-compliant with using the video interpreter device and instead used written notes to communicate. When asked why the communication strategies were not listed on the resident's care plan, the DON did not answer.
On 9/18/24 at 11:09 AM, an interview with the Admissions Director (Staff #34) and Assistant Admissions Director (Staff #35) was conducted by telephone. Staff #34 said that when Resident #10 was admitted , the Admissions office gave the resident a facility-owned iPad which had the interpretation software downloaded on it. She explained that the device was placed in the resident's room and instructions were posted on the wall, and the resident was also provided with pen and paper, and a white board. Staff #34 described how the software worked to easily connect to a live ASL video interpreter. When asked why the device was not in the resident's room, Staff #34 said that there was an error logging in and that the software crashed on us. When asked how long the device had been unavailable, Staff #34 said almost a month, and Staff #35 said about a week and a half. When asked if there was any alternative provided by the interpretative service, they both said no.
On 9/18/24 at 11:31 AM the surveyor called the company that managed the software to confirm the software problem that Staff #34 had reported. A voice message was left with technical support.
On 9/18/24 at 12:39 PM, an email was received from the company in response to the voice message left by the surveyor, and an email reply was sent to ask if the software had not worked in the past week and a half.
On 9/18/24 at 12:59 PM an email reply was received from a complany representative which stated There have not been any disruptions to the interpretaive service in that timeframe.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on medical record review, and staff interviews, it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by providing incontinen...
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Based on medical record review, and staff interviews, it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by providing incontinent care in a timely manner. This was evident for 1 (Resident #16) out of 132 residents reviewed during the survey process.
The finding include:
On 9/17/24 at 5:40 AM, an observation was made of the second-floor nursing units.
On 9/17/24 at 5:44 AM, an observation revealed the call light flashing above Residents #16's room, along with an accompanying audible alarm.
On 9/17/24 at 5:51 AM, an observation was made of the Assistant Director of Nursing (ADON) entering Residents #16's room.
On 9/17/24 at 5:51AM, an observation was made of the call light turned off and the ADON exiting the room.
On 9/17/24 at 5:52 AM, Resident #16 was interviewed. During the interview s/he reported that s/he had first put her call light on at 5:10 AM. Resident #16 stated that the nurse came in shortly after 5:10 AM and told her/him that he would get someone to come in and assist her/him. Resident #16 reported that s/he told him s/he need to be changed and requested that he not turn off the light when he left. Resident #16 reported that the nurse stated it was company policy to turn off the light. In addition, s/he reported that the ADON just came in a turned off the light and said she would get someone to help her. Resident #16 reported that s/he had been sitting in their stool for 40 minutes.
On 9/17/24 at 6:00 AM, an observation was made of nighttime nurse supervisor RN (Staff # 38) entering Residents #16 room.
On 9/17/24 at 6:05 AM, Nurse RN (Staff # 39) was interviewed. During the interview he confirmed that the Resident #16 put her/his call light on around 5:10AM and that he did go in and turn it off. Also, Staff #38 reported that he told her/him that he would get a nursing assistant (CNA) to come and assist her.
On 9/17/24 at 6:20 AM, an observation was made of the nighttime nurse supervisor (Staff # 38) exiting Resident #16 room.
On 9/17/24 at 6:20 AM, during a brief interview was conducted with the nighttime nurse supervisor (Staff # 38). During the interview she reported that she just provided incontinent care to Resident #16 who was incontinent of bowel and bladder.
On 9/17/24 at 9:05 AM, Resident #16 Material Data Set section GG, dated 8/28/24 was reviewed. The review revealed the resident was always incontinent of bowel and bladder and that the resident was dependent on staff for toiletings needs. Continued review of section C revealed that the Resident was assessed to have a BIMS of 15. (BIMS of 15 indicates no cognitive decline)
On 9/17/24 at 7:3 AM, the ADON was interviewed regaridng a resident waiting 50 minutes to be changed after reporting to a nurse that they needed incontinent care. During the interview she reported the time frame goal for the staff to answer a residents call light is 5 minutes. She reported that the expectation is that staff answer call lights and determine the urgency of the request, and it's okay to have someone come back in a few minutes and assist the resident. The ADON reported that it is her expectation that a resident does not sit in a stool soiled brief for more than 10 minutes, due to the risk of skin breakdown in the perineal area.
On 9/20/24 at 10:25 AM, The surveyor requested the facility call light policy.
On 9/20/24 at 10:29 AM, The Nursing Home administrator reported that the facility did not have a call light policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on record review, observations and interviews, it was determined the facility failed to accurately assess the presence of pressure injuries and implement pressure prevention therapies. This was ...
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Based on record review, observations and interviews, it was determined the facility failed to accurately assess the presence of pressure injuries and implement pressure prevention therapies. This was evident for 2 (Resident #328, #109) out of 5 residents reviewed for pressure injuries. The findings include:
1.On 9/11/24 at 8:02 AM, a review of medical records revealed that Resident # 328 was admitted to the facility for rehabilitation following a hospital stay.
On 9/11/24 at 2:59 PM, review of orders for Resident #328 failed to reveal any orders for pressure preventions.
On 9/12/24 at 8:06 AM, a review of Resident # 328's hospital discharge summary revealed a list of discharge conditions. Review of the discharge instructions failed to reveal that Resident had a pressure injury.
On 9/12/24 at 8:09 AM, a review of the medical records titled admission Nursing/readmission Collection Tool, with an effective date of 8/31/2024 6:10 PM, revealed a section to document a skin observation. Review of the skin observation section revealed that a head to toes skin assessment was completed for Resident #328. Further review failed to reveal any pressure injuries of skin discoloration in the sacral area.
On 9/12/24 at 8:11 AM, a review of the medical records titled Skilled Daily Observations, with the effective date of 8/31/20 9:47 PM, revealed a section to document skin conditions and interventions provided during the shift. Further review revealed a question on the form: does the resident have a pressure injury? The question was answered, no. Continued review failed to reveal any pressure injury preventions or interventions that were provided.
On 9/12/24 at 8:16 AM, a review of the medical records titled Skilled Daily Observations with an effective date of 9/1/24 10:13 PM, revealed a section to document the skin conditions and interventions provided during the shift.? Further review revealed, a question on the form: does the resident have a pressure injury? The question was answered, no. Continued review failed to reveal any pressure injury prevention interventions were provided or that a wound was present.
On 9/12/24 at 8:27 AM, a review of the medical records titled Skilled Daily Observations with an effective date of 9/2/24 at 9:39PM, revealed a section to document skin conditions and interventions provided during the shift. Further review revealed a question on the form: does the resident have a pressure injury? The question was answered no. Continued review failed to reveal any pressure injury prevention interventions were provided.
On 9/12/24 at 8:30 AM, a review, of the medical records titled Skin Observation Tool-V2 with an effective date 9/3/24 at 13:26 AM and completed by the facilities wound nurse (Staff #41), revealed that Resident #328 had a stage 2 pressure injury on the sacrum (buttocks area).
On 9/12/24 at 8:35 AM, a review of the medical records titled Skilled Daily Observations with an effective date of 9/4/24 at 11:36PM, revealed a section to document skin conditions and interventions provided during the shift. Further review revealed a question on the form: does the resident have a pressure injury? The questions was answer, no. Continued review of the pressure injury preventions/interventions provided during the shift were listed as; pressure reducing device for chair, pressure reducing device for bed, and with turning and repositioning.
On 9/12/24 at 8:27 AM, a review of the medical records titled Skilled Daily Observations with an effective date of 9/5/24 at 10:12 PM, revealed a section to document skin conditions and interventions provided during the shift. Further review revealed a question on the form: does the resident have a pressure injury? The answer was recorded as no. Continued review failed to reveal that any pressure injury prevention or interventions were provided.
On 9/11/24 at 2:55 PM, review of the material data set (MDS) assessment, dated 9/6/2024, revealed that Resident #328 had a stage 2 pressure injury. Further review revealed that the pressure injury was present upon admission.
On 9/12/24 at 9:00 AM, the MDS coordinator was interviewed regarding the wound being documented as being present on admission. During the interview, she reported that she used the information based on the wound nurse's documentation completed on 9/3/24. She reported that she did not use the information from the admission skin assessment completed on 8/31/24 (the date of admission).
On 9/12/24 at 9:48 AM, the wound care nurse LPN (Staff # 41) was interviewed. During the interview, she reported that the expectation is that the nursing staff can identify and document any concerns with skin integrity. She reported that, if a nurse is unable to determine the exact stage of a pressure injury, the nurse should have described the wound by location, size, color, open or closed, and odor. This observation should have been documented and reported to the wound nurse. The wound nurse reported that the nurse admitting the resident to the facility can request wound prevention orders from the physician. She reported that her expectation of orders for a suspected pressure injury would include, an order for turning and repositioning and a supportive mattress. On 9/12/24, Review of Wound assessment report from Nurse Practitioner Staff #45) dated 9/9/24, revealed that the residents wound was documented as a stage 3 pressure injury.
A stage 2 pressure injury is when there is a partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also presents an intact or open/ruptured blister.
A Stage 3 A pressure injury where there is full thickness tissue loss. Subcutaneous fat may be visible,
but bone, tendon, or muscles not exposed. Slough may be present but does not obscure the depth of tissue loss.
On 9/13/24 at 8:12 AM during a brief interview, the Wound Care Nurse (staff #41) confirmed that there were no pressure injury prevention orders for Resident #323 prior to 9/12/24.
On 9/20/24 at 10:50 AM, the above concerns were discussed with the administrator and the Director of Nursing. No additional information was provided to the survey team.
2. On 9/10/24 10:23 AM, an observation of Resident #109's, a long-term resident of the facility, room was made. The observation revealed that a pair of green heel protection boots (used for heel pressure relief) were in the resident's closet. Further observation revealed a very thin pillow under residents' legs with the residents' heels laying against the bed.
On 9/10/24 at 10:24 AM, during a brief interview with Resident's #109 family member he/she reported that the staff have never put the green booties on the resident.
On 9/11/24 at 10:23 AM, an observation was made of Resident # 109 in her bed supine with head of bed elevated about 30 degrees. The green heel protection booties were not on the resident and the Resident' s heels were laying against the bed. The resident's family was in the room and reported: that is how s/he has been lying this way all day and that the booties are in closet.
On 9/11/24 at 3:00 PM, an observation was made in Resident # 109 room. Observation revealed the residents heals were against laying against the bed and the green heel protection booties were in the closet.
On 9/12/24 at 10:55 AM, review of orders revealed an order with a start date of 7/12/14 for Heel boots to bilateral feet as resident allows, while in bed. Remove every shift and assess skin for any deconditioning of current sites or new areas of concern.
On 9/16/24 at 4:00 PM, an observation in resident #109 room was made. Observation revealed a pair of green heel protection booties in the closet. Further observation revealed resident laying in bed with heels laying against the bed.
On 9/19/24 at 12:33 PM, an observation in resident #109 room was made. Observation revealed a pair of green booties in the closet. Further observation revealed resident laying in bed with heels laying against the bed and bed linen.
On 9/19/24 at 12:34 PM, Nurse RN (Staff # 48) was interviewed. She reported that she has regularly provided care to Resident # 109. She reported that she did not know if the resident had an order for bilateral heel protection boots and needed to check.
On 9/19/24 at 12:46 PM, nurse RN (Staff #48) reported that the resident does have boots but she does not have them on because they are in the laundry.
On 9/19/24 at 12:42 PM, the first floor Unit Manager RN (Staff # 14) and surveyor, made an observation of the laundry room to look for Resident # 109's boots. The observation of the laundry room failed to reveal Resident #109s green heel protection booties. Laundry manager said there were no green heel protection booties in the laundry.
On 9/19/24 at 12:44 PM, the laundry manager (Staff #49) reported there were no heal boots in the laundry.
On 9/19/24 at 12:48 PM, Staff #48 and the surveyor made an observation of Resident #109s room. Observation revealed a pair of green booties in the closet. Further observation revealed staff #48 taking the boots out of the closet and attempting to put them on the resident. However, the resident refused to wear the heel boots.
Review of progress notes from 9/10/24 to 9/19/24 at 12:00 PM, failed to reveal documentation that the resident refused wearing the green heel protection booties.
9/12/24 at 9:48 AM, the Wound Care Nurse, LPN (Staff # 41) was interviewed. During the interview she reported that the green heel protection booties were used as a device to prevent pressure injuries on the heels. Her expectations were that the nursing staff would notify her if residents refused to comply with pressure injury prevention therapies such as wearing heel protection booties. Staff #41 continued: if a resident refuses a pressure injury prevention therapy, that alternative therapies would be tried.
On 9/20/24 at 10:50 AM, the above concerns were discussed with administrator and the Director of Nursing. No additional information was provided to the survey team.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to develop a care plan to ensure that a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined that the facility failed to develop a care plan to ensure that advances in mobility that were achieved during therapy were maintained. This was found to be evident for one (Resident #23) out of three residents reviewed for falls during the survey. The findings include:
Review of Resident #23's medical record revealed that the resident was admitted in June 2024 after a hospitalization. Review of the 6/11/24 Minimum Data Set (MDS) assessment revealed that the resident had functional limitations in range of motion on both sides for upper extremities (arms) and impairment on one side for lower extremities (legs). The resident was dependent on staff for activities of daily living. The resident was receiving occupational, speech and physical therapy in June.
On 9/17/24 at 1:58 PM, review of the medical record failed to reveal a Multidisciplinary Care Conference note that would indicate a care plan meeting had occurred during the resident's admission.
On 9/18/24 at 10:17 AM, the unit nurse manager #12 was interviewed. During this interview she reported the resident was finished with physical therapy but was unable to provide information regarding what therapy's recommendations were upon dishcarge and stated: I can't see the note. She confirmed the resident was continuing to receive occupational and speech therapy.
On 9/18/24 at 10:29 AM, the Rehab Director #27 was interviewed. When asked how information from the therapist were conveyed to nursing staff when discharged , the Rehab Director reported that it was verbal and that they would occasionally do an inservice. When asked about a restorative nursing program, the Rehab Director reported they did not have a restorative nursing aide.
On 9/18/24 at 11:00 AM, the Rehab Director presented the surveyor with the resident's physical therapy Discharge summary, dated [DATE]. The Rehab Director reported that the resident had made great progress in therapy and at the time of discharge, the resient's gait distance (walking) was 125 feet with hand held assist and could transfer from chair to bed and bed to chair with contact guard.
A transfer with contact guard assist means the care giver places one or two hands on the resident to help with balance but no other assistance is provided.
When asked if the ability to walk and transfer with contact guard was reflected in the resident's care plan, the Rehab Director replied: it might be. When asked if the resident should continue to walk, the Rehab Director reported that because of cognitive deficits, this would not be realistic to maintain but that theortically could have been walking to the dining room. Surveyor clarified that the resident could be doing some walking, to which the Rehab Director responded: yes, [s/he could] with support obviously. The Rehab Director indicated that therapy personnel would be part of a care plan meeting for a short term (skilled) admission.
On 9/18/24, after requesting documentation from the Director of Nursing of any care plan meetings that occurred for the resident, staff provided a note completed by the unit nurse manager titled Care plan meeting dated 9/3/24 that stated: Care plan meeting held with resident's [family members]. Resident medications reviewed with no concerns voiced. Plan of care continues.
No documentation was found to indicate who attended the 9/3/24 meeting other than the family and the unit nurse manager who wrote the note. No documentation was found to indicate that members of the interdisciplinary team attended the meeting, or provided input. No documentation was found to indicate that a respresentative from the therapy department attended or provided input for the 9/3/24 care plan meeting.
Review of care plan addressing the resident's risk for falls revealed a revision date of 9/13/24. The interventions included, but were not limited to : Resident is a hoyer lift transfer with 2 GNAs. This intervention was created and initiated on 8/14/24.
A hoyer lift is a mechanical lift used for residents who are completely dependent on staff for transfers. A hoyer lift pad is placed under the resident and then attached to the lift. Two staff members would then use the mechanical lift to raise the resident from the bed and transfer to a chair or vice versa.
During the 9/18/24 11:00 AM interview, surveyor reviewed with the Rehab Director that the current care plan indicated the resident required a hoyer lift with 2 GNA assist, in place since 8/14/24. The Rehab Director responded: could have been at that time. Surveyor also reviewed the concern that the unit nurse manager was unable to verbalize any recommendations made by therapy.
Further review of the 8/27/24 Physical Therapy Discharge summary revealed Prognosis to Maintain CLOF [current level of function] = Excellent with strong family support, excellent with consistent staff support. Depsite indicating strong family and consistent staff support, the discharge recommendation failed to include recommendations for either the family or staff to assist the resident in maintaining the current level of functioning. In the sections for Restorative Program and Functional Maintenance Program the Physical Therapist documented : Not Indicated at this time. The documented Discharge Recommendation was Quarterly assessment to improve/maintain highest levels of functional mobility.
On 9/18/24 at 11:52 AM, the unit nurse manager #12 reported the resident does stand with one person assist and in regard to walking, she reported: if we see [him/her] get up, we walk around with [him/her]. The unit nurse manager indicated they did conduct staff training but confirmed it was not documented. Surveyor reviewed the concern that the care plan still stated the resident required a hoyer lift for transfers, the unit manager indicated she would update this information.
On 9/18/24 at 12:11 PM, when asked if the facility has any restorative nursing, the Director of Nursing responded: No.
On 9/18/24 at approximately 12:45 PM, the Rehab Director presented the surveyor with a form that he reported was just created to help facilitate communication with nursing staff regarding a resident's status when a resident is discharged since they (nursing) are unable to access rehabs notes.
CONCERN
(D)
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, observations, and interviews, it was determined that the facility failed to have a system in pla...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and interviews, it was determined that the facility failed to have a system in place for monitoring residents who have been identified as high risk for elopement. This was evident for 1 (#59) of 6 residents reviewed for accidents.
The findings include:
The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility with the information necessary to develop a care plan, provide the appropriate care and services to the resident, and modify the care plan based on the Resident's status.
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.
A medical record review for Resident #59 on 9/18/24 at 10:45 AM showed that Resident #59 had been residing in the facility since May 2020. Diagnoses included Schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). The review also noted that Resident #59 was able to ambulate independently.
Continued review contained a care plan focus for Resident #59 that stated that the Resident is at risk for elopement related to Schizophrenia. The review also found an MDS assessment for Resident #59 dated 8/3/24, which had documented that the Resident had severely impaired cognition.
Further review contained an elopement risk tool assessment, dated 8/8/24, for Resident #59.
An elopement risk tool assessment helps determine who is at risk of leaving the facility without supervision. It is scored by adding up the scores assigned to each assessed area. 0 - 7 is low risk, 8 - 9 means at risk for elopement/exit seeking, and 10 is above High Risk.
The assessment documented that Resident #59 Has history of elopement/exit seeking (past hospitalization or history from resident/family) and scored a 10, meaning s/he was above high risk for elopement/exit seeking.
Observation of Resident #59 on 9/18/24 at 10:48 AM noted him/her off the 2nd-floor unit where s/he resided. The Resident was sitting on a couch in the lounge on the 1st-floor unit hallway leading to the front desk and not wearing any monitoring device. The Resident stated, I'm waiting here to go home. Resident #59 could neither state his/her room number nor the name of the facility where s/he resided. The Resident seemed confused.
In an interview on 9/18/24 at 10:50 AM, staff #22, a certified nurse aid, was asked to name all the residents on the second-floor unit who were at high risk for elopement. Staff #22 responded that Resident #59 was at high risk for elopement because s/he was confused and always going downstairs.
In an interview on 9/18/24 at 11:25 AM, staff #12, a unit manager, stated that a wander guard bracelet for monitoring was placed on any resident identified as high risk for elopement. Staff #12 also added that the Resident's name with their picture would be placed on the elopement list at the front desk. However, the interview failed to show that staff was monitoring Resident #59 for exit-seeking behaviors, and a review of the elopement binder at the front desk did not include his/her name and picture.
In an interview on 9/18/24 at 12:17 PM, the director of nursing stated that the facility placed a wander guard bracelet only on residents who exhibited exit-seeking behaviors.
However, the interview failed to show that the facility was monitoring Resident #59 for exit-seeking behaviors even though an earlier review of Resident #59's elopement risk tool assessment dated [DATE] contained documentation that s/he had Has history of elopement/exit seeking (past hospitalization or history from resident/family).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that the facility failed to identify a resident with a critically low body mass index (BMI) and failed to have a policy and procedure in place t...
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Based on record review and interview, it was determined that the facility failed to identify a resident with a critically low body mass index (BMI) and failed to have a policy and procedure in place to measure residents' height. This was evident for 1 resident (Resident #17) of 5 residents reviewed for nutrition during the recertification survey and had the potential to affect all residents.
The findings include:
Body Mass Index (BMI) is a measurement of weight relative to height. It is used as a reliable screening measure for underweight, overweight, or obesity.
On 9/11/24 at 9:34 AM, a review of Resident #17's weight and height documentation in the electronic record revealed:
Weight
9/05/24 = 105.7 lbs Mechanical Lift
8/05/24 = 106.4 lbs Mechanical Lift
7/30/24 = 106.1 lbs Mechanical Lift
7/23/24 = 106.0 lbs Mechanical Lift
Height
7/23/24 = 61.0 inches lying down
12/16/16 = 72.0 inches Standing
12/08/16 = 72.0 inches Standing
On 9/16/24 at 3:41 PM in an interview with the Director of Nursing (DON), she was asked about the difference in Resident #17's height in 2024 and 2016 and she was asked what process the facility used to measure residents' height. She said she was not sure and would check. When she was asked about the staff who documented the height of 61 inches, she replied that the staff no longer worked at the facility.
On 9/19/24 at 2:12 PM another interview was conducted with the DON regarding the discrepancy in Resident #17's height documentation. She agreed to check the resident's height that day. The surveyor asked to speak to the dietitian, and the DON said the dietitian (Staff #30) was not in the building today but would be here tomorrow.
On 9/19/24 at 2:45 PM, the DON brought a copy of the facility's weight monitoring and tracking policy and said the facility does not have a policy for measuring residents' height. She also said she measured the resident's height today using a tape measure that she had in her hand and said the resident's height was 70 inches. The dietitian's (Staff #30) phone number was requested, provided, and a voice message was left.
On 9/20/24 at 9:16 AM, an interview with the Regional Dietitian (Staff #24) was conducted. She said that she was a contractor employed by NutraCo, employed since 9/09/24, and started work at the facility on Wednesday 9/18/24. When she was asked if dietitians made in person visits to residents, Staff #24 refused to answer the question and instead explained that the company had a hybrid program and offered to provide the policy.
A review of Resident #17's dietitian progress note, dated 9/16/24, and written by Staff #30, was conducted with
Staff #24. Staff #30 had documented that the resident's BMI was 20, and weight was 106 lbs. When Staff #24 reviewed the resident's weight history, Staff #24 stated that the resident's weight was stable since July 2024 and this was the indicator used to determine treatment. When Staff #24 was asked to review the resident's height documentation, she noticed the discrepancy between 61 inches and 72 inches documented. When asked what Resident #17's BMI would be for a height of 70 inches (the height the DON measured on 9/19/24) and a weight of 106 lbs, Staff #24 calculated that Resident #17's BMI was actually 15.
On 9/20/2024 at approximately 11:00 AM, Staff #24 provided surveyors with hybrid policy and procedure for the dieticians at the facility and she also reported that the dietician, Staff #30, no longer worked at the facility as of 9/19/24 and provided the surveyor with the phone number of the director of Nutraco for any questions. A review of the hybrid policy revealed no clarification on whether dietitians made in person visits to residents.
On 9/20/24 at 10:34 AM, a telephone interview was conducted with the Medical Director who was also Resident #17's attending physician. He said that the dietitian was responsible for monitoring residents' nutritional status and for entering the appropriate orders and treatments. He also said that he relied on the dietitian to bring any concerns to the weekly risk meetings, and that in between meetings, the dietitian would call him and made recommendations. The Medical Director reviewed Resident #17's weight and height entries, acknowledged the discrepancies, and then was informed of the recheck of the resident's height and new BMI calculation of 15. The Medical Director said that he was unaware of the resident's BMI of 15 and that this was a critical value.
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
Tube Feeding
(Tag F0693)
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 feedings via a g-tube were administered as ordered and failed to ensure a plan to try to restore...
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Based on medical record review and interview, it was determined that the facility failed to ensure that feedings via a g-tube were administered as ordered and failed to ensure a plan to try to restore oral eating was established. This was found to be evident for one (Resident #23) out of one resident reviewed for tube feeding.
The findings include:
Review of Resident #23's medical record revealed the resident was admitted in June 2024 after a hospitalization. The resident's diagnosis included dysphagia which is difficulty swallowing and the resident had a g-tube for the administration of nutrition. The resident was admitted with orders that nothing was to be given by mouth, and a g-tube with orders for bolus feedings of Jevity 1.5 four times a day.
A bolus is when a large amount of feeding is given at one time.
Further review of the medical record revealed there were two different enteral feed (g-tube) orders in effect from 6/6/24 until they were both discontinued on 7/26/24.
The first order, placed on 6/6 at 4:22 AM, was for Jevity 1.5 425 ml bolus four times a day every 6 hours per protocol. Review of the Medication Administration Record (MAR) revealed these feedings were scheduled for midnight, 6:00 AM, noon and 6:00 PM. Review of the MAR revealed a check mark to indicate the 425 ml bolus feed was administered as ordered four times a day from 6/6 until the order was discontined on 7/26, except for one dose on 7/4 at 6 am was noted to be blank.
The Jevity 1.5 provides 1.5 calories per ml, thus a 425 ml bolus provides 638 calories per bolus and four bolus per day would provide 2550 calories per day.
This first order also included instructions to document the amount of feeding provided every 8 hours. Further review of the medical record failed to reveal documentation of the actual amount of Jevity that was being administered during each bolus feed or every 8 hours as ordered.
The second g-tube feeding order was placed on 6/6/24 at 12:51 PM and was for Jevity 1.5 one carton 4 times a day. The order includes a notation that, in addition to the Jevity, the resident would also be receiving ALP (Active Liquid Protein) 30 ml three times a day and that this would provide an additional 300 calories and that the resident would receive a total of 1720 cals per day.
Review of the manufacturers website revealed the Jevity 1.5 cartons are 8 ounces. There are only 236 ml per 8 ounces. The website indicated that there were 355 calories per 8 ounce carton, so four bolus per day would provide 1420 calories per day from the Jevity.
Review of the MAR revealed documentation that staff administered one carton of the Jevity 1.5 four times a day at 9:00 AM; 1:00 PM, 5:00 PM and 9:00 PM every day from 6/6/24, until the order was discontinued on 7/26/24.
Further review of the medical record revealed a 7/26/24 registered dietitian (Staff #30) note which documented that the resident's weight on 6/7 was 132 lbs and on 7/8 the weight was 125 lbs which was considered a significant weight loss. The resident's estimated caloric need per day were 1710- 2000 calories. The dietitian's summary revealed that the resident appeared to have a significant weight loss over 1 month which was unfavorable and unplanned, the tube feeding was providing 1420 calories per day and the resident was receiving an additional 180 calories from a supplement which totaled 1600 calories per day. Needs do not appear to be met with current rate as evidenced by wt loss. Recommend changing TF regimen Jevity 1.5 1 carton q3hour [every 3 hours], 6 times a day. The new regimen would provide 2130 calories per day.
No documentation was found to indicate the weight loss identified on 7/8/24 was addressed by the dietitian prior to 7/26/24.
Further review of the medical record revealed a new g-tube order was put in place on 7/26/24 at 2:35 PM for one carton Jevity 1.5 bolus 6x/day. There was a notation that this feeding would provide 2130 cals per day. This order was discontinued on 9/18/24.
Review of the MAR revealed staff documented the Jevity bolus feeds were administered 6 times a day as ordered every day from 7/27/24 thru 9/17/24, except for two feedings that were due scheduled to be administered on 9/5/24 at 10:00 AM and 1:00 PM. The area to document these feedings were noted to be blank, there was no documentation to see nurse's note or that these two feedings were held.
On 9/17/24 at 1:10 PM, review of the medical record revealed an order, dated 8/28/24 to hold the 10 AM bolus feed. There was also an order for dysphagia advanced texture diet for lunch only on 8/28/24.
Further review of the medical record on 9/18/24 revealed the RD #30 had seen the resident on 9/17/24 and entered a note at 5:31 PM. This note acknowledged that the resident was receiving lunch only and tube feeding for all other meals. It documented the current tube feeding as being Jevity 1.5 bolus 6 x/day. The note included the following weights: 6/7: 132 lbs; 8/5: 132 lbs and 9/4: 132 lbs. The recommendation was to continue the diet and tube feeding as ordered. The note failed to include notation that there was a current order to hold the 10 AM feeding.
On 9/18/24 10:01 AM, surveyor asked Nurse #59, who was assigned to care for the resident, when the next bolus feed will occur. The nurse reported that the resident was eating at the time, that s/he would get a bolus at 6 AM the next was not until the evening. She then confirmed that she was not administering the 10 AM or the 1 PM bolus feeds.
On 9/18/24 at 10:08 AM, the unit nurse manager #12 reported the resident received bolus feeds and proceeded to check the documentation in the computer. She went on to report the resident gets lunch only and bolus of Jevity 1.5 six times a day. When asked if the 10 oclock feeding was held, the unit nurse manager responded: yes for lunch and then she clarified that the resident was getting 5 bolus'. After reviewing the MAR, the unit nurse manager stated: they are signing for it but not giving it and confirmed the order in August to hold the 10 AM feed.
On 9/18/24 at 1:54 PM, surveyor reviewed the concern with the DON that the RD assessment from yesterday failed to address the order to hold the 10 AM feeding which meant resident is only receiving 5 bolus feedings per day, not the 6 as indicated in the RD note.
Continued review of the medical record on 9/23/24, revealed a note completed by RD #24 on 9/18/24 which revealed Noted NP [nurse practitioner] order 8/28 for holding TF @ 10am to help promote oral intakes, per nursing staff holding bolus has benefited [him/her] as [s/he] has been able to eat well and has great appetite for lunch (intakes of 50-100% per nursing charts). I discussed TF regimen w/dtr [daughter] today via phone. Dtr agrees to adjust the amount of bolus provided while taking into consideration current oral intakes. Will also d/w SLP [speech therapist] possibility of evaluation to determine if frequency of meals could be increased. The recommendations included adjusting the tube feeding orders to Jevity 1.5 1 carton 4 x/day and speech therapy for diet eval.
A corresponding physician order for the Jevity 1.5 1 carton 4 x/day was found for 9/18/24.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined that the facility failed to provide behavioral health monitoring to ensure a resident's highest practicable mental and psychosocial well...
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Based on medical record review and interview, it was determined that the facility failed to provide behavioral health monitoring to ensure a resident's highest practicable mental and psychosocial well being.This was found to be evident for 1 (Resident #30) out of 5 residents reviewed for unnecessary medications.
The findings include:
Review of Resident #30's medical record revealed the resident had resided at the facility for several years and whose diagnoses included, but was not limited to: high blood pressure, kidney disease, major depressive disorder and dementia. Review of the Minimum Data Set assessment, with a reference date of 6/5/24, revealed the resident had a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment.
Review of the medical record revealed that the resident was seen about once a month by either the Psychiatrist #37 or the Psychiatric Nurse Practitioner (NP) #36.
1) Review of the Psychiatric NP #36's note, dated 2/7/24, revealed the resident's current psychiatric medications included Seroquel (an antipsychotic) 25 mg two times a day and Zoloft (Sertraline- an antidepressant) 50 mg daily. The Treatment Plan/Recommendation section included: Continue Current Meds. No documentation was found in this note to indicate a GDR of the Zoloft was being considered or planned.
Further review of the medical record revealed that the resident was receiving the antidepressant medication, Sertraline 50 mg one time every day from 10/24/23 until 2/29/24. On 2/29/24, the Sertraline 50 mg every day order was discontinued by the primary care physician #26. A new order was put in place on 2/29/24 for Sertraline 25 mg one time a day for 90 days. The medication was not renewed after the 90 days was completed. This tapering down and then discontinuation of a psychoactive medication is referred to as a gradual dose reduction (GDR).
Review of the Psychiatrist #37's note, dated 3/25/24, revealed a notation that the resident was currently being treated with Zoloft and that the current dose was 25 mg every day. However, no documentation was found to indicate the 25 mg every day dose was a recently initiated GDR. The Treatment Plan/Recommendations section included: GDR is not recommended at this time as the benefit of the medication outweigh the risks of dosage reduction.
Review of the Psychiatric NP #36's notes, dated 5/8/24 and 5/15/24, revealed the resident's current psychiatric medications included Serorquel (an antipsychotic) 25 mg two times a day and Zoloft (Sertraline) 25 mg daily. The Treatment Plan/Recommendation section included: Continue Current Meds. No documentation was found in this note to indicate there was a plan to continue the GDR of the antidepressant.
The 2/29/24 order for Sertraline for 90 days was completed at the end of May. No documentation was found to indicate that the resident had received this antidepressant since May 2024.
Further review of the medical record revealed a change in condition note that revealed on 6/8/24, the resident was highly agitated and was observed being verbally abusive and throwing items at the resident's roommate. The psychiatrist #37 was notified, there was an order to transfer the resident to the hospital. After the resident refused the transfer, the psychiatrist was notified and there was then an order for IM Haldol (an antipsychotic) and IM Benedryl (an antihistamine) for aggressive behavior. These IM medications were administered on 6/9/24 at 1:50 AM.
Review of the Psychiatric NP #36's notes, dated 6/12/24, revealed the following: Chart reviewed; Spoke with staff regarding patient's progress; No new behavioral concerns reported; No agitation, irritability or aggression noted this visit. The Treatment Plan/Recommendation section included: Continue Current Meds. No documentation was found in this note regarding the recent discontinuation of the antidepressant medication or the 6/8/24 episode which resulted in the use of an IM antipsychotic medication.
Review of the Psychiatrist #37's notes, dated 6/17/24 and 7/15/24, revealed a notation that the resident was current being treated with Zoloft, Depakote and Seroquel.
On 9/23/24 at approximately 9:00 AM, surveyor reviewed the concern with the Director of Nursing that the resident's antidepressant was stopped but no documentation was found to indicate this was a planned GDR. The DON then provided a copy of the 2/29/24 order to discontinue the Zoloft which included GDR in the area to document the reason for discontinuation. No other documentation was provided at the time.
On 9/23/24 at 10:40 AM, an interview was conducted with the psychiatrist #37, in the presence of the Director of Nursing. When asked if psychiatric providers were involved in GDRs, the Psychiatrist reported the nurse practitioner (NP) sat with the staff to review for GDR. When asked if he expected the NP to document a GDR, psychiatrist #37 responded: yes, of course, she would document the dose of the GDR. Surveyor reviewed the concern that the resident's antidepressant was reduced and then stopped at the end of May, but no documentation was found in the NP notes to address this GDR.
2) Review of the Medication Administration Record (MAR) revealed areas for nursing staff to document resident behaviors on the day, evening and night shifts. Review of the MAR revealed staff could document based on the following coding: 1 - compulsive; 2 - pacing continuously; 3 - Continuously screaming and yelling; 4 - danger to others; 5 - danger to self; 6- false beliefs; 7 - finger painting feces; 8 - spitting; 9 - other. On 9/16/24, review of the documentation for this monitoring for June, July, August and September thru the 16th, 2024 revealed only a check mark for each shift.
On 9/16/23 at 3:52 PM interview with Nurse #8 revealed that a check on the behavior monitoring sheets meant that the resident had none of those behaviors.
On 9/16/24 at 3:58 PM, interview with the unit nurse manager #12 revealed that, when the nurses see this item on the computer, they have to answer yes or no. The unit nurse manager confirmed that the checks indicated that the resident was not displaying behaviors. After reviewing the September MAR with the unit nurse manager, surveyor asked if that was an accurate assessments of the resident, the unit nurse manager stated: no. When asked where were staff documenting the resident's behaviors, the manager indicated they were supposed to use the MAR.
Further review of the MAR revealed there was another section to document other psychiatric symptoms: 1- mood swings; 2 - sad; 3 - continuous crying; 4 - withdrawn; 5 - depressed; 6 - angry; 7 - poor eye contact; 8 - other. Review of the nursing documentation from June, July, August and September thru the 16th, 2024 revealed that staff documented every shift either a 0 or an N, thus indicating the resident was not experiencing these symptoms.
Based on review of the behavior monitoring documentation being completed every shift by nursing staff, the resident was not experiencing any behaviors of concern for June, July, August or September.
On 9/17/24 review of the physician orders revealed the resident had orders for Seroquel 25 mg twice a day from November 2023 until 6/17/24.
Review of the 6/17/24 psychiatrist #37 note revealed documentation to indicate staff was reporting the resident was getting aggressive with the roommate and there was a documented plan to increase the Seroquel dose to 50 mg two times a day. This increase occurred more than a week after the 6/8/24 incident resulting in the order for the IM Haldol and after the 6/12/24 NP visit in which the NP documented that she spoke with staff regarding the resident's progress and there were no new behavioral concerns reported.
From 6/17/24 until 7/10/24, the order was for Seroquel 50 mg two times a day.
Further review of the physician orders revealed from 7/10/24 until 9/17/24, the order was for Seroquel 100 mg two times a day.
On 7/15/24, there was a new order for Risperdal (antipsychotic) 0.5 mg two times a day that was in effect until 9/5/24.
Review of the 7/15/24 psychiatrist #37 note revealed documentation to indicate staff was reporting the resident was getting aggressive toward roommate due to paranoia to the point they had to move the resident out of the room. The note documents the start of the Risperdal 0.5mg twice a day for paranoia and stated if the resident does well with Risperdal, would consider tapering off Seroquel.
Review of the Psychiatric NP #36's notes, dated 8/7/24, revealed staff reporting episodes of getting aggressive towards roommate and does not want a roommate. The note included a notation of Risperdal 0.5 mg bid (two times a day) and included a plan to Continue Current Meds.
Further review of the medical record on 9/17/24 revealed that, on 9/5/24, there was a new order for Risperdal 1 mg two times a day that was currently in effect. No documentation was found to indicate why this antipsychotic medication was increased on 9/5/24.
Review of the Psychiatric NP #36's notes, dated 9/11/24, revealed: Chart reviewed; Spoke with staff regarding patient's progress; No new behavioral concerns reported; Per staff [s/he] has been stable and has not exhibited symptoms of depression, mania, anxiety, psychosis or self-injurious behavior. The note did include Risperdone 1 mg bid in the list of current psychiatric medications but failed to address why the dose was double less than a week before this visit. The note included the plan to Continue Current Meds.
On 9/17/24 at 11:31 AM, surveyor reviewed the concern with the Director of Nursing regarding the increase in the antipsychotic medication without adequate indication. Reviewed that the behavior monitoring sheets since June failed to reveal documentation of behaviors to indicate the need for this increase. Surveyor requested any additional documentation they may have regarding this concern.
On 9/23/24, review of the medical record revealed a note written by the NP #36 which included the plan to attempt GDR on seroquel to 100 mg at time of sleep.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3). A brief review of Resident #50's medical record indicated that s/he was admitted to the facility in August of 2024.
On 9/13...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3). A brief review of Resident #50's medical record indicated that s/he was admitted to the facility in August of 2024.
On 9/13/24 at 12:43 PM, the Director of Nursing (DON) was interviewed regarding the facility's process with Medication Regimen Review (MRR). The DON reported that, after the initial review, the consultant pharmacist reviews all the resident's medication orders monthly. When an irregularity is identified, the pharmacist sends the report via email to the DON. The DON prints the report and hands it to the physician, the physician then writes their response on the report and hands it back to the DON. Finally, the DON then makes the changes with the resident's medication regimen per the attending physicians' response.
On another interview with the DON on 9/16/24 at 11:33 AM, she reported that physician response from recommendation by the pharmacist for MRR can be found either in the doctor's note or the written response on the reports are scanned in the resident's medical record and were titled Actual Meds.
On 9/17/24 at 10:57 AM, the MRR for Resident #50 with a reference date of 8/26/24 was reviewed. The review indicated that irregularities were identified by the pharmacist.
Subsequently at 11:00 AM, Resident #50's medical record was reviewed but failed to reveal the attending physician's response to the irregularities identified.
On 9/17/24 at 11:34 AM, the concern was discussed with the DON, and she indicated that she would review Resident #50's medical record to look for the physician note or the written response that she scans and attaches to the resident's medical record.
Later that day at 1:17 PM, the DON reported and confirmed that the attending physician had not documented his response to the pharmacy recommendations and stated, I looked in the resident's medical record, but I did not find any.
2) On 9/17/24 at 11:53 AM, a review of Consultant Pharmacist medication reviews revealed a New admission Medication Review for Resident #78, that had a review date of 7/1/24 at 3:08 PM, and the printed statement Please consider the following Pharmacist recommendations in assessing this resident's drug regimen. The provider and/or nursing staff should respond appropriately. Recommendations marked clinically significant should be resolved by midnight the next calendar day, copied to the MDS (Minimum Data Set) Coordinator and filed in the Resident's chart appropriately. The statement was followed by the heading, Drug Therapy Problems Identified, and pharmacist documentation of 5 irregularities with Resident #78's medication, the significance of the recommendations, the pharmacist's recommended action for the provider, and an area for the practitioner to document any comments and/or action taken in response to the pharmacist's recommendations.
The medication review form documented the drug therapy problems identified with Resident #78's medications as follows:
2a) Resident #78 was prescribed the medications, Gabapentin (Neurontin) (seizure & nerve pain medication), Lexapro (Escitalopram) (antidepressant), Oxycodone (narcotic pain medication), and Oxycontin (oxycodone) oral tablet ER (extended release), with recommendations marked clinically significant.
The pharmacist documented the risks of concurrent use of 3 or more different central nervous system (CNS) active medications that should be avoided in older adults [AGE] years of age and older due to an increased risk of falls, with the recommended action for the provider, the patient is currently receiving the above medication(s which is considered a high-risk medication for an elderly patient. Please evaluate, consider using a safer alternative, or document a risk/benefit analysis within the patient medication record for continued utilization. Following the pharmacist's recommendation, no documentation was found to indicate the attending physician reviewed the above identified irregularities and/or the action taken or not taken to address the irregularities.
2b) Resident #78 was prescribed the medication, Enoxaparin (Lovenox) (anticoagulant) (blood thinner) Sodium Injection, with recommendations marked clinically significant. The pharmacist documented that a stop date for use of the medication was needed, and the recommended action for the provider, resident is currently receiving the above medication which is normally subject to a stop date. Please evaluate this resident to see if it is appropriate to DC (discontinue) the medication at this time. If you wish to continue drug therapy, please indicate rational for use below
Following the pharmacist's recommendation, no documentation was found to indicate the attending physician reviewed the above identified irregularities and/or the action taken or not taken to address the irregularities.
2c) Resident #78 was prescribed the medication, Amlodipine Besylate (Norvasc) (lowers blood pressure), with recommendations marked clinically significant, and wrote the recommended action for the provider, The patient was receiving the above medication(s) at home prior to their admission but is not noted on the current facility orders. Please evaluate and consider restoring if appropriate.
Following the pharmacist's recommendation, no documentation was found to indicate the attending physician reviewed the above identified irregularities and/or the action taken or not taken to address the irregularities.
2d) Resident #78 was prescribed the medications, Aspirin EC (enteric coated) (anti-inflammatory) (blood thinner) delayed release 81 MG, Enoxaparin (Lovenox) Sodium Injection, with recommendations marked high risk. The pharmacist wrote the recommended action for provider, please consider changing this pharmacotherapy and indicate as per below. If continuing therapy, please document your response to assure this facility's compliance with CMS regulations, which was followed by a checklist with 3 possible practitioner responses.
None of the potential responses had been checked by the practitioner, and no documentation was found to indicate the attending physician reviewed the above identified irregularities and/or the action taken or not taken to address the irregularities.
2e) Resident #78 was prescribed Metformin (Glucophage) (anti-diabetic) (lowers blood sugar), with recommendations marked nursing, and the pharmacist documented the pharmacist's this medication should generally be taken with food or a meal to prevent gastric irritation and/or GI bleeding.
Following the pharmacist's recommendations, there no documentation in the medication review to indicate the attending physician reviewed the identified irregularities and/or the action taken or not taken to address the irregularities.
Continued review of the Resident #78's medical record failed to reveal documentation to indicate the irregularities identified by the pharmacist were reviewed by the attending physician, timely acted upon and documented in the resident's medical record.
On 9/18/24 at 5:11 PM, the DON was made aware that a review of the resident's medical record failed to reveal evidence the attending physician reviewed and responded to the pharmacist identified irregularities with Resident #78's medication. The DON acknowledged the concerns at that time, and indicated that if found, evidence of the provider's response would be provided to the surveyor. No additional information was provided to the surveyor by the time of exit on 9/23/24.
Based on medical record review and interview with staff, it was determined that the facility failed to ensure that Irregularities identified by the pharmacist were reviewed by the attending physician, timely acted upon and documented in the resident's medical record. This was evident for 3 (#30, #78, 50 ) of 5 residents reviewed for unnecessary medications.
The findings include:
1) Review of Resident #30's medical record revealed the resident had resided at the facility for several years and whose diagnoses included, but was not limited to: high blood pressure, kidney disease, major depressive disorder and dementia.
On 9/16/24, review of the medical record revealed a Consultant Pharmacist's Recommendation to Physician, dated 5/6/24, which stated: Federal guidelines state antipsychotic drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with at least 1 month between attempts, then annually thereafter. This resident has been taking Seroquel 25 mg bid [two times a day] since (11/2/2023) without a GDR. Could we attempt a dose reduction at this time to perhaps 25 mg daily to verify this resident is on the lowest possible dose? If not, please indicate response below:.
Further review of the medical record failed to reveal documentation to indicate either the primary care provider, or the psychiatric provider, reviewed or addressed this recommendation.
On 9/16/24 at 4:37 PM, the Director of Nursing reported that they were unable to find a response to the May pharmacy recommendation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined that the facility failed to ensure the resident was free from unnecessary psychotropic medications. This was found to be evident for 1 (...
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Based on medical record review and interview, it was determined that the facility failed to ensure the resident was free from unnecessary psychotropic medications. This was found to be evident for 1 (Resident #30) out of 5 residents reviewed for unnecessary medications.
The findings include:
Review of Resident #30's medical record revealed the resident had resided at the facility for several years and whose diagnoses included, but was not limited to: high blood pressure, kidney disease, major depressive disorder and dementia. Review of the Minimum Data Set assessment, with a reference date of 6/5/24, revealed the resident had a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment.
Review of the medical record revealed the resident was seen about once a month by either the Psychiatrist #37 or the Psychiatric Nurse Practitioner (NP) #36.
1) Further review of the medical record revealed a change in condition note that, on 6/8/24, the resident was highly agitated and was observed being verbally abusive and throwing items at the resident's roommate. The psychiatrist #37 was notified, and there was an order to transfer the resident to the hospital. After the resident refused the transfer the psychiatrist was notified and there was then an order for IM Haldol (an antipsychotic) and IM Benedryl (an antihistamine) for aggressive behavior. These orders were entered between 7:30 PM and 8:00 PM. These IM medications were administered on 6/9/24 at 1:50 AM.
No further documentation was found to indicate the resident was continuing to experience aggressive behaviors in the five hours between the medication being ordered and the administration of the IM antipsychotic medication.
On 9/23/24 at 11:30 AM, surveyor reviewed with Psychiatrist #37 the concern that the order was put in around 7:30 PM on 6/8/24, but the IM injections were not documented as administered until 1:50 AM on 6/9/24 by a different nurse. Psychiatrist #37 indicated the injections should of been given STAT and questioned if this was just late documentation.
On 9/23/24 at 11:36 AM, review of Nurse #46's punch card information revealed the nurse was off on 6/7/24. Nurse #46 punched in at 11:40 PM on 6/8/24 and punched out at 7:44 AM on 6/9/24.
On 9/23/24 at 11:44 AM, surveyor reviewed with the DON that the nurses who documented the behaviors on 6/8/24 and obtained the orders did not administer the IM injections and the that the nurse that did administer the injections was not in the facility when the STAT order was given.
Cross reference to F 605
2) Continued review of Resident #30's medical record revealed behavior monitoring documentation being completed every shift by nursing staff. Based on review of this documentation, the resident was not experiencing any behaviors of concern for June, July, August or September.
On 9/17/24, review of the physician orders revealed that the resident had orders for Seroquel 25 mg twice a day from November 2023 until 6/17/24.
Review of the 6/17/24 psychiatrist #37 note does reveal documentation to indicate that staff was reporting the resident was getting aggressive with the roommate and there was a documented plan to increase the Seroquel dose to 50 mg two times a day. This increase occurred more than a week after the 6/8/24 incident resulting in the order for the IM Haldol and after the 6/12/24 NP visit in which the NP documented that she spoke with staff regarding the resident's progress and there were no new behavioral concerns reported.
From 6/17/24 until 7/10/24, the order was for Seroquel 50 mg two times a day.
Further review of the physician orders revealed that, from 7/10/24 until the time of the survey, the order was for Seroquel 100 mg two times a day.
On 7/15/24, there was a new order for Risperdal (antipsychotic) 0.5 mg two times a day that was in effect until 9/5/24.
Review of the 7/15/24 psychiatrist #37's note revealed documentation to indicate staff was reporting the resident was getting aggressive toward their roommate due to paranoia to the point they had to move the resident out of the room. The note documented the start of the Risperdal 0.5mg twice a day for paranoia and stated if the resident does well with Risperdal, will consider tapering off Seroquel.
Review of the Psychiatric NP #36's notes dated 8/7/24 revealed staff reporting episodes of getting aggressive towards roommate and not wanting a roommate. The note includes a notation of Risperdal 0.5 mg bid (two times a day) and included a plan to Continue Current Meds.
Further review of the medical record on 9/17/24 revealed that, on 9/5/24, there was a new order for Risperdal 1 mg two times a day that was currently in effect. No documentation was found to indicate why this antipsychotic medication was increased on 9/5/24.
Review of the Psychiatric NP #36's notes, dated 9/11/24, revealed: Chart reviewed; Spoke with staff regarding patient's progress; No new behavioral concerns reported; Per staff [s/he] has been stable and has not exhibited symptoms of depression, mania, anxiety, psychosis or self-injurious behavior. The note did include Risperdone 1 mg bid in the list of current psychiatric medications but failed to address why the dose was doubled less than a week before the 9/11/24 visit. The note included the plan to Continue Current Meds.
On 9/17/24 at 11:31 AM, surveyor reviewed the concern with the Director of Nursing regarding the increase in the antipsychotic medication without adequate indication. Reviewed that the behavior monitoring sheets since June failed to reveal any documentation of behaviors to indicate the need for the increase. Surveyor requested any additional documentation regarding this concern.
On 9/23/24, further review of the medical record revealed a note written by the NP #36 on 9/18/24, which included the plan to attempt GDR on seroquel to 100 mg at time of sleep.
Cross reference to F 740
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
1) An observation of medication administration on 9/16/24 at 8:13 AM showed that staff #21, a certified medicine aid (CMA), prepared and administered 6 medications to Resident #78.
Following the medi...
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1) An observation of medication administration on 9/16/24 at 8:13 AM showed that staff #21, a certified medicine aid (CMA), prepared and administered 6 medications to Resident #78.
Following the medication administration, a review of Resident #78's medication administration record (MAR)for September 1 to September 16, 2024, was done. The review noted an attending provider's order for Resident #78 for Empagliflozin Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth one time a day for DM. The medication was recorded as given on 9/16/24 at 08:29.
However, the surveyor did not observe the medicine being administered to the resident.
In an interview on 9/16/24 at 12:28 PM, staff #21 said she did not administer the medication even though she signed that she did.
On 9/17/24 at 9:31 AM, the surveyor reviewed with the Director of Nursing the medication error of not administering the antidiabetic medicine on 9/16/24 as ordered.
Based on observation, medical record review and interview, it was determined the facility failed to maintain a medication error rate of less than 5%. This was found to be evident based on 3 errors identified out of 25 opportunities for error. The findings include:
1) On 9/13/24 at 9:45 AM, during an observation of medication administration, Staff 13, Licensed Practical Nurse (LPN) was observed dispensing 5 pills into a medication cup and administering the pills to Resident #383. One of the pills dispensed and administered to Resident #383 by mouth was Calcium 600 mg (milligram) tablet.
Following the medication observation, a review of Resident #383's September 2024 Medication Administration Record (MAR) revealed an 8/30/24 order for Calcium 600 mg (milligram) + Vitamin D3 (Cholecalciferol) 20 mcg (microgram) give 0.5 tablet by mouth one time a day, that Staff #13 documented as given on 9/13/24.
The medication ordered was a combination drug of Calcium 600 mg and Vitamin D3 20 mcg, which was different than the Calcium 600 mg tablet Staff #13 administered to Resident #383. Staff #13 committed a medication error by administering the wrong medication to Resident #383 and failing to administer the correct combination of medication as ordered.
2) On 9/13/24 at 10:10 AM, during an observation of medication administration, Staff #13, LPN, was observed dispensing 12 pills into a medication cup and administer the pills to Resident #122. One of the pills dispensed and administered to Resident #122 by mouth was a Vitamin B-12 1000 mcg tablet.
Following the medication observation, a review of Resident #122's September 2024 MAR revealed an 8/20/24 order for Vitamin B12 (Cyanocobalamin) tablet 500 mcg one time a day that Staff #13 documented as given on 9/13/24.
The dose of the Vitamin B12,1000 mcg dose which was administered to the resident, was different than the Vitamin B12, 500 mcg which was ordered. Staff #13 committed a medication error while administering the medication to Resident #122 by failing to administer the right dose of Vitamin B-12 medication.
The above medication administration error concerns were discussed with Staff #13, LPN on 9/13/24 at 4:20 PM, and Staff #13 confirmed the medication administration errors at that time, with no comments.
The Director of Nurses was made aware of the above medication error concerns on 9/20/2024 at 3:30 PM. The DON acknowledged the concerns and offered no further comments at that time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected 1 resident
Based on the interview and review of relevant documentation, it was determined that the facility failed to have a full time clinically qualified Food Service Director and failed to ensure scheduled co...
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Based on the interview and review of relevant documentation, it was determined that the facility failed to have a full time clinically qualified Food Service Director and failed to ensure scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This was evident for 1 (Staff #62) of 1 Food Service Director reviewed for required credentialing.
The findings include:
On 9/14/24 at 12:30 PM, an interview was conducted with the current Food Service Director (FSD-Staff #62) who reported she had worked at the facility for 4 years but was not a Certified Dietary Manager. Surveyor requested the FSD's current credentials. The FSD confirmed that the facility's Registered Dietitian (RD) was not involved in the running of the kitchen, and indicated she thought the facility did not currently employ a full time RD.
State regulations require in a nursing home with more than 50 beds, overall supervisory responsibilities for the food service department and food production shall be assigned to a full-time qualified dietetic service supervisor. The state regulations define a dietetic service supervisor as a person who:
a) Is a graduate of a dietetic technician program approved by the American Dietetic Association;
(b) Is a graduate of a dietetic technician program approved by the American Dietetic Association;
(c) Is a certified dietary manager who has successfully completed the required course and maintains certification as required by the certifying board for the Dietary Managers Association;
(d) Is a graduate of a State-approved course that provided 90 or more hours of classroom instruction in food service supervision and has experience as a supervisor in a health care institution with consultation from a dietitian; or
(e) Has training and experience in food service supervision and management in a military service equivalent in content to §B(15)(b) and (d) of this regulation. [ See COMAR S0790-10.07.02.21B]
Review of FSD #62's credentials failed to reveal documentation to indicate the FSD was a qualified dietitian or other clinically qualified nutrition professional.
On 9/16/24 at 2:30 PM, the FSD #62 reported there was a Registered Dietitian (RD) on call but she did not meet regularly with the RD.
On 9/18/24 at 1:21 PM, surveyor informed the District Manager (Staff 64) of the concern that the FSD credentials did not meet the state regulation and that there was no RD consulting on a regular basis. He reported the FSD was enrolled in CDM program thru Univ of Florida and he thought that as long as they were enrolled that was good enough. Surveyor requested any additional documentation they may have.
The District Manager provided documentation that the FSD #62 was enrolled in a Nutrition Foodservice Professional Training Pathway I course on 5/28/24.
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 ensure clean dishes were stored and maintained in a manner to prevent contamination. This practice had the potential ...
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Based on observation, and interview, it was determined that the facility failed to ensure clean dishes were stored and maintained in a manner to prevent contamination. This practice had the potential to affect all the residents in the facility.
The findings include:
On 9/10/24, an initial tour of the kitchen was conducted at 7:30 AM. During this tour, surveyor observed in the dishwashing room a cart with approximately 20 cups, in stacks of about 4-5 where the cups were inverted and stored open area down on a tray. Significant moisture was noted in all of these cups. The dietary aide (Staff #61) reported these cups were for lunch. Surveyor then asked the [NAME] (Staff 63) to observe the glasses; at first the [NAME] said that the staff will wipe them. When surveyor repeated this statement back, the [NAME] then said: will send them thru the washer again and let them air dry.
The practice of storing dishes prior to being completely air dried is known as wet nesting. Wet nesting creates conditions in which microorganism can grow.
On 9/12/24 at 11:45 AM, during a revisit to the kitchen surveyor observed a tray, similar to the one observed on 9/10/24, with 6 stacks of 5 cups each with moisture noted in the cups. These cups were on a cart with a drink container. The District Manager (Staff #64) confirmed these cups were to be used with lunch service. Surveyor reviewed the concern regarding the wet nesting found on day 1 of the survey and again today. District manager then proceeded to place the cups in rack to air dry.
2) On 9/10/24 during the initial kitchen tour, surveyor noted the tray with the cups had significant chipping.
On 9/12/24 at 11:45 AM, during a revisit to the kitchen, chipped trays were again observed while trays were being prepared.
On 9/12/24 at 12:30 PM while observing a test tray with the Food Service Director, surveyor noted the test tray with a chip. Surveyor discussed the observations of multiple chipped trays with the FSD. The FSD reported they have ordered new trays but they were non back order. Surveyor requested documentation to support this.
As of time of survey exit on 9/23/24 at 1:00 PM, no documentation was provided to indicate new trays were on order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that the facility failed to document clinical assessments. This was evident for 1 resident (Resident #17) of 5 residents reviewed for nutrition ...
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Based on record review and interview, it was determined that the facility failed to document clinical assessments. This was evident for 1 resident (Resident #17) of 5 residents reviewed for nutrition during the recertification survey.
The findings include:
On 9/11/24 at 9:34 AM, a review of Resident #17's height and weight documentation was conducted. There were 3 entries in the Height Summary:
7/23/24 61.0 inches lying down
12/16/16 72.0 inches Standing
12/08/16 72.0 inches Standing
On 9/19/24 at 2:12 PM, an interview with the Director of Nursing (DON) was conducted to review the discrepancy in the resident's documented heights., 72 inches, and 61 inches. When asked to confirm the resident's current height, the DON agreed to measure the resident's height.
On 9/19/24 at 2:45 PM, the DON informed the surveyor that she measured the resident's height today and it was 70 inches.
On 9/23/24 at 8:54 AM, an updated printout of Resident #17's height measurements was requested. When the DON provided the printed copy, there were no additional entries beyond 7/23/24. The record did not contain the measurement obtained by the DON on 9/19/24. When the DON was asked where the measurement of 70 inches on 9/19/24 was recorded, she confirmed that she did not document it and that she did not think she needed to do so.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
3. On 9/12/24 at 2:25 PM, the Director of Housekeeping (Staff #49) was interviewed regarding the facility's process with laundry. Simultaneously, while Staff #49 explained the facility's process, a to...
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3. On 9/12/24 at 2:25 PM, the Director of Housekeeping (Staff #49) was interviewed regarding the facility's process with laundry. Simultaneously, while Staff #49 explained the facility's process, a tour of the laundry room was conducted with the surveyor.
While Staff #49 explained the different areas of the facility's laundry room, an observation was made on 9/12/24 at 2:31 PM, of Hoyer/lifting pads or sling and washable chucks/underpads hanging on a platform over the bins containing soiled laundry.
Staff #49 was questioned about the observation, and she indicated that all of the lifting pads and washable chucks have been washed and were placed in that location for drying. She further indicated that the items could not be put in the dryer because it would ruin them.
A Hoyer lift is a patient lift used by caregivers to safely transfer patients. It can be used for lifting patients from the floor or onto a healthcare bed. The lift also can assist in other surface-to-surface patient transfers, such as moving from a bed to a bath or chair. The sling or lifting pads are made of durable materials placed under the individual with straps that attach to the lift or sling bar.
Underpads are absorbent sheets that lay between the user and the furniture or bed that the user is laying or sitting on. They help to absorb any fluid due to incontinence to avoid leakage and damage to the furniture or bed.
Subsequently, at 2:37 PM, the assigned Laundry Aide (Staff #58) arrived in the laundry room for her shift. Staff #58 began her shift by removing the washed laundry and placed them in a bin with rollers. While still in the soiled area of the laundry room, Staff #58 donned disposable gloves, a gown, and a face shield, and proceeded to load the washer with the soiled laundry. After removing the personal protective equipment and discarding them, Staff #58 rolled the bin, with the washed laundry in them, to the clean side of the laundry room where the dryers were located.
On 9/12/24 at 3:01 PM, Staff #49 was invited to come back in the laundry room and the concerns that the surveyor had observed were reported to both Staff #49 and #58. The concern was that the lifting pads and washable chucks were being hung dried in the soiled area of the laundry room; and that Staff #58 was observed to process soiled laundry while the clean laundry was in close proximity, about 3 feet away. Both staff verbalized understanding that these observations were concerns with cross contamination. Staff #49 instructed Staff #58 to rewash all the items immediately, including the lifting pads and chucks, and to find an area in the clean side of the laundry room to hang them for drying afterwards. Both staff thanked the surveyor.
Based on record review, observation, and interview, it was determined the facility failed to maintain a resident's medical equipment in proper sanitary conditions and failed to process linens in a manner that prevents cross contamination. This was evident for 2 (Resident #88, #330) out of 2 residents, reviewed for urinary catheter or urinary tract infection during a survey and evident in 1 of 1 laundry room observations during the recertification survey and had the potential to affect all residents of the facility.
.The findings include:
1. 0n 9/10/24 at 2:29 PM, review of medical records revealed that Resident #88 was a long-term resident of the facility. Further review revealed that Resident # 88 had a foley catheter in place and was being treated for a urinary tract infection.
On 9/13/24 at 8:53 AM, an observation was made in Resident #88's room. The observation revealed the Foley tubing was attached to the lower bar on his/her bed and the drainage bag was resting on the floor.
On 9/13/24 at 9:14 AM, an observation was made with the Unit Manager LPN, (Staff # 12) and the Assistant Director of Nursing in Resident #88's room. Staff #12 stated that the Foley urine drainage collection bag was touching the floor because the bag was attached to the lower rung of the bed, and the bed was in the low position. Staff #12 reported she would fix the bag immediately and educate the staff on maintaining the Foley urine drainage bag, off the floor and under sanitary conditions.
On 9/20/24 at 10:50 AM, The above concerns were discussed with administrator and the Director of Nursing. No additional information was provided to the survey team.
2. On 9/11/24 at 9:40AM, review of Resident # 330s medical records revealed that Resident #330 was admitted to the facility with a tracheostomy.
A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs.
On 9/11/24 at 11:45 AM, an observation of Resident #330 revealed that the resident was receiving oxygen. The equipment used to administer the oxygen included a condensation reservoir bag. Further observation revealed the reservoir bag was resting on the floor.
On 9/11/24 at11:46 AM, an observation with first floor Unit Manager LPN (Staff #14) was made in Resident # 330 room.
On 9/11/24 at 11:47 AM, brief Interview with she reported that bag should not be resting on the floor and the tubbing may be too long. Unit manager stated she would correct the situation.
09/20/24 10:50 On 9/20/24 at 10:50 AM, The above concerns were discussed concerns with administrator and the Director of nursing. No additional information was provided to the survey team.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
2) On 9/17/24 at 3:20PM, Resident #328, admitted to the facility for rehab, was interviewed. During
the interview Resident # 328's family expressed concerns regarding the resident's bathroom.
On 9/17/...
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2) On 9/17/24 at 3:20PM, Resident #328, admitted to the facility for rehab, was interviewed. During
the interview Resident # 328's family expressed concerns regarding the resident's bathroom.
On 9/17/24 at 3:22PM, an observation was made of Resident #328 bathroom. The observation
revealed that the safety rail next to the toilet was loose. The fasteners affixing the rail to the wall
were exposed, with a visible hole in the dry wall.
09/17/24 08:16 AM, the maintenance Director (Staff # 25 ) and surveyor made an observation of
Resident #328's bathroom. The maintenance director confirmed that the safety rail in the
bathroom was loose and needed repair.
Based on family and staff interview, and observation, it was determined the facility failed to maintain electrical equipment in safe operating condition and failed to maintain a bathroom safety rail in a safe operating condition. This was evident for 1 of 1 microwave observed during the survey and evident for 1 residents room.
1) On 9/20/24 at approximately 10:00 AM, Resident #380's family member asked if the surveyor had seen the microwave in the 1st floor pantry where residents could have food reheated. The family member then stated that the interior of the microwave was rusty and s/he was concerned the microwave was not safe to use.
9/20/24 at 10:05 AM, observation of microwave revealed the white coating on the walls and floor of the microwave was peeling with areas of coating missing, exposing areas of rust. This included a larger, irregular area, approximately 7-inch x 1 inch, in the back floor of the microwave, where the coating was missing, and peeling, and the area in the microwave was rusted. Also, on the left interior wall of the microwave, there was an irregular area, approximately 3 inches in diameter where the coating was missing, and the microwave wall was rusted.
On 9/20/24 at 10:15 AM, accompanied by Staff #25, Maintenance Director, a second observation of the 1st floor pantry microwave was made. At that time, Staff #25 was made aware of the concern with the rusted microwave, had been reported to the surveyor by a resident's family member. Following the observation of the interior of the microwave, Staff #25 confirmed the findings and stated that nursing had never notified maintenance that there was a problem with the microwave. Staff #25 reported that the rusted microwave should not be used, and indicated the microwave would be disposed of. Staff #25 was then observed removing the microwave and carrying it out of the building.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation and staff interviews, it was determined that the Facility failed to have the call light within reach of a dependent resident. This was evident for 1 (#402) of 3 residents reviewed...
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Based on observation and staff interviews, it was determined that the Facility failed to have the call light within reach of a dependent resident. This was evident for 1 (#402) of 3 residents reviewed for Activity of Daily need (ADL) dependence during a revisit survey.
The finding include:
On 12/18/23 at 2:00 PM Resident #402 was observed lying in bed half asleep, further observation revealed that the call light could not be found. The resident was asked about their call light, and they stated that they did not know where it was. At 2:03 PM a Geriatric Nursing Assistant (GNA) #16 was called into the resident's room. She was asked how resident calls for assistance, and she said resident can use the call light. She was asked about the whereabouts of the call light. Staff #16 proceeded to look for the resident's call light. She searched around the room and underneath the resident's bed but could not find it. She asked the resident, and s/he said they did not know where it was. She searched some more and finally located it tucked inside the top drawer of the resident's nightstand; she pulled it out and clipped it next to the resident on the bed linen stating that night shift must have left it inside the drawer.
At 2:10 PM, the Director of Nursing (DON) was made aware of the findings and that this was a concern.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to maintain a safe, clean, comfortable and homeli...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. This was found to be evident on both floors of the nursing facility. The findings include:
1) On 9/16/24 between 1:00 PM - 2:00 PM, surveyor and the Maintenance Director #25 toured several resident rooms on both floors of the facility. During this tour, five out of nine bathrooms observed failed to have a functioning air vent exhaust system. When it was discovered that the exhaust in room [ROOM NUMBER]'s bathroom was not functioning, the Maintenance Director removed the vent cover and examined the vent with a flashlight, and stated he was not sure why there was no exhaust. In addition to room [ROOM NUMBER], the exhaust vents were found not to be working in the bathrooms in rooms 123; 205; 207; or. 231.
The concern regarding the ventilation system was addressed with the Nursing Home Administrator (NHA) on 9/18/24 at 4:20 PM.
2) On 9/10/24 at 12:27PM, Resident #55 reported the air conditioner unit in his/her room was not working and had not been working all summer. The resident reported it had been ok since the heat didn't bother him/her much, altough it did bother the roommate. The resident went on to express a concern that the heat might not work.
During an interview with the Maintenance Director on 9/16/24 at 12:50, he reported they have some back up units and if they can't fix a unit, then they will replace it. The director indicated he was aware that Resident #102's unit was not working and had just put in an order for a replacement.
On 9/18/24 at 4:20 PM, suveyor informed the NHA that multiple housekeeping and maintenance concerns were identified during the survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
Based on record review and interview, it was determined that the facility failed to honor residents' right to self-determination. This was evident for 1 resident (Resident #37) of 17 residents reviewe...
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Based on record review and interview, it was determined that the facility failed to honor residents' right to self-determination. This was evident for 1 resident (Resident #37) of 17 residents reviewed for Medical Orders for Life Sustaining Treatments (MOLST) documentation related to the Immediate Jeopardy investigation during the recertification survey. This had the potential to affect all residents who could make their own decisions.
The findings include:
On 9/13/24, an Immediate Jeopardy situation was declared due to conflicting resuscitation (code status) instructions for Resident #328. As a result of this situation, the facility conducted an audit to confirm all residents' choice of code status.
On 9/17/24 at 2:27 PM, a review of Resident #37's clinical records revealed that the resident was evaluated by the Medical Director on 7/18/24 and was determined to have capacity to make decisions.
On 9/17/24 at 2:39 PM, a review of documentation was conducted to verify that the facility had confirmed Resident #37's code status choice. The record contained a progress note, dated 9/17/24, written by Regional Social Work Director (SW #17) that stated Regional SWDP contacted patient's family to confirm full code status. The documentation did not include the name of the person contacted. A review of Resident #37's profile revealed 2 family members listed, a daughter and a sibling.
On 9/18/24 at 9:50 am, the Nursing Home Administrator (NHA) provided the survey team with an updated resident MOLST audit list and said that the list was correct and accurate.
On 9/19/24 at 9:34 AM, a review of the facility's audit list revealed that the facility alleged that Resident #37's code status had been confirmed.
On 9/19/24 at approximately 11:45 AM, during an interview with the Medical Director, Resident #37's clinical documentation was reviewed. Although the Medical Director had documented that the resident had capacity to make decisions, SW #17 documented that she asked the resident's family about the resident's code status but did not indicate the resident was asked. The Medical Director confirmed that Resident #37 should have been asked about his code status choice and that there was no evidence this was done.
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** 8). On 9/18/24 at 2:09 PM, an observation of room [ROOM NUMBER]-B was conducted. There was a hole in the drywall behind the resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8). On 9/18/24 at 2:09 PM, an observation of room [ROOM NUMBER]-B was conducted. There was a hole in the drywall behind the resident's bed at the level of the floor that measured approximately 8 inches long and 8 inches high and a 2-inch gaping hole.
On 9/18/24 at 2:15 PM, Licensed Practical Nurse (LPN #8) was interviewed in room [ROOM NUMBER]-B and when asked if she was aware of the hole in the wall, she said that the bed frame must have damaged it. When asked if the Maintenance Director was aware of the damaged wall, she said she was not sure but would ask him to come to the room.
On 9/18/24 at 2:25 PM, the Maintenance Director (Staff #25) was interviewed in room [ROOM NUMBER]-B and confirmed the damaged wall but said he was not aware of it. He described the process for staff to notify maintenance of any maintenance concerns; staff told the unit clerk and the unit clerk entered the information into the maintenance system which prompted a notification in the application that he used to track facility maintenance issues.
On 9/20/24 at 1:14 PM, an interview with the Director of Nursing (DON) was conducted to review that the wall was damaged in room [ROOM NUMBER]-B. The DON acknowledged the finding.
Based on observation and interview, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. This was found to be evident on both floors of the nursing facility. The findings include:
1a) On 9/10/24 at 2:37 PM, surveyor noted carpet in hallway near room [ROOM NUMBER] was stained in multiple areas. Continued observations made throughout the survey, on both the first and second floor, revealed multiple stains to the carpeting. On 9/13/24 at 10:04 AM during an interview with the Housekeeping Supervisor (Staff #49), she reported they have cleaned the carpets but the stains were still there and she was hoping they could pull them up. On 9/16/24 at 12:50 PM, in an interview with the Maintenance Director (Staff #25) it was reported that the facility had a plan in motion for the carpets and was just told by their supervisor a few weeks ago to get some quotes.
The NHA was made aware of the concern regarding the carpeting on 9/18/24 at 4:20 PM.
1b) On 9/11/24 at 9:48 AM, surveyor observed in room [ROOM NUMBER] in front of the HVAC (heating airconditioning and ventilation ) unit 6 floor imitation wood planks missing out of floor creating debits in the floor. Trim on wall opposite residents bed was coming off.
On 9/11/24 at 10:15 AM, surveyor observed in room [ROOM NUMBER] loose wooden floor planks in front of the HVAC unit. On 9/11/24 at 11:36 AM, observation in room [ROOM NUMBER] revealed wooden planks in the floor that were loose/coming off. On 9/11/24 at 12:50 PM, surveyor observed loose and missing floor tiles/ wooden planks in front of HVAC unit in room [ROOM NUMBER]. The tour of the facility on 9/16/24 with the Maintenance Director revealed several rooms on the first floor that had floors that were covered with a laminate that looked like wooden planks in which areas of the planks were missing. This included room [ROOM NUMBER] with a plank approximately 10 inches long missing; room [ROOM NUMBER] with loose planks in front of the HVAC unit which the Maintenance Director stated they needed to be glued down; and in room [ROOM NUMBER] which had multiple missing planks. As of time of survey exit on 9/23/24 at 1:00 PM, no documentation was provided to indicate new carpets or other flooring were ordered.
2a) On 9/11/24 at 1:01 PM, surveyor observed holes in Resident #378's bed linen.
On 9/11/24 at 11:38 AM surveyor observed Resident #13 in bed. A dime sized hole was noted in the fitted sheet near the foot of the bed. On 9/16/24 at 2:22 PM, the housekeeping supervisor reported laundry staff are suppose to check the sheets to make sure they are clean and without holes. She indicated sheets with holes should not go up to the units. Surveyor reviewed the concern that there were two seperate observations by surveyors of sheets with holes during the first few days of the survey.
2b) On 9/10/24 at 1:05 PM, Resident #55 reported a concern about not having sheets that fit [his/her] bed, indicating the facility only has 1 bariatric fitted sheet. A bariatric bed is larger than a standard sized bed.
On 9/16/24 at 2:22 PM, the housekeeping supervisor reported she had ordered bariatric sheets but was having a hard time getting them back after use. She confirmed the bariatric sheets were not coming back to the laundry. On 9/17/24 at 8:48 AM the Housekeeping supervisor provided documentation to support that bariatric sheets were ordered in April and August but confirmed that they had not been returned to laundry (for cleaning).
3) On 9/10/24 at 12:41 PM, observation of Resident #95's wheelchair revealed the padding on the right and left arm rest had multiple cracks. On 9/18/24 at 10:25 AM, surveyor and unit nurse manager observed Resident #95 in his/her wheelchair. The unit manager acknowledged the cracks in the arm rests and stated she would have them changed.
4a) On 9/11/24 at 10:42 AM surveyor observed a hole in wall where main door meets the wall in room [ROOM NUMBER]. On 9/13/24 at 1:45 PM observation in room [ROOM NUMBER]revealed the hole remains in the wall behind the door, additional concerns identified at this time included bed side table with damage; baseboard in bathroom with damage; and damage to the dresser. On 9/13/24 at 1:50 PM, surveyor observed the damage found in room [ROOM NUMBER] with housekeeper (Staff #60). Staff #60 reported the hole in the wall had been reported to maintenance. She also reported that she had reported the light not working on the computer [electronic reporting system], and that they fixed the bathroom light but not the room light.
4b) On 9/11/24 at 12:57 PM, observation of the bathroom in room [ROOM NUMBER] revealed a rectangular shaped hole under the sink approximately 10 inches by 3 inches where the plumbing was located. Additionally, the cord for the emergency call light was noted to be missing from the bathroom. On 9/11/24 at 3:14 PM surveyor informed the DON of the observation of no call bell cord on the emergency call bell in the bathroom.
5) On 9/11/24 at 11:33 AM, interview with Resident #24's family member revealed a concern with room cleaning, reporting it takes a long time for them to clean and they don't clean outside the schedule.
5a) On 9/11/24 at 12:57 PM, surveyor observed a brownish smudge on the wall behind the headboard of bed A in room [ROOM NUMBER]. Additionally, some of the laminate strip was noted to be missing on the side table, on part of the dresser drawer and along about half of the footboard.
On 9/13/24 at 10:04 AM, interview with the housekeeping supervisor revealed the resident rooms are cleaned every day, including the resident's bathroom. She reported they dust, sweep, mop, clean the window sills, check the walls and check the wheelchairs. She reports, if told to, they will clean the wheelchairs. If any environmental/maintenance issue are identified the staff should let her know and that they also have an electronic way to report concerns.
On 9/13/24 between 10:05-10:30AM, surveyor and housekeeping supervisor toured the facility.
On 9/13/24 at 10:15 AM, surveyor and housekeeping supervisor observed the brown smudge, like a swirled line, on an approxiately three x two inch area on the wall behind 240 bed A's headboard. Surveyor informed the supervisor this brown smudge was observed a few days earlier during the survey. The supervisor indicated she would have housekeeping wipe that off. Also observed damage to the baseboards in the bathroom, which housekeeping supervisor indicated had not been reported to her, and stated they may have thought already reported. Surveyor also pointed out the large hole under the sink, supervisor indicated this is a maintenance issue but indicated she would submit a report now that she was aware.
6b) On 9/11/24 at 11:06 AM, surveyor observed, in the bathroom of room [ROOM NUMBER], multiple brown spots on the wall to the left of the bathroom door and next to the emergency call light.
Additionally in the room paint was missing to the left and right of the mounted TV; and a large area of paint was missing under the hand sanitizer dispenser to the left of the outside bathroom door.
On 9/13/24, during the tour of the facility with the housekeeping supervisor, surveyor and supervisor observed the brown spots on the wall in the room [ROOM NUMBER]'s bathroom. Surveyor informed her they had previously been observed two days prior. Supervisor indicated the housekeeper should have caught this.
6c) On 9/16/24 at 3:45 PM, observation, with nurse #8, of the 2nd floor shower room, revealed cracked flooring, with an approximately 3 x 5 inch area missing; blue pads for shower bed observed with multiple cracks of approximatley 5 to 8 inch in length. On 9/16/24 at 4:10 PM, observation of the 2nd floor shower room was made with the unit nurse manager #12 who reported they wipe the showers down between residents. At that time, brown spots were observed on the floor of the shower and the unit nurse manager stated that it looked like stool and she indicated she would have the area cleaned. The unit nurse manager also observed and acknowledged the damage to flooring and the cracks in the pads to the shower chairs.
7) On 9/16/24 between 1:00 PM-2:00 PM during a tour of the facility with the maintenance director, surveyor observed 4 ceiling tiles with brown stains in the hallway between room [ROOM NUMBER] and 109.; and 3 ceiling tiles with brown stains between room [ROOM NUMBER] - 102. The Maintenance Director acknowledged the stains and indicated he thought it was from condensation from the air conditioner.
On 9/18/24 at 4:20 PM, suveyor informed the NHA that multiple housekeeping and maintenance concerns were identified during the survey.
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
Based on medical record review and staff interview, it was determined that the facility staff failed to develop and implement a comprehensive, resident centered care plan for a resident receiving psyc...
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Based on medical record review and staff interview, it was determined that the facility staff failed to develop and implement a comprehensive, resident centered care plan for a resident receiving psychotropic medications. This was evident for 1 (#78) of 5 residents reviewed for unnecessary medications, and 1 #(78) of 5 residents reviewed for unnecessary medications.
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 residents care
The findings include:
1) On 9/18/24 at 12:04 PM, a review of Resident #78's medical record documented the resident was admitted to the facility at the end of June 2024 and had a diagnosis which included depression.
Review of Resident #78's September 2024 Medication Administration Record (MAR) revealed an 8/20/24 order for Escitalopram Oxalate (Lexapro) (antidepressant) (psychotropic medication) by mouth one time a day for Depression that was documented as given every day from 9/1/24 to 9/13/24.
Review of Resident #78's care plans revealed a care plan with the focus, the resident has behaviors related to depressive disorder, initiated on 8/13/24, with the goal, the resident' s behaviors will not cause them or other resident' s distress thru the review period, that had 3 interventions, administer, medications as ordered, physician review of medications as needed, and remove resident from environment.
The care plan was not comprehensive, and resident centered, with no indication in the care plan of theresident's behaviors for which a psychotropic medication had been prescribed. In addition, the care plan failed to have measurable goals and interventions, including non-pharmaceutical interventions, to assist the resident with his/her behaviors.
The Director of Nurses (DON) was made aware of the above concerns on 9/18/24 and offered no comments at that time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
4). On 9/10/24 at 11:53 PM, Resident # 109, a long-term resident of the facility and her/his family were interviewed. During the interview, Resident # 109 and her/his family reported that s/he just si...
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4). On 9/10/24 at 11:53 PM, Resident # 109, a long-term resident of the facility and her/his family were interviewed. During the interview, Resident # 109 and her/his family reported that s/he just sits in her/his bed all day and that he/she would like more interaction with the staff.
On 9/12/24, Resident #109's care plan was reviewed. The review revealed that the resident prefers or requires 1:1 activity. Further review revealed that activity preferences of the resident should be reviewed with the resident or the resident's representative if the resident was unable to communicate preferences.
On 9/12/24, Resident # 109's activity assessment was reviewed. The review revealed that the facility staff were interviewed regarding the residents' preferences for activities three days after the resident was admitted . Further review revealed a section titled past activity interests with 10 questions regarding the residents past activity interest. Review of this section revealed that 0 out of the 10 questions were answered on the assessment form.
On 9/12/24 at 3:58 PM, the Activity Director (Staff #9) reported that she documented all 1:1 activity done with residents at the facility in an activity binder. In addition, she reported that, if a resident cannot communicate what they like or dislike, she would interview the facility and staff and residents' family to obtain this information.
On 9/12/24 at 4:00 PM, observation of the activity logbook with the activity director failed to reveal that Resident #109 received any 1:1 activity since her/his admission in the facility.
On 9/12.24 at 4:01PM, continued interview with Staff # 9 revealed that she was aware that the resident family member visited the resident almost every day, but she had never interviewed the family to obtain information about resident's activity preferences.
On 9/20/24 at 10:50 AM, The above concerns were discussed concerns with admin and the DON. No additional information was provided to the survey team.
Based on medical record review, observation and interviews, it was determined that the facility failed to ensure that activities were provided to meet the needs of the residents. This was found to be evident for 4 (Resident #30, #95,
#13 and #109) out of 4 residents reviewed for activities during the survey.
The findings include
1) On 9/11/24 at 10:40 AM, Resident #30 was observed alone in his/her room in a wheelchair by, no music or other activity was observed at that time.
On 9/12/24, review of Resident #30's medical record revealed the resident had resided at the facility for several years and whose diagnoses included, but were not limited to: high blood pressure, kidney disease, major depressive disorder and dementia. Review of the Minimum Data Set (MDS) assessment, with a reference date of 6/5/24, revealed that the resident had a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment.
Review of the 9/5/24 MDS Section B revealed that the resident had clear speech and the ability to be understood and to understand others. Continued review of the 9/5/24 MDS revealed that the resident was interviewed in regard to activity preferences. This assessment revealed it was somewhat important for the resident to listen to music s/he liked and to go outside to get fresh air when the weather is good.
Review of the care plans revealed a plan initiated 10/30/23, with a revision date of 9/10/24 that stated: [Resident's name]'s behaviors have reduced. Resident prefers to attend group activities such as BINGO, group reminiscing, holiday celebrations, movie watching. The stated goal was that the resident would be satisfied with group activities thru the review period. The interventions included: activity calendar and assist resident to group activities as needed.
Further review of the care plans revealed another plan, initiated on 9/5/24 with a revision date of 9/10/24, that stated: [Resident #30's name] requires 1:1 activities due to being unwilling to participate in other activities , [his/her] behavior is unstable. The stated goal was that the resident will be satisfied with their 1:1 activities provided thru the review period. The interventions included: explore likes and dislikes of activities; provide 1:1 activities in the room or location that is the resident's preference as needed; and review activities preferences with the resident or resident representative if the resident is unable as needed.
No documentation was found in the care plan to reflect the activity assessment that indicated it was somewhat important for the resident to listen to music s/he liked, or to go outside when the weather was nice.
Further review of the medical record failed to reveal documentation to indicate the facility held an interdisciplinary care plan meeting since October 2023.
Further review of the medical record revealed a Multidisciplinary Care Conference note for the meeting held on 10/31/23. Review of this note failed to reveal documentation to indicate anyone from the activity department attended the meeting or provided input/summary as evidenced by blanks in the section of the note for activities staff to provide a summary.
On 9/12/24 at 3:38 PM interview with the Activity Director (Staff #9) revealed she had been the director for almost two months but worked at the facility as an activity assistant for 2 years. She confirmed she conducted the MDS assessment and created the care plans. She reported there was documentation for activity participation in the electronic health record and that she had a file for documentation of 1:1 visits. Surveyor was unable to view activity participation in the electronic health record, when asked to show surveyor documentation of participation in the computer the Activity Director was unable to do so. The Activity Director then indicated she would provide the 1:1 documentation.
On 9/12/24 at 4:19 PM the Activity Director provided documentation of a 1:1 Activities Log that had documentation of a 1:1 visit on 4/27/24 for Resident #30. She later confirmed this was the only documentation for Activities for Resident #30.
2) On 9/10/24 at 12:08 PM, Resident #95 was observed up and dressed and sitting in a wheelchair in the hallway.
On 9/11/24 at 10:07 AM, the resident was again observed sitting in the hallway in a wheelchair alone; At 10:44 AM, the resident was observed still in the wheelchair in the hallway but had wheeled self about half way down hall and was interacting with the staff working at a cart. On 9/11/24 at 12:04 PM, the resident was observed sitting in a wheelchair in the doorway of the resident's room. Resident was not observed to be attending any group activites on either 9/10/24 or 9/11/24. No observations were made of activity staff engaging with the resident.
On 9/12/24, a review of Resident #95's medical record revealed the resident had resided at the facility for a over one year and whose diagnoses include, but not limited to, dementia and lung disease.
Review of the 1/24/24 MDS assessment revealed that the resident's family was interviewed in regard to Activity Preferences. This assessment revealed it was very important to listen to music the resident liked and to participate in religious activities.
Review of the care plans revealed a plan for 1:1 Activities: [Resident #95's name] prefers or requires 1:1 activities due to being unable or unwilling to participate in other activities. The goal is [Resident] will be satisfied with their 1:1 activities provided thru the review period. The interventions include: provide 1:1 activities in the room or location that is the residents preference as needed and review activities preferences with the resident or resident representative if the resident is unable as needed. These interventions were established in August 2023 and have not been updated or personalized since then; although the goal included a notation by the unit nurse manager that it was revised on 7/29/24. The care plan failed to reflect the January assessment that listening to music and attending religious activites were very important to the resident.
Further review of the medical record failed to reveal documentation to indicate a care plan meeting had occurred since December 2023.
On 9/12/24 at 10:54 AM, the resident's responsible party reported being at the facility frequently. She also confirmed that there had been no recent care plan meetings.
On 9/12/24 at 4:27 PM, the Activity Director reported that the resident attended a celebration outside around 3:30 in the afternoon, indicated that the resident stayed for about 10 minutes then wanted to go back. The Activity Director was unable to provide documentation to support that the resident attended activities or was provided 1:1 visits. Surveyor also reviewed the concern regarding the failure to update the care plan interventions.
3) Review of Resident #13's medical record revealed the resident had resided at the facility for more than one year and whose diagnoses included, but were not limited to, dementia, heart disease and diabetes. Review of the 2/17/24 MDS assessment revealed that the resident was interviewed for Activity Preferences and that it was somewhat important to do things with groups of people; to go outside to get fresh air when the weather is good and to participate in religious services or practices.
Review of the care plans revealed a plan initiated on 8/30/24 for 1:1 Activities: the resident prefers or requires 1:1 activities due to being unable or unwilling to participate in other activities. The goal was the resident will be satisfied with their 1:1 activities provided thru the review period, there was a notation that this goal was revised by the unit nurse manager on 9/3/24. The interventions include: explore likes and dislikes of activities; provide 1:1 activities in the room or location that is the residents preference as needed and review activities preferences with the resident or resident representative if the resident was unable as needed. This care plan failed to reflect the February assessment that indicated it was somewhat important to do things with groups; to go outside to get fresh air or to attend/participate in religious services.
On 9/12/24 at 4:11 PM, surveyor was unable to find any activity documentation in the electronic health record for Resident #13 and proceeded to look through the 1:1 Activitiy log book. The Activity Director reported she could not locate the 1:1 documentation for this resident but stated: I know [he/she] came to the birthday bash and sometimes attends the master gardener, and sometimes the bible study.
On 9/18/24 at 4:20 PM, surveyor reviewed the concern regarding the facility's failure to provide activities with the Nursing Home Administrator and the Director of Nursing. As of time of survey exit on 9/23/24 at 1:00 PM, no additional documentation was provided to indicate activity participation or 1:1 visits for Residents #30, #95 or #13.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
3) In an interview with Resident #50 on 9/11/24 at 10:15 AM, s/he indicated that it was very important for him/her to receive pain medication on time. Timely administration of his/her pain medication ...
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3) In an interview with Resident #50 on 9/11/24 at 10:15 AM, s/he indicated that it was very important for him/her to receive pain medication on time. Timely administration of his/her pain medication prevents the pain from being unmanageable which makes it difficult for the resident to relax and sleep.
On 9/13/24 at 9:56 AM, Resident #50's medical record was reviewed and revealed a care plan for pain management with interventions to administer medications, notify physician as indicated, and to observe for indicators of pain. There was no evidence that non-pharmacological interventions were included to manage the resident's pain.
Current orders for Resident #50 were reviewed on 9/13/24 at 10:12 AM. The review revealed orders for the resident to be monitored for pain every shift and an opioid to be given routinely every six hours to control pain and discomfort. There was no evidence that non-pharmacological interventions were included to manage the resident's pain.
Opioids - Opioids are a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant. Opioids work in the brain to produce a variety of effects, including pain relief. Opioid is the proper term, but opioid drugs may also be called opiates, painkillers, or narcotics.
On 9/16/24 at 12:23 PM, the facility's pain management policy, provided by the Director of Nursing (DON), was reviewed and indicated that non-pharmacological interventions are attempted prior to medication administration and were to be documented in the medical record.
On 9/16/24 at 2:09 PM, the narcotic count sheet for Resident #50 was reviewed in contrast with the electronic Medication Administration Record (eMAR). The review revealed that on 8/28/24, 9/7/24, and 9/10/24, Licensed Practical Nurse (LPN Staff #18) documented that she pulled the resident's narcotic pain medication at 2 PM when it was scheduled to be administered at 12 PM.
A medication administration audit report was provided by the DON, for the 3 dates stated above, that revealed the actual time the nurses were documenting their medication administration. A review of the report on 9/17/24 at 11:44 AM revealed that Resident #50's narcotic pain medication was administered late on 8/28/24, 12 PM dose was administered at 1:27 PM by Staff #18; on 9/7/24, 12 AM dose was administered at 2:10 AM by Registered Nurse (RN Staff #53); and on 9/10/24, 12 AM dose was administered at 1:38 AM by Registered Nurse (RN Staff #54), 6 PM dose was administered at 7:28 PM by Staff #18.
On 9/17/24 at 12:09 PM, Staff #18 was interviewed about her process for pain management. Staff #18 reported that when a resident complained of new pain she would notify the physician and for pain that was known or old pain, she would administer pain medication and recheck the resident after an hour to see if the medication was effective. Staff #18 failed to report that she would attempt non-pharmacological interventions prior to medication administration.
Staff #18 also reported her process with narcotic medications and when she documents on the narcotic count sheet. The concern was discussed that on 3 occasions, she documented that the 12 PM dose of Resident #50's pain medication was pulled at 2 PM. Staff #18 indicated that it was an error in documentation, and stated, I was not able to write the #1 to make it a #12. She further reported that the time the nurses sign the eMAR would be more accurate anyway and that they have an hour before or an hour after the schedule to administer medications.
The concerns were discussed with the DON that Resident #50's medical record failed to reveal that non-pharmacological interventions were attempted prior to administering pain medications and of the 3 days that was reviewed for medication administration, the nurses had administered the resident's pain medication late on 4 occasions. The DON verbalized understanding and acknowledged the concern.
2). On 9/10/24 at 7:23 AM in an observation of Resident #57, the resident was in bed and appeared to be asleep. The resident's family was at the bedside and was interviewed, and said the resident had reported pain from their sacral ulcer.
On 9/17/24 at 11:11 AM, a review of Resident #57's physician orders revealed that there were no active orders for any pain medication. A review of the September 2024 Medication Administration Record (MAR) revealed a section titled pain monitoring with an entry on 9/16/24 and that indicated that the resident's pain was 0 and was documented by Certified Medicine Aide (CMA #16). A review of the resident's September 2024 Treatment Administration Record (TAR) revealed documentation that the resident's sacral ulcer dressing was changed daily.
On 9/17/24 at 12:01 PM in an interview with Licensed Practical Nurse (LPN #34), she said that Resident #57 sometimes complained of pain, usually in their foot or shoulder. When LPN #34 was asked about the medicine aide's entries for pain monitoring on the resident's MAR, LPN #34 said that a medicine aide should not document a resident's pain, and that pain assessment and monitoring should be done by a licensed nurse.
On 9/18/24 at 2:15 PM in a follow up interview with Staff #34, she was asked if she was aware there were no pain medications ordered for Resident #57. Staff #34 replied that she thought the resident had Tylenol ordered but the CMA gave the resident's medications, so she was not sure.
On 9/18/24 at 1:07 PM, an interview with the Director of Nursing (DON) was conducted to review Resident #57's documentation of pain monitoring by the CMA. The DON said no CMA should document pain monitoring; it should be done by the nurse. The September 2024 MAR pain monitoring entries were reviewed with the DON and an additional 8 days were found where Staff #16 documented pain monitoring for Resident #57.
On 9/19/24 beginning at 10:57 AM, an interview was conducted with the Medical Director to review multiple clinical concerns. When he was informed that Resident #57 had a sacral wound but had no pain medications ordered, he responded that he was unaware of it and that any resident who had a sacral ulcer would be likely to have pain and should have pain medications ordered.
Based on interview and observation, it was determined that the facility 1). failed to provide a Resident with a physician ordered pain medication. 2). failed to ensure that residents' pain was evaluated and managed. 3). failed to develop and implement non-pharmacological interventions prior to administering pain medication and failed to administer the pain medication on time. This was evident for 3 (Resident # 31, # 57 #50,) out of 4 residents reviewed for pain management during a survey.
The finding include:
1). On 9/16/24 at 11:19 AM, Resident #31, a long-term care resident, requested an interview with surveyor. During the interview, s/he expressed concerns that he/she was not receiving his/her oxycodone pain medication.
On 9/16/24 at 11:53 AM, Resident #31's physician orders were reviewed. The review revealed an order for oxycodone HCL oral tablet 20mg 4 times a day for pain management.
On 9/16/24 at 11:55 AM, Resident 31's Medication administration record review revealed that from September first through September 16th at 8:00 AM, the resident received his medication 42 times out of the 62 times the medication was scheduled to be administered.
On 9/16/24 at 12:00 PM, review of progress notes revealed that no reason was documented when the oxycodone was not administered.
The Oxycodone HCL 20mg was not administered as prescribed the following date and times
9/1/24
8:00 AM
call made to the pharmacy pending delivery
9/1/24
2:00 PM
pending delivery
9/1/24
8:00 PM
awaiting delivery
9/2/24
8:00 AM
awaiting pharmacy to delivery
9/2/24
2:00 PM
awaiting pharmacy to send medications medications
9/2/24
8:00 PM
awaiting pharmacy to delivery medications
9/3/24
2:00 PM
awaiting pharmacy delivery
9/3/24
8:00 PM
awaiting pharmacy approval
9/4/24
2:00 AM
awaiting pharmacy approval
9/4/24
2:00 PM
awaiting pharmacy to send the medication
9/8/24
2:00 AM
No documentation as to why medication was not documented as administered on the MAR.
9/15/24
8:00 AM
Not administered pharmacy called
9/15/24
2:00 PM
Not administered
9/15/24
8:00 PM
PRN medication exposed
9/16/24
2:00 AM
Awaiting delivery from pharmacy
9/16/24
8:00 AM
Pending pharmacy delivery
On 9/16/24 at 12:23 PM, Nurse LPN (Staff # 8) was interviewed. She reproted that she was familiar with Resident #31's care. During the interview, she reported that the resident's medication was not available. She reported that it was her understanding that the residents insurance would not pay for the medication and that was why the pharmacy had not delivered the medication. She reported that last time Resident # 30 was administered his pain medication was 9/15/24 at 2:00AM.
On 9/16/24 at 2:10 PM, The Director of Nursing (DON)was interviewed. She reproted she is familiar with the care of Resident #31 and problems with his medication delivery. She repsoted she thought it was an insurance issue. The DON reported that the facility was responsible for obtaining the medications for a resident once they are admitted .
09/16/24 at 3:38 PM. the DON reported that the facility would ensure that the resident received his ordered medication, She stated the nurses were aware and were able to order ahead of time to ensure the medications were availabe for administration when scheduled.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
4). On 9/18/24 at 2:09 PM an observation of Resident #57 was conducted. The resident was in bed and the bed had half rail bed rails on both sides of the bed.
On 9/18/24 at 2:15 PM, an interview was co...
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4). On 9/18/24 at 2:09 PM an observation of Resident #57 was conducted. The resident was in bed and the bed had half rail bed rails on both sides of the bed.
On 9/18/24 at 2:15 PM, an interview was conducted with Licensed Practical Nurse (LPN #34) at Resident #57's bedside. LPN #34 was asked to check if the bed rail was secure and when she checked, it she said it was too loose and said she would call the Maintenance Director to repair it.
On 9/18/24 at 2:25 PM, the Maintenance Director (Staff #) came to Resident #57's room and was interviewed. He tested the bed rail and said that it was too loose and that he would repair it. He said he did regular checks on bed rails but was unaware that this one was loose.
On 9/20/24 at 1:14 PM in an interview with the Director of Nursing (DON), she said she was unaware of that Resident #57's bed had a loose bed rail. She was asked to provide any additional evidence for this observation but none was provided by the end of the survey.
Based on observation, medical record review, and staff interview, it was determined that prior to the installation or use of bed rails, the facility failed to ensure, 1) appropriate alternatives were identified and used, 2) the resident's risk of injury or entrapment was assessed, 3) the risks and benefits of bed rails was discussed with the resident/representative, 4) informed consent for bed rails was obtained, and 5) failed to ensure that a care plan with measurable objectives and specific interventions was developed for a resident's use of a bed rail. 6) that monitoring and supervision were provided during the resident's use of the bed rails, This was evident for 4 (#78, #380, #13, #57) of 4 residents reviewed for side rails.
The findings include:
Bed rails are adjustable bars that attach to the bed and are available in a variety of types, shapes, and sizes. As enablers, bedrails facilitate movement and may promote independence. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail.
1) On 9/11/24 at 11:00 AM, an observation was made of Resident #78 lying in bed with bilateral bed rails attached to the resident's bed. On 9/18/24 at 2:39 PM, Resident #78 was again observed lying in bed, and bilateral bed rails were observed attached to the resident's bed.
On 9/18/24 at 12:04 PM, a review of Resident #78's medical record revealed an Admission/readmission Collection Tool, with an effective date, 6/30/24 at 10:41 PM, that included a Bed Side Rail Tool with the heading Nursing Evaluation and Consent Tracking, followed by 8 bed rail evaluation questions. The evaluation asked, Does the resident need bed rails for positioning and/or rising from supine to sitting/standing position as mobility enabler? and documented the response, No, indicating Resident #78 did not need bed rails as a mobility enabler for positioning and/or rising. The responses to the remaining questions were blank, with no other documentation found in the bed rail evaluation tool.
Continued review of Resident #78's medical record failed to reveal a physician's order for the resident's use of bed rails. In addition, the medical record failed to reveal documentation that, prior to the installation or use of the bed rails, appropriate alternatives were identified and used, the resident's risk of injury or entrapment was assessed, that the risks and benefits of bed rails was discussed with Resident #78 or resident representative and informed consent obtained. The medical record failed to reveal documentation of monitoring and supervision provided during the resident's use of the bed rails and failed to reveal a care plan with measurable objectives and specific interventions for use of the bed rail had been developed for Resident #78.
2) On 9/11/24 AT 10:37 AM, an observation was made of Resident #380 lying in bed and bilateral bed rails were observed attached to the resident's bed
On 9/19/24 at 3:36 PM, a review of Resident #380s medical record revealed an Admission/readmission Collection Tool with an effective date of 9/5/24 at 8:20 PM, that revealed a Bed Side Rail Tool, followed by 8 bed rail evaluation questions. The evaluation asked, Does the resident need bed rails for positioning and/or rising from supine to sitting/standing position as mobility enabler? and had the documented response, No, indicating Resident #380 did not need bed rails as a mobility enabler for positioning and/or rising. The responses to the remaining questions were blank, with no other documentation found in the bed rail evaluation tool.
Continued review of Resident #380's medical record failed to reveal a physician's order for the resident's use of bed rails. In addition, the medical record failed to reveal documentation that prior to the installation or use of the bed rails, appropriate alternatives were identified and used, the resident's risk of injury or entrapment was assessed, that the risks and benefits of bed rails was discussed with Resident #380 or resident representative and informed consent obtained. The medical record reviewed failed to reveal documentation of monitoring and supervision provided during the resident's use of the bed rails and failed to reveal a care plan with measurable objectives and specific interventions for use of the bed rail had been developed for Resident #380.
3) On 9/11/24 at 11:36 AM, an observation was made of Resident #13 lying in bed and a quarter side rail in the up position was observed attached to the right side of the resident's bed.
On 9/18/24 at 3:28 PM, a review of Resident #13's medical record revealed the resident resided in the facility for long term care since the end of July 2022 and had multiple diagnosis which included dementia. Review of the resident's quarterly assessment with an assessment reference date of 8/19/24 revealed Resident #13's Brief Interview For Mental Status (BIMS) summary score was 3, indicating the resident had severe cognitive impairment.
Further review of Resident #13's medical record revealed a Bed Side Rail Tool with an effective date of 5/1/14 at 12:04 PM with the heading Nursing Evaluation and Consent Tracking, followed by 8 bed rail evaluation questions. The bed rail evaluation tool asked, Does the resident need bed rails for positioning and/or rising from supine to sitting/standing position as mobility enabler? with the documented response, Yes, indicating the resident used the bed rails for positioning and/or as a mobility enabler, however, the evaluation tool also documented bed rails were not indicated as a mobility enabler at that time. The bed side rail tool documented bed rails were a resident/representative preference and a ½ partial bed rail was on the right side of Resident #13's bed. The Bed Side Rail tool also included the question, Risk verses benefits and consent obtained for side rails, and documented the response patient/resident, indicating the consent for the side rails was obtained from the resident, however, no documentation was found to indicate what were the risks verses benefits of side rails that were discussed with Resident #13. In the bed side rail tool, was a heading, Plans for side rail reduction which was followed by the statement, explain the plan and update the care plan, that had the printed response, Daughter, and documented the bed rail did not restrict the patient/resident movements,
Continued review of Resident #13 medical record failed to reveal a physician's order for the resident's use of bed rails, failed to reveal documentation that prior to the installation or using the bed rails, appropriate alternatives were identified and used, and failed to reveal documentation that an assessment of the resident, the bed, the mattress, and rail for entrapment risk (which would include ensuring bed dimensions are appropriate for resident size/weight), and was assessed. The medical record review failed to reveal documentation of any monitoring and supervision provided during the resident's use of the bed rails and failed to reveal a care plan with measurable objectives and specific interventions for use of the bed rail had been developed for Resident #13.
On 9/19/24 at 3:40 PM, the above concerns related to bed rails were discussed with the Director of Nurses (DON), who acknowledged the concerns and offered no further comments at that time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
2a) A brief look into Resident #24's medical record indicated that s/he was admitted in August of 2024 with diagnoses that included congestive heart failure.
Congestive heart failure (CHF) is a seriou...
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2a) A brief look into Resident #24's medical record indicated that s/he was admitted in August of 2024 with diagnoses that included congestive heart failure.
Congestive heart failure (CHF) is a serious condition that occurs when the heart can't pump enough blood to meet the body's needs. This causes fluid to build up in the body's organs, which is known as congestive. Most patients will be started on a diuretic when they are first diagnosed with heart failure to help relieve congestion
A diuretic is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics increase the excretion of water from the body, through the kidneys.
A review of Resident #24's medication orders on 9/12/24 at 9:09 AM include an order of a diuretic to be given in the morning with instructions to hold for a systolic blood pressure less than 110 and update the physician.
Blood pressure (BP) is often written as an upper and lower number. Systolic blood pressure (SBP) is the upper number. It measures the pressure in the arteries during heart muscle contraction.
On 9/12/24 at 10:06 AM, Resident #24's BP report was reviewed and revealed that, on 9/6/24, the resident's BP was 105/60, documented by Registered Nurse (RN Staff #48) at 7:40 AM.
Subsequently, at 10:14 AM, Resident #24's electronic Medication Administration Record (eMAR) was reviewed and revealed that, on 9/6/24, Staff #48 administered the diuretic that was scheduled at 8:00 AM.
On 9/17/2024 at 1:08 PM, the concern was discussed with the Director of Nursing (DON) that Staff #48 did not hold the administration of the diuretic per instructions. The DON acknowledged the concern but offered no explanation.
2b). Resident #50 was admitted in August of 2024 with diagnoses that included Chronic Pain.
A review of Resident #50's medical record on 9/13/24 at 10:12 AM, revealed a narcotic pain medication order to be administered every 6 hours as needed for pain. this order had a start date of 8/24/24 and was discontinued on 8/28/24.
Opioids - Opioids are a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant. Opioids work in the brain to produce a variety of effects, including pain relief. Opioid is the proper term, but opioid drugs may also be called opiates, painkillers, or narcotics.
A subsequent review of Resident #50's electronic Medication Administration Record (eMAR) on 9/16/24 at 2:09 PM, indicated that the narcotic pain medication was administered on 8/27/24 at 4:10 PM for a pain score of 0 by Licensed Practical Nurse (LPN Staff #55).
The findings in Resident #50's eMAR was discussed with the Director of Nursing (DON) on 9/17/24 at 1:17 PM. The DON acknowledged the concern and agreed that pain medications should not be administered when there are no reports/complaints of pain. the DON offered no explanation as to why Staff #55 administered the narcotic pain medication for a pain level of 0.
3) A medical record review completed for Resident #78 on 9/16/24 at 8:30 AM found an attending provider's order, dated 7/10/24, that stated, Lidocaine External Patch 5 % (Lidocaine) Apply to back topically one time a day for pains in back, CDI (clear, dry, and intact) skin only take off after 12 hours.
Further review contained Resident #78 medication administration record for August 2024. The review showed that the patch was placed on Resident #78's back daily from August 1 to September 16, 2024; however, it failed to show that the patch was removed daily.
Lidocaine Patch is used to manage pain. Depending on the product, the patch may be left on the skin for up to 8 or 12 hours. Applying too many patches or topical systems or leaving them on too long may cause serious side effects.
In an interview on 9/16/24 at 12:28 PM, staff #21, a certified medicine aide (CMA), reported that the attending provider's order for Resident #78's Lidocaine patch was incomplete because it did not contain the time to remove it. Therefore, there was no place in the medication administration record (MAR) to sign for the removal.
In an interview on 9/17/24 at 9:31 AM, the director of nursing (DON) confirmed that the attending provider's order for Resident #78's Lidocaine patch did not contain a removal time or schedule and, therefore, did not have a place on the MAR for the nurses who removed it to document.
Based on medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by 1) failing to follow physician ordered blood pressure parameters for administering medication, and 2) failing to ensure prescribed medications had adequate parameters in place to indicate when to administer as needed medications for pain. 3) failing to ensure that an attending provider's orders for a resident's topical anesthetic medication included a time to remove it This was evident for 3 (#78, # 25, # 50) of 5 residents reviewed for unnecessary medications, and 1 (#380) of 4 residents reviewed for pain management.
The findings include:
1) On 9/13/24 at 12:36 PM, a review of Resident #78's medical record revealed the resident was admitted to the facility at the end of June 2024 following an acute hospitalization with multiple diagnosies including left hip fracture, and hypotension (low blood pressure).
1a) Review of Resident #78's July 2024 Medication Administration Record (MAR) revealed a 7//1/24 order for Oxycontin (oxycodone) (narcotic) tablet by mouth two times a day for pain level greater than 5 for 30 days, hold for S (systolic) BP (blood pressure) (1st number of a BP) less than 110, hold for excessive sedation, which was discontinued on 7/11/24. The MAR documented that Resident #78 received the Oxycontin two times a day, every day from 7/2/24 to 7/10/24.
There was no documentation in the MAR to indicate that Resident #78's blood pressure was monitored prior to the administration of the oxycontin, and that the Oxycontin had been administered within the parameters of the physician's order. In addition, there was no documentation in the MAR to indicate Resident #78's pain level was assessed prior to the administration of the narcotic medication, and there was no documentation to indicate the effectiveness of the medication in managing the resident's pain.
1b) Review of Resident #78's September 2024 MAR) revealed an 8/13/24 order for Midodrine (treats low BP), Give 1 tablet by mouth three times a day for hypotension (low BP) hold for SBP more than 130. The Midodrine was documented as given at 9:00 AM on 11 (9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/11, 9/12, 9/13) of 11 days in September 2024, documented as given at 1:00 PM on 10 (9/3, 9/4, 9/5, 9/6, 9/7, 9/9, 9/10, 9/11, 9/12, 9/13) of 11 days in September, and the Midodrine was documented as given on 7 (9/3, 9/5, 9/7, 9/8, 9/9, 9/11, 9/12) of 10 days in September 2024 with no documentation found in the MAR to indicate the resident's BP was monitored prior to the administration Midodrine and that the Midodrine had been administered within the parameters of the physician's order.
The above concerns were discussed with the Director of Nurses (DON) on 9/18/24 at 5:11 PM, with no response offered at that time.
2) On 9/19/24 at 10:55 AM, a review of Resident #380's medical record was conducted. Review of Resident #380's September 2025 MAR revealed a two orders for medication which were prescribed to be administered as needed for pain. The resident had a 9/5/24 order for Acetaminophen (Tylenol) Oral Tablet 325 MG (milligrams) give 2 tablets by mouth every 4 hours as needed for pain, and a 9/6/24 order for Percocet Oral Tablet 10-325 MG (Oxycodone w/ Acetaminophen) give 1 tablet by mouth every 4 hours as needed for pain. There was no indication in either order as to when to give which medication, the Acetaminophen or the Percocet, first for pain.
The above concerns were discussed with the Director of Nurses on 9/19/24 at 3:40 PM. DON acknowledged the concerns at that and offered no further comments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
Based on observation, review of meal tickets and interview, it was determined the facility failed to ensure residents were served the correct portions and items as indicated on their meal tickets. Thi...
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Based on observation, review of meal tickets and interview, it was determined the facility failed to ensure residents were served the correct portions and items as indicated on their meal tickets. This was found to be evident for one out of one test tray obtained during the survey.
The findings include:
On 9/11/24 at 10:44 AM, Resident #115 reported the physician had advised him/her to get a high protein diet but there seemed to be a disconnect because the resident was not getting that diet consistently.
On 9/12/24 at 11:45 AM, observation of the tray line revealed a 1/2 cup scoop was being used for the portions, except for the beef pepper steak (Chopped up thinnly sliced beef) which was being served by the [NAME] (Staff #63) with a set of tongs. When asked about this practice, the [NAME] confirmed only using the tongs and proceeded to pick up a portion stating it was three ounces.
During this observation, surveyor picked a tray at random from trays already made up and on the food cart. A copy of the ticket was obtained. The ticket was for Resident # 35 and indicated the tray was suppose to include:
Grilled cheese sandwich 1 sandwich
Sugar snap peas 1 cup
Mashed potatoes 1/2 cup
Dinner roll
Margarine 1 each
Tossed salad with dressing
Chocolate pudding parfait 1/2 cup
Hot Tea
The observation of this test tray did not match the ticket for the following items:
Sugar snap peas: half cup
No dinner roll
no chocolate pudding parfait; instead it was a chocolate cream pie
On 9/12/24 at 1230 PM, the test tray was observed by the Food Service Director (Staff #62) who confirmed the pea serving was half a cup; that there was no dinner roll and that they made a mistake in regard to the chocolate cream pie being serviced rather than the parafait. She confirmed all the scoops being used during the tray service line were half cup.
Surveyor reviewed the concern with the FSD #62 that a resident had made a report about not receiving the correct portions. Also reviewed the concern that the cook was not using a scoop for the chopped meat , she confirmed the scoop should of been used.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected multiple residents
Based on observation, medical record review and staff interview, it was determined the facility failed to conduct a regular inspection of all bed frames, mattresses, and bed rails, as part of a regula...
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Based on observation, medical record review and staff interview, it was determined the facility failed to conduct a regular inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment and failed to ensure the equipment was inspected and maintained according to manufacturer's recommendations and requirements and timeframes. This was evident for 3 (#78, #380, #13) of 3 residents reviewed for bed side rails and had the potential to affect all residents. The findings include:
On 9/11/24 AT 10:37 AM, an observation was made of Resident #380 lying in bed and bilateral bed rails were observed attached to the resident's bed. On 9/11/24 at 11:00 AM, an observation was made of Resident #78 lying in bed and bilateral bed rails were observed attached to the resident's bed, and on 9/18/24 at 2:39 PM, Resident #78 was again observed lying in bed with bilateral bed rails observed attached to the resident's bed.
On 9/11/24 at 11:36 AM, an observation was made of Resident #13 lying in bed. At that time, a quarter side rail in the up position was observed attached to the right side of the resident's bed.
On 9/18/24 at 4:50 PM, during an interview, Staff #25, Maintenance Director, indicated he was employed as the maintenance director for approximately 1 year. When asked if the facility assured the inspection of all bed frames, mattresses, and bed rails, as part of their regular maintenance program, Staff #25 stated that since he had been at the facility, one audit of resident beds had been done to make sure there was no gap between the mattress and the rail, but that routine bed audits were not done. Staff #25 reported that the bed audit only included resident beds on the first floor of the facility, and an audit of the resident beds on the second floor had not been completed. Staff #25 indicated when there was a problem with a resident's bed, mattress or siderail, the problem would be reported to maintenance by nursing or housekeeping, and maintenance replaced the mattress as needed. Staff #25 indicated that maintenance did not add rails to resident beds unless instructed to do so. Staff #25 stated that if an existing resident bed had a bed rail that broke, the facility might have a spare rail to replace it, however, new beds purchased for the facility didn't come with rails, and a bed rail could not be added to those beds.
Following the interview, the concerns with failing to conduct regular inspection of all bed frames, mattresses, and bed rails, to prevent risk of entrapment, and ensure the equipment was inspected and maintained according to manufacturer's recommendations, requirements, and timeframes were discussed with Staff #25, who at that time, indicated understanding of the concerns.
The Director of Nurses was made aware of the concerns on 9/19/24 at 3:40 PM, and the DON acknowledged the concerns with no further comments offered at that time,
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7). On 9/11/24 at 12:31 PM, a review of Resident #10's clinical record revealed a care plan entry that stated SKIN IMPAIRMENT: t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7). On 9/11/24 at 12:31 PM, a review of Resident #10's clinical record revealed a care plan entry that stated SKIN IMPAIRMENT: the resident has a skin impairment, Date Initiated: 07/25/2024, Created on: 07/25/2024, Created by: [Licensed Practical Nurse (LPN #47)].
On 9/16/24 at 2:13 PM, an interview was conducted with the Director of Nursing (DON) who said the resident does not have any skin issues.
On 9/17/24 at 11:41 AM, an interview with unit nurse, LPN #34, was conducted and she explained that Resident #10 had an issue with the skin on their leg, but it was healed now. When asked what the process was for revising the care plan, Staff #34 said usually either the unit manager or the social worker updated resident care plans, she said that she did not really know how to do it.
On 9/17/24 at 1:01 PM, the DON was interviewed again and confirmed that Resident #10's skin issue remained on the care plan but should have been discontinued as the resident no longer had any skin issues.
8). On 9/16/24 at 10:35 AM, a review of Resident #100 revealed care plan meeting documentation, dated 11/29/23.
On 9/16/24 at 10:44 AM, the Director of Social Work (SW #19) was interviewed and asked when Resident #100's last care plan meeting was held. SW #19 said the last care plan meeting was held on 11/29/23 and confirmed that the resident should have had care plan meetings February 2024, May 2024, and August 2024 but did not.
6). On 9/10/24 at 7:34 AM, Resident #84, a long-term resident of the facility, was interviewed. During the interview s/he reported that s/he could not recall the last care plan meeting that she attended.
On 9/11/24 at 11:36 AM, review of a progress note revealed a care plan meeting on 1/29/24. Further review failed to reveal any additional care plan meetings in 2024.
On 09/12/24 at 3:09 PM, a review of assessment documents titled Multidisciplinary care conference, revealed the resident had care plan meetings on 6/2/23, 10/14/22 and 1/29/24.
On 09/12/24 at 1:52 PM, during an interview with the Director of Social Services (Staff #19), she reported that care plan meetings should be quarterly.
On 09/12/24 03:45 PM, during an interview the Director of Nursing, it was confirmed that Resident #84 had only one care plan in 2024.
On 09/19/24, the Director of Nursing provided the care planning policy with an effective date of 11/01/2019. Review of the care plan revealed the quarterly care plan meeting should occur after the quarterly assessment.
On 09/20/24 at 10:50 AM, review of concerns with the Administrator and the Director of Nursing provided no additional information to the survey team.
4) On 9/11/24 at 10:57 AM, when asked if the resident attended care plan meetings and participated in his/her care planning, Resident #78 stated that s/he could not recall attending care plan meetings.
On 9/13/24 at 12:36 PM, a review of Resident #78's medical record revealed the resident was admitted to the facility at the end of June 2024. Review of Resident #78's MDS assessments revealed assessments which included a 5-day admission assessment with an assessment reference date (ARD) of 7/4/24 and quarterly assessment with an ARD of 8/28/24.
Continued review of the medical record failed to reveal documentation to indicate that a care plan meeting had been conducted following Resident #78's admission assessment with an ARD of 7/4/24, or that an interdisciplinary care plan meeting had been conducted following Resident #78's quarterly assessment with an ARD of 8/28/24.
On 9/16/24, at approximately 2:30 PM, Staff #20, Licensed Practical Nurse (LPN), Regional Director Of Clinical Reimbursement, was made aware of the concern that there was no evidence a care conference had been conducted with Resident #78 since his/her admission assessment. ARD 7/4/24 or since the resident's quarterly assessment 8/28/24. Staff #20 confirmed the findings, and no further comments were offered at that time.
Continued review of Resident #78's medical record on 9/18/24 at 12:04 PM, revealed that, on 6/30/24 at 10:41 PM, in an admission/readmission nursing note, the nurse documented that Resident #78 was admitted to the facility following a hospitalization with a chief complaint of a fall which resulted in a hip fracture.
Continued review of Resident #78's medical record revealed on 7/10/24 at 2:00 PM, in a SBAR (Situation, Background, Assessment, Recommendation) (a standard way to communicate medical information) Summary for Providers note, the nurse documented Resident #78 had a fall, and the resident was found kneeling at the bedside.
Review of Resident #78's care plans revealed a care plan, the resident is at risk for falls r/t (related to) unsteady gate, created on 6/30/24, with the goal, the resident will not have an injury related to a fall through the review period. The care plan had 2 interventions, place common items within reach of the resident and remind the resident to use their call light to ask for assistance with ADLs (activities of daily living), created on 6/30/24, and included 2 interventions, place bed in lowest position while resident is in bed, and therapy referral, created 7/11/24, which was after the resident's fall on 7/10/24.
In a SBAR Summary for Providers note, on 7/17/24 at 9:10 PM, the nurse documented that Resident #78 had a fall, and indicated the physician was notified and a urinalysis, and urine culture and sensitivity were ordered. There was no summary of the observation, and no other documentation in SBAR to indicate the circumstances around the resident's fall.
Continue review of Resident #78's medical record failed to reveal documentation to indicate that, following the resident's fall on 7/17/24, Resident #78's fall care plan was reviewed for effective interventions and failed to reveal evidence that following the resident's quarterly assessment with an ARD of 8/28/24, Resident #78's care plans were reviewed by the interdisciplinary team and revised based on the changing goals, preferences and needs of the resident and in response to current interventions.
On 9/18/24 at 5:11 PM, the Director of Nurses (DON) was made aware of the above concerns on 9/18/24 at 5:11 PM, and the DON offered no further comments at that time.
5). On 9/12/24 at 10:20 AM, a review of the EMR (Electronic Medical Record) revealed Resident #55 resided in the facility for long term care since 2020 and was readmitted to the facility following a brief hospitalization in the beginning of August 2024.
Review of Resident #55's completed MDS assessments revealed a 9/10/23 quarterly assessment, a 12/11/23 quarterly assessment, a 3/10/24 annual assessment, a 6/10/24 quarterly assessment, and an 8/13/24 5-day assessment. Review of Resident #55's most recent 5-day assessment with an assessment reference date (ARD) of 8/13/24 documented Resident #55's BIMS (brief interview for mental status) summary score was 15, indicating the resident was cognitively intact.
Further review of Resident #55's medical record revealed, on 10/3/23 at 11:30 AM, in a Multidisciplinary Care Conference note, Social Services indicated Resident #55 had an interdisciplinary team (IDT) care plan meeting on that date. No further documentation was found in Resident #55's medical record to indicate that IDT care plan meetings had been conducted with Resident #55 following his/her completed MDS assessments with an ARD 12/11/23, 3/10/24, 6/10/24 and 8/13/24.
On 9/16/24 at 12:25 PM, the above concerns were discussed with Staff #19, Director of Social Services. At that time, Staff #19 indicated that there had been a turnover of social services staff which affected the long-term care conferences, and that it was most likely no care conferences were done during that time. Staff #19 then confirmed that a care plan meeting had not been conducted with Resident #55 following since October 2023 and following each assessment.
Based on medical record review and interview, it was determined that the facility failed to
have an effective system in place to ensure interdisciplinary care plan meetings were
occurring after assessments; and failed to ensure care plans were being reviewed and
revised as needed. This was found to be evident for 8 (Resident #30; #23; #95; #78, #55. #84, #10, #100 ) out of 17 residents reviewed during the survey
The findings include:
1) Review of Resident #30s medical record revealed the resident had resided at the
facility for several years and whose diagnoses included, but were not limited to, high blood
pressure, kidney disease, major depressive disorder and dementia. Review of the
Minimum Data Set assessment, with a reference date of 6/5/24, revealed the resident
has a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive
impairment.
On 9/13/24 at 11:09 AM, the unit nurse manager #12 reported care plan meetings are
scheduled and family and residents are invited, and that therapy, dietary, social work
and nursing also attend. When asked how the physicians or nurse practitioners are
involved in the care plans, the unit manager reported if the family has concerns they
would ask the physician to call the family and then referred the surveyor to the
Multidisciplinary Care Conference note. The unit nurse manager confirmed that
whenever there is a care conference this note will be used.
Further review of the Multidisciplinary Care Conference note template revealed
an area for summaries from nursing, dietary, recreation, social work, pharmacy,
restorative/PT/OT, and the physician. There is also a section at the end for
Resident/Family expectation/Concerns and Care Level Review.
Further review of the medical record revealed a Multidisciplinary Care Conference note
for a meeting held on 10/31/23. Review of this note revealed the participants included a
registered nurse, social worker, resident and the health care agent. Although in the
attendance section Registered Nurse is checked, no documentation was found in the note
to identify the name of the nurse that attended. The areas of the note for
input/summaries from nursing, dietary, recreation (Activities), pharmacy, restorative and
physician were all noted to be blank.
On 9/16/24, review of Resident #30's medical record failed to reveal documentation to
indicate a care plan meeting has occurred since the 10/31/23 meeting. This information
was reviewed with the SSD #19 during an interview on 9/16/24 at 10:01 AM. The SSD
reported she attempted a care plan meeting but there should be a note that the Health
Care Agent (HCA) declined. Further review of the medical record revealed a Discharge
Planning Progress note, signed by SSD #19 on 6/19/24, which indicated that the HCA
declined a transfer and included the following: SW notified resident that a care plan
meeting would be initiated to support a possible transfer and provide more information
from the IDT team. Further review of the medical record failed to reveal documentation
to indicate that a care plan meeting was scheduled as indicated in the 6/19/24 note.
2) Review of Resident #23's medical record revealed the resident was originally
admitted to the facility in June 2024. Review of the 6/11/24 Minimum Data Set (MDS)
assessment revealed the resident had functional limitations in range of motion on both
sides for upper extremities (arms) and impairment on one side for lower extremities
(legs). The resident was dependent on staff for activities of daily living. The resident
was receiving occupational, speech and physical therapy in June.
During an interview with the resident 39's Health Care Power of Attorney (HCPOA) on
9/11/24 at 1:22 PM revealed concerns regarding not being informed about the resident's
care.
On 9/17/24 at 1:58 PM, review of the medical record failed to reveal a Multidisciplinary
Care Conference note that would indicate a care plan meeting had occurred during the
resident's admission.
On 9/18/24, after requesting documentation from the Director of Nursing of any care plan that may have occurred for the resident, staff provided a note completed by the unit
nurse manager titled Care plan meeting dated 9/3/24 that stated: Care plan meeting
held with resident 23's [family members]. Resident medications reviewed with no concerns
voiced. Plan of care continues. No documentation was found to indicate who attended the 9/3/24 meeting other than the family and the unit nurse manager who wrote the note. No documentation was found to indicate other members of the interdisciplinary team attended the meeting, or
provided input.
On 9/18/24 at 11:00 AM, the Rehab Director presented the surveyor with the resident's physical therapy Discharge summary, dated [DATE]. The Rehab Director reported the resident
had made great progress in therapy and at the time of discharge the resident's gait
distance (walking) was 125 feet with hand held assist and could transfer from chair to
bed and bed to chair with contact guard. (A transfer with contact guard assist means the care giver places one or two hands onthe resident to help with balance but no other assistance is provided).
When asked if the ability to walk and transfer with contact guard was reflected in the
resident's care plan, the Rehab Director replied that it might be. When asked if the resident
should continue to walk, the Rehab Director reported that, because of cognitive deficits
this would not be realistic to maintain but that theortically could have been walking to the
dining room. Surveyor clarified that the resident could be doing some walking, to which
the Rehab Director responded: yes, [s/he] could with support obviously. The Rehab
Director indicated that therapy personnel would be part of a care plan meeting for a
short term (skilled) admission.
No documentation was found to indicate a respresentative from the therapy department
attended or provided input for the 9/3/24 care plan meeting.
Review of care plan addressing the residents risk for falls revealed a revision date of
9/13/24. The interventions included, but were not limited to, : Resident is a hoyer lift transfer
with 2 GNAs. This intervention was created and initiated on 8/14/24. No
documentation was found to indicate that, when the revision was completed on 9/13/24
that the person completing the revision was aware that the resident was no longer using
a hoyer lift.
A hoyer lift is a mechanical lift used for residents who are completely dependent on staff
for transfers. A hoyer lift pad is placed under the resident and then attached to the lift.
Two staff members will then use the mechanical lift to raise the resident from the bed
and transfer to a chair or vice versa.
During the 9/18/24 11:00 AM interview, surveyor reviewed with the Rehab Director that
the current care plan indicated the resident required a hoyer lift with 2 GNA assist, in
place since 8/14/24. The Rehab Director responded that it could have been so at that time.
On 9/18/24 at 11:52 AM, the unit nurse manager #12 reported the resident does stand
with one person assist and in regard to walking, she reported: if we see [him/her] get up
we walk around with [him/her]. The unit nurse manager indicated they did conduct staff
training but confirmed it was not documented. Surveyor reviewed the concern that the
care plan still stated the resident requireda hoyer lift for transfers, the unit manager
indicated she would update this information.
3) On 9/12/24, review of Resident #95's medical record revealed the resident had
resided at the facility for a over one year and whose diagnoses included, but were not limited
to, dementia and lung disease.
Review of the 1/24/24 MDS assessment revealed the resident's family was interviewed
in regard to Activity Preferences. This assessment revealed it was very important to
listen to music the resident liked; and to participate in religious activities.
Review of the care plans revealed a plan for 1:1 Activities: [Resident #95 name]
prefers or requires 1:1 activities due to being unable or unwilling to participate in other
activities. The goal is [Resident] will be satisfied with their 1:1 activities provided thru
the review period. The interventions included: provide 1:1 activities in the room or
location that is the residents preference as needed and review activities preferences
with the resident or resident representative if the resident is unable as needed. These
interventions were established in August 2023 and have not been updated or
personalized since then; although the goal included a notation by the unit nurse
manager that it was revised on 7/29/24. The care plan failed to reflect the January
assessment that listening to music and attending religious activites were very important
to the resident.
Further review of the medical record failed to reveal documentation to indicate a care
plan meeting had occurred since December 2023.
On 9/12/24 at 10:54 AM the resident's responsible party reported being at the facility
frequently. She also confirmed that there have been no recent care plan meetings.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, it was determined that the facility failed to post nursing staffing. This was evident during the staffing investigation portion of the recertificatio...
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Based on observation, interview and record review, it was determined that the facility failed to post nursing staffing. This was evident during the staffing investigation portion of the recertification survey and had the potential to affect all residents, residents' representatives and visitors. The findings include:
On 9/10/24 at 7:00 AM, the survey team entered the facility. A brief observation revealed a staffing list on the reception desk which contained a list of nursing staff by unit and by shift.
On 9/12/24 at 8:52 AM, an interview with the Staffing Coordinator (Staff #3) was conducted to review the staff posting at the reception desk. Staff #3 provided multiple copies of the daily staffing lists that were posted at the reception desk and explained that they listed nurse staffing for each unit and each shift. She further explained that staff were expected to initial or sign next to their name when they arrived at the facility to work. There were also handwritten names which she explained were orientee staff names written next to the staff who were training them that shift. Staff #3 confirmed that the forms did not contain the resident census nor a total actual hours worked for nursing. She confirmed that the facility did not post a document that had all actual nursing hours worked and resident census.
On 9/12/24 at 9:24 AM, an interview with the Nursing Home Administrator (NHA) was conducted to review the nursing staff posting documents and he confirmed that they did not contain the facility census or the actual nursing hours worked. The NHA said he would ask the staffing coordinator for more information about it. No further information was provided by the end of the survey.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on pertinent document review and interview, it was determined that the facility failed to address identified issues with t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on pertinent document review and interview, it was determined that the facility failed to address identified issues with the facility MOLST forms to ensure that residents wishes regarding CPR treatments were correctly documented in the residents' medical record. This has the potential to affect all residents in the facility.
The findings are:
A Maryland MOLST, (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. The orders on a MOLST are commonly referred to as code status.
The facility's annual survey conducted on [DATE] through [DATE] identified non-compliance for the failure to have a system in place to properly void MOLST forms and ensure there was only one active MOLST in a Residents electronic health record.
On [DATE] at 10:57 AM, the Facility's Medical Director was interviewed. During the interview, he reported that he was aware of concerns in [DATE] regarding the facility's failure to have a process in place to correctly void residents MOLST orders.
On [DATE] at 11:12?AM, the Medical Director provided documentation (emails) of correspondence with Assistant Attorney General, Counsel for Health Decisions Policy, regarding the proper voiding of MOLST forms. Further review of the emails revealed that the Facility Administrator and Director of Nursing were cced on the correspondence. Continued review revealed the following response from the Assistant Attorney General was sent on [DATE] and included the following. There are various ways to manage voided MOLST forms, but each provider must establish a system that works in their facility. The appropriate staff must be trained in the established system. The system described would not be deficient in and of itself, but if their own staff could not explain the system, a deficiency may result.
[DATE] 01:47 PM, The Facility Administrator (NHA) and the Director of Nursing (DON) were interviewed. They reported that the Administrator and the DON oversee the facilities quality assurance and performance improvement program (QUAPI). The DON and the NHA reported that they were not aware of the MOLST concerns identified by the Medical Director in April and these concerns had not been discussed in QUAPI.
0n [DATE] review of the QUAPI documents provided by the facility revealed that the following concerns were identified by the facility: Pressure ulcer reduction, In house staff communication, re-hospitalization. Continued review failed to reveal that MOLST forms were identified as an issue.
On [DATE], the Facility Administrator (NHA) provided the quality assurance committee meeting with attendance sheets for [DATE] through [DATE], Review of the attendance sheets failed to reveal that the Medical Director attended the meetings in [DATE], [DATE], and [DATE] and failed to attend a meeting after he identified the concerns with the MOLST.
On [DATE] at 3:44 PM, during an interview with the NHA, he confirmed that the Medical Director (Staff # 26) was absent from 3 consecutive monthly QUAPI meetings (equivalent to 1 quarterly meeting) [DATE] through [DATE], and there was no substitute medical director in attendance.
[DATE] 10:50 AM, the above concerns were addressed with Administrator. He reported that the facility was in the process of developing an effective system that accurately recorded the residents' resuscitative wishes on the MOSLT form and would educate the facility staff on this system.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, it was determined that the facility failed to establish a quality assurance committee th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, it was determined that the facility failed to establish a quality assurance committee that included a medical director at every quarterly meeting.
The findings include:
On 9/19/24, the Facility Administrator (NHA) provided the quality assurance committee meeting with attendance sheets [DATE] through August 2024. Review of the attendance sheets failed to reveal that the medical director attended the meetings in May 2024, June 2024, and July 2024.
On 9/19/24 at 3:44 PM during an interview, the NHA confirmed that the Medical Director (Staff # 26) was absent for three monthly consecutive meetings, which is equivalent to one quarterly meeting in the time period of September 2023, through August 2024. In addition, the NHA reported that there was not a substitute medical director that attended the quality assurance committee meetings in May 2024, June 2024 and July 2024.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0941
(Tag F0941)
Could have caused harm · This affected most or all residents
Based on record review and interview, it was determined that the facility failed to ensure that staff had training in interpersonal communication. This was evident for 9 staff (NHA, DON, ADON, SW #11,...
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Based on record review and interview, it was determined that the facility failed to ensure that staff had training in interpersonal communication. This was evident for 9 staff (NHA, DON, ADON, SW #11, SW #19, Staff #27, Staff #12, Staff #14, LPN #28, and Staff #29) of 10 staff training records reviewed during the extended survey portion of the recertification survey and had the potential to affect all residents.
The findings include:
On 9/19/24 at 10:29 AM, extended survey task triggered due to an Immediate Jeopardy situation related to duplicate but conflicting Medical Orders for Life Sustaining Treatment (MOLST) and resuscitation code status documents in resident records, which was determined on 9/13/24.
In the morning of 9/19/24, The Director of Human Resources was asked to provide the training records for the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), both Social Workers (SW#11 & SW #19), the Director of Rehabilitation (Staff #27), the Unit Managers (Staff #12, Staff #14), and 2 Licensed Practical Nurse (LPN) nursing supervisors (LPN #28, LPN#29), for a total of 10 staff.
On 9/19/24 at 3:09 PM, a review of the training records revealed that 9 staff (NHA, DON, ADON, SW #11, SW #19, Staff #27, Staff #12, Staff #14, LPN #28, and Staff #29) lacked any evidence of communication training.
On 9/20/24 at 2:07 PM, an interview with the NHA was conducted to review the finding of the lack of communication training for 9 of 10 staff reviewed. He acknowledged the finding.
Jun 2024
24 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0583
(Tag F0583)
A resident was harmed · This affected 1 resident
Based on medical record review and staff interview, facility staff failed to provide privacy to a vulnerable resident (resident #26). This was evident for 1 of 8 residents reviewed during a complaint ...
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Based on medical record review and staff interview, facility staff failed to provide privacy to a vulnerable resident (resident #26). This was evident for 1 of 8 residents reviewed during a complaint survey and resulted in psychosocial harm to resident #26.
The findings include:
On 6/12/24 at 7:50 am, the surveyor received a facility reported incident (FRI) (MD00189048) that is associated with complaint MD00189537 which alleged a male facility housekeeper entered a facility shower room while a resident was bathing on 2/12/23. The resident was being assisted by another facility staff member at the time of the incident. The FRI reported resident #26's family contacted the Administrator on 2/15/23 complaining that a male facility housekeeper #15 violated the resident's privacy when he/she entered a facility shower room without permission from the resident while the resident was bathing.
Review of the facility investigation on 6/12/24 at 9:30am revealed a written statement by resident #26 on 2/15/23 stated that his/her privacy was violated in two incidents on 2/12/23. The first incident was in a facility shower room. The second incident was in the resident's room.
Review of GNA #16's interview statement written on 2/15/23 revealed he/she was assisting resident #26 to bathe in a facility shower room at approximately 10:00 am on 2/12/23. Male facility housekeeper #15 entered the facility shower room without knocking on the door. GNA #16 told male facility housekeeper #15 to stop entering the shower room because he/she was assisting resident #26 to bathe. Male facility housekeeper #15 ignored GNA #16 and continued to enter the shower room. Male facility housekeeper #15 walked through the shower room to the attached bathroom. GNA #16 stated that resident #26 was upset that male facility housekeeper #15 entered the shower room without permission. GNA #16 and resident #26 immediately reported the shower room incident to RN weekend Supervisor #17.
GNA #16's interview statement written on 2/15/23 also revealed a second privacy incident occurred on 2/12/23 at approximately 10:30am. Male facility housekeeper #15 knocked on resident #26's room door and entered the resident's room without the resident's permission. Resident #26 was being assisted by GNA#16 with personal care when male facility housekeeper #15 knocked and entered the resident's room. When resident #26 saw male facility housekeeper #15, he/she started to cry and became fearful that male facility housekeeper #15 entered his/her personal space without permission twice on 2/12/23. GNA #16 and resident #26 reported the second privacy incident to RN weekend Supervisor #17 immediately after the second incident.
Review of RN weekend Supervisor #17's witness statement on 6/12/24 at 9:30 am revealed the statement was written on 6/15/23. The statement confirmed that GNA #16 and resident #26 reported both privacy incidents between resident #26 and male facility housekeeper #15 on 2/12/23. RN weekend Supervisor #17 admitted in his/her statement that he/she did not make a facility self-report that day because he/she felt that the incidents did not require an immediate self-report.
Further review of the facility investigation on 9/12/24 at 9:30am revealed that the Administrator filed the facility self-report of the two privacy incidents between resident #26 and male facility housekeeper on 2/15/23 at 12:00 pm. The facility also provided resident #26 with a psychiatric assessment on 2/15/23 at 10:00 am. The psychiatric assessment record revealed that resident #26 felt violated by male facility housekeeper #15 when he/she violated the resident's privacy twice on 2/12/23. Resident #26 also stated that he/she felt the privacy incidents on 2/12/23 triggered his/her anxiety.
Interview with resident #26 on 6/12/24 at 9:00 am revealed the resident was still traumatized by the events on 2/12/23. Resident #26 stated during the interview, I still have nightmares about that man that walked in on me in the shower and in my room. The resident also stated that facility supervisors failed to contact the Administrator when the resident reported the events on 2/12/23. The resident's family informed the Administrator of the events on 2/12/23 during a telephone call.
Surveyor interview with Health Services Corporation District Manager #19 on 6/12/24 at 12:30 pm revealed that male facility housekeeper #15 was suspended from work duties on 2/15/23 and terminated from the facility on 2/20/23. Health Services Corporation District Manager #19 also was unable to confirm that male facility housekeeper #15 had any abuse training before or after the privacy incidents on 2/12/23.
Surveyor interview with former administrator #24 on 6/13/24 at 10:35 am revealed that RN weekend Supervisor # 17 failed to inform administration of the privacy incidents on 2/12/23. Former administrator #24 also confirmed that he/she became aware of the privacy incidents on 2/12/23 by resident #26's family who called to complain about the privacy incidents on 2/15/23.
On 6/13/24 at 12:30pm, the surveyor reviewed concerns with the Director of Nursing (DON) regarding staff supervisors' failure to report the privacy incidents on 2/12/23 to administration. The DON stated that he/she understood.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on record review and staff interview it was determined that the facility failed to ensure that residents were free from abuse. This was evident for 2 (#3 and #29) of 27 residents reviewed for ab...
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Based on record review and staff interview it was determined that the facility failed to ensure that residents were free from abuse. This was evident for 2 (#3 and #29) of 27 residents reviewed for abuse. These identified concerns rose to the level of harm for both identified residents.
The findings include:
Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition.
The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility 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.
1. Review of the facility reported incident regarding an alleged abuse on 6/11/24 at 7:39 AM revealed Resident #3 made an allegation on 4/5/24 at approximately 2:00 AM that a GNA, staff #7, was assisting Resident #3 with perineal care. Resident #3 was attempting to assist and adjust the brief and pull it up, however, the GNA, staff #7 asked [Resident] to leave the brief alone and let her, the GNA, fix it. However, Resident #3, wanted to assist, as is in their care plan.
According to Resident #3 ' s care plan, reviewed on 6/11/24 at 8:23 AM, staff was to allow the resident to make decisions about care and treatment and provide a sense of control and encourage as much participation as possible during care activities. Resident #3 was also noted with a diagnosis including hemiplegia/hemiparesis and lack of coordination. In addition, a BIMS score was most recently completed on 3/24/24 with a score of 15.
According to a statement from LPN #6, the nurse on duty that night, available in the investigation packet, he stated that Resident #3 reported to him that GNA staff #7 refused to allow him/her to assist in care and then the GNA hit his/her left hand. The resident admitted to hitting the GNA staff back in the hand and chest and the GNA then grabbed Resident #3 ' s left hand and twisted it causing pain.
LPN #6 was notified of the incident after the GNA left Resident #3 ' s room and reported an ' interaction ' between her and the resident, all according to the facility investigation report. Staff LPN #6 then proceeded to check on Resident #3 who corroborated the incident. LPN #6 notified GNA, staff #7 not to interact with Resident #3 anymore, however, he did not report the incident to the supervisor on duty and the GNA continued to work the remainder of their shift interacting with other residents.
A statement from the supervisor that was on duty the night of the allegation, documented as acquired on 4/12/24, revealed that he had no idea about the incident until he came back the next night and was notified that GNA staff #7 was not at work because she was suspended.
Facility policy and procedure on abuse, reviewed on 6/12/24 from 10/17/2023, revealed that according to #3 all employees are responsible for immediately reporting to the Administrator or in their absence the DON, or their immediate supervisor, any and all suspected or witnessed incidents or patient abuse, neglect .and/or mistreatment .against a patient and #4 Failure by an employee to report any suspected or witnessed incident of mistreatment . against a patient will result in corrective action.
According to the facility report that was reviewed on 6/11/24, GNA #7 continued to work her entire 11 PM-7 AM shift from 4/4/24 into 4/5/24.
Further, according to the investigative report, Resident #3 notified the charge nurse on 4/5/24 at 9:00 AM about the incident that occurred on the night shift of 4/4/24 into 4/5/24. This prompted notification to the facility DON and a physical assessment of Resident #3 that determined s/he would need further treatment including an x-ray and Tylenol that was ordered 3 times a day for 5 days.
Surveyor interviewed Resident #3 on 6/12/24 at 7:20 AM. Resident #3 at first was hesitant to talk about the incident but then was reassured after this surveyor stated the reason for being here was to ensure that the facility had investigated the incident appropriately and to see if s/he feels safe. Resident #3 stated during this interview that at the time of the incident s/he didn ' t feel safe, the employees ' attitude was ' wrong, she twisted [residents] thumb, and it was swollen and hurt. '
A continued review of the facility investigation revealed that according to the list of statements in the packet, the facility interviewed staff present starting on the day shift of 4/5/24, but not all the staff that worked on the 11 PM-7AM shift from 4/4/24 into 4/5/24.
Additionally, the facility failed to acquire interviews of potential witnesses from the night of the incident. The statements in the investigation packet also failed to document who was completing the interviews of the staff that worked and the dates of the interviews completed were noted and documented as occurring 7 days after the incident. Surveyor interviewed the DON on 6/11/24 at 10:10 AM regarding the facility investigation and she stated that the dates on the interviews were just when the previous Administrator had typed up the interviews, and that he was the one that had completed them. However, there was no name, signature, or time on the interviews as to who had completed them besides the signatures of the respondents.
A review on 6/12/24 of the employee file for GNA staff #7 revealed that she was hired in 2019, however, her new hire GNA skills checklist that was included in the investigation packet was never completed. This was reviewed with the DON on 6/12/24. There was no evidence of follow up education or training information provided to the survey team.
2. A medical record review for Resident #29 on 6/11/24 at 11:34 AM revealed Review of the physician ' s history and physical notes revealed that the resident was alert and oriented to person and place. A situation background, assessment, and recommendation (SBAR - a form for staff to use when notifying the doctor regarding a resident ' s condition) was completed on 12/5/22 to notify the physician the resident had a fall that day and indicated there were no injuries noted. Staff documented that the physician gave the order to continue to monitor. A radiology report dated 12/5/22 revealed the resident had an x-ray of the pelvis due to a fall and pain. The admission MDS with ARD of 12/6/22 revealed the resident had moderate cognitive (ability to think and process information) impairment and staff were able to understand what the resident said and the resident understood what staff said. On 12/7/22 the resident was seen by a geriatric psychiatric service and reported to the clinician that someone had pushed him/her down in the hallway on their buttocks.
On 6/11/24 at 10:38 AM a review of the facility ' s investigation file for the facility reported incident #MD00186435 revealed a self-report form that documented on 12/5/22 at 2:25 PM the resident reported that Housekeeper #20 had pushed him/her which resulted in a fall. The facility failed to obtain a statement from the resident and to whom the resident reported the incident.
On 6/13/24 at 8:00 AM a review of the facility ' s Housekeeping and Laundry Service Agreement that went into effect on 7/20/18, revealed that the Scope of Work was that the contracted company would provide housekeeping and laundry management, supervision, labor, and materials as the determine necessary. There was no mention that the contracted staff were to provide redirection and/or direct care for the residents.
An interview conducted by the previous Administrator #24 on 12/7/22 with Housekeeper #20 revealed the information was confined to 3 questions: 1) where was the resident standing when you approached them, 2) How did the resident fall, and 3) Did you ask the resident not to enter the housekeeping closet? The information collected was that Resident #29 was standing outside the housekeeping closet on the 2nd floor Maplewood nursing unit. The resident was trying to enter the closet and Housekeeper #20 placed his hands on the resident ' s arm to redirect them from entering the housekeeping closet and the resident fell. The nurse did come to assist the resident off the floor. The housekeeper reported he told the resident they were not allowed to come into the housekeeping closet and again stated that he put his hands on the resident ' s arm to redirect them out.
A review of the staff statements and interviews revealed that three staff had been potential witnesses of the incident Unit Clerk (UC) #26, Registered Nurse (RN) #22, and RN #21, however, none of them witnessed the interaction between the Housekeeper #20 and Resident #29. When they heard a noise, they looked over and saw the resident on the floor. Some stated the resident was lying and some stated sitting on the floor, however, the facility failed to reconcile these differences in their investigation. The surveyor could not reconcile the differences because staff were not available for an interview and/or were unable to recall the details.
RN #22 wrote in his statement that he when he saw Resident #29 lying on the floor, he went to them to assess and assist them off the floor. He did not write that the resident said anything to him at the time but stated that he asked Housekeeper #20 if he had pushed the resident to which the housekeeper replied he had pushed the resident because they were attempting to come into the housekeeping closet. The surveyor was unable to interview RN #20 because the facility had no contact information available, therefore it was uncertain if he was the staff member that Resident #29 had reported they were pushed by the housekeeper as stated on the self-report form.
A review of the Disciplinary Action Form dated 12/9/23 for Housekeeper #20 revealed that facility staff determined that the housekeeper had placed his hands on the resident to redirect them from the housekeeping closet and as a result the resident fell, however, the housekeeper failed to assist or seek assistance for the resident once they fell and instead went back to his duties. Further review of the documents revealed that due to Housekeeper #20 physically and intentionally touching the resident which resulted in a fall as well as the lack of insight and judgment when Housekeeper #20 stated that he did not get help or choose to notify a nurse but rather focused on his duties he was terminated. This document was signed by the housekeeper ' s supervisor, a witness, and the previous Administrator #24. The surveyor attempted to interview the housekeeper but was unable to reach him because the phone number on his application was no longer his phone number.
An interview with Unit Clerk (UC) #26 on 6/14/24 at 9:12 AM, via a telephone call, revealed she recalled sitting at the nurses ' station on the day of the incident (12/5/22) which faced the housekeeping closet where the incident had occurred. She recalled RN #22 was sitting next to her but did not recall where RN #21 was located. She reported that she did not recall any other details of the incident. She reported she had written a statement that day regarding the incident, however, this was not provided to the surveyor.
RN #21 was interviewed on 6/11/24 at 11:34 AM, he reported that he had not witnessed the interaction between Housekeeper #20 and Resident #29. He heard a noise and turned around to see the resident sitting in the middle of the hallway outside the housekeeping closet. He did not recall seeing the housekeeper.
An interview conducted over the phone with the previous Administrator #24 on 6/13/24 at 10:12 AM revealed that he did not think it was appropriate for housekeeping staff to touch the resident to redirect them. He confirmed that Housekeeper #20 was terminated for the reasons as stated on the disciplinary form. When asked if the actions of the employee were willful without intention to harm the resident was considered abuse and if it was abusive for the housekeeper to go about his duties without assisting the resident after they fell, he stated that he could see where it could be perceived that it was abuse. According to the definition of abuse it is the willful act of an employee that causes harm or pain. The willful act of the housekeeper placing his hands on the resident resulted in a fall with pain that meets the definition of abuse.
The concerns were reviewed with the current Administrator and Director of Nursing on 6/13/24 at 12:34 PM.
This deficient practice resulted in harm to Resident #29 since the resident suffered pain as a result of the fall.
Cross Reference F609 and 610
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to ensure Resident #35's responsible p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, it was determined the facility staff failed to ensure Resident #35's responsible party (RP) was provided the opportunity to consent to the COVID-19 vaccine for Resident #35. This was evident for 1 of 81 residents selected for reviewed during the complaint survey.
The findings include:
Investigation of complaint MD00179248 on 6/13/24, at 11 AM revealed the facility staff failed to have a representative present when a resident signed documents.
A Brief Interview for Mental Status (BIMS) score is a cognitive screening tool that evaluates memory and orientation in older adults. It's often used in nursing homes and other long-term care facilities to identify and treat changes in mental abilities. A BIMS score of 0 indicates severely impaired cognition.
Review of Resident #35's medical record revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include blindness and a BIMS of 0.
Further review of Resident #35's medical record revealed the Resident refused the administration of the COVID-19 vaccine, the resident's name was printed by staff, had no witness documented on the consent form and failed to have a representative present.
Interview with the Director of Nursing on 6/14/24 at 11 AM confirmed the facility staff failed to allow the Resident to have a representative present when signing documents.
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 F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observations and interview with staff it was determined that the facility failed to assess a resident for capability to self-administer medications. This was identified during a resident inte...
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Based on observations and interview with staff it was determined that the facility failed to assess a resident for capability to self-administer medications. This was identified during a resident interview where medications were randomly observed on the nightstand. (#43)
The findings include:
During interview with Resident #43 on 6/18/24 at 7:45 AM this surveyor noted multiple bottles of vitamin supplements piled up on the resident's nightstand.
Surveyor interviewed the facility DON on 6/18/24 at 8:20 AM after leaving the residents room and asked what the process was to determine if a resident can self-administer medication. She stated that no residents here in the facility self-administer medications. I further asked what about supplements. She stated again that the facility is the one that provides the supplements to the residents.
Concurrently during the interview, this surveyor had pulled up the electronic medical record for Resident #43. According to the physician orders, there were no orders in place or assessments completed that stated s/he could self-administer medications.
The observation of the multiple pill bottles in the resident's room was reviewed with the DON at this 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
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to answer Resident #10's call bell in a timely manner.
Review of Resident #10's medical record on 6...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to answer Resident #10's call bell in a timely manner.
Review of Resident #10's medical record on 6/14/24 revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation.
Further review of Resident #10's medical record revealed the facility assessed the Resident on 8/29/23 admission MDS (Minimum Data Set) in Section G 0110 B Functional Status: Transfers as Total dependence with 2+ person assist.
During an interview of Resident #10's Responsible Party (RP) on 6/17/24 at 2:36 PM with the Resident on the phone, the RP stated on 9/14/23 therapy staff had placed the Resident in a wheelchair for the RP to take the Resident outside. The RP stated when the Resident stated he/she had to go to the bathroom, he/she brought the Resident back inside and took the Resident to their room and hit the call bell at 12:45 PM. The RP stated when no one came in the room, he/she attempted to locate staff in the hallway but could not locate anyone. The RP stated eventually a dietary worker came in to pick up the Resident's tray and stated he/she would get help. The RP stated it took until 1:30 PM for staff to come and assist the Resident but at that time the Resident had already gone to the bathroom in his/her pants and had slipped from the wheelchair to the wheelchair's foot rests.
The Director of Nursing was notified of the concern of not answering call bells timely on 6/17/24 at 2:50 PM.
Based on random observations from tours and complaints that were placed with the Office of Health Care quality, it was determined that the facility failed to attend to and answer call bells timely for dependent residents. This was evident during tour of the first and second floor and the validated review of 1 of 49 complaints. (Resident #10)
The findings include:
1. Tour of the facility on 6/12/24 at 7:09 AM to observe and interview residents, a call bell could be heard from the first-floor elevator. As this surveyor waited for the elevator to come, the call bell was heard continuing to go off. This surveyor proceeded down the hall towards unit one and 5 nursing staff, a mix of GNA's and nurses, were observed standing and or sitting at the desk. To the left a call light was observed flashing on. This surveyor proceeded down the hall towards the call light. Moments later a GNA appeared behind this surveyor and entered the room where the call light was on and was heard asking the resident if they needed anything. This surveyor proceeded back to the nursing station where the Director of nursing (DON) was now standing.
At 7:13 AM in the presence of the DON, the staff sitting at the desk was asked if they were aware the call bell was going off. They stated 'yes,' or nodded their heads. They were asked why they didn't respond until this surveyor proceeded down the hallway. One GNA spoke up and said they thought someone was in there, even though the call bell was continuing to go off. The DON was notified that this was a potential concern as the OHCQ has received multiple complaints about staff not answering call bells timely.
This surveyor then proceeded up to the second floor. As I exited the elevator at 7:14 AM again call bells were audible. There are 3 hallways on each unit. The call bell was identified as going off in the middle hallway and was visible from the nurse's station where again 5 staff were standing and or sitting down. There were 2 GNAs, staff # 27 and #28 who were standing facing the middle hallway and talking amongst themselves. The call light was visible from their vantage point. This surveyor even stood next to them and looked down the hall at the call light, no one moved.
This surveyor proceeded down the hallway to the resident's room. The resident stated that s/he needed assistance and this surveyor stated that I would get someone for them.
This surveyor proceeded back to the nurse's station and reported to the 2 GNAs, staff #27 and #28, that the resident needed assistance. This surveyor also asked why they did not respond when the call bell was going off. They both shrugged and looked at each other and mumbled incoherently. They also stated that they had already responded to the call bell once. At this time the DON arrived on the unit. The observed situation was reported to her and the concern that staff are not attending to call bells, especially after this was just observed on the first floor and staff on the second floor are just standing around and looking at the call bells going off and not responding or following up on call bells that are still going off even if someone may be in the room.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of a closed electronic medical record and staff interview, it was determined that the facility medical staff fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of a closed electronic medical record and staff interview, it was determined that the facility medical staff failed to create a MOLST for a resident upon admission. This was evident for 1 (Resident #57) of 65 residents reviewed during a complaint survey.
The findings include:
A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient.
Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must accurately and legibly complete the form and then sign and date it. This also includes correctly identifying the name of the resident at the top of the form.
Voiding the Form: to void this medical order form, a physician or nurse practitioner shall draw a 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 or nurse practitioner to void the MOLST form. Keep the voided order form in the patient's active or archived medical record.
In Maryland Law: Surrogates and Life-Sustaining Treatment: A surrogate may consent to the withholding or withdrawal of life-sustaining procedures if the patient's attending physician and a consulting physician certify, to a reasonable degree of medical certainty, that the patient has a terminal or end-stage condition or is in a persistent vegetative state. A surrogate may not consider a patient's pre-existing, long-term mental or physical disability in making a decision to withhold or withdraw life-sustaining procedures. A surrogate who is a guardian usually must obtain the court's permission to authorize the withholding or withdrawal of life-sustaining procedures.
A review of Resident #57's closed electronic medical record on 06/11/24 revealed that Resident #57 was admitted to the facility on [DATE] without a completed MOLST form. No documents were observed in Resident #57's closed electronic medical record to indicate the facility staff had gone through the process of speaking to Resident #57 about his/her life sustaining wishes or formulate a set of advanced directives upon admission.
In an interview with Resident #57's attending physician on 06/13/24 at 11:15 AM, Resident #57's attending physician stated that s/he was not available to admit Resident #57 on 06/25/21 and that another facility physician completed Resident #57's admission history and physical. Resident #57's attending physician could not give a reason as to why the covering physician did not complete a MOLST form for Resident #57 upon admission.
In an interview with the facility Administrator and Director of Nurses (DON) on 06/13/24 at 12:17 PM, the DON stated that the facility does not have a MOLST policy but does have a Living Wills/Agent for Health Care Decisions policy. A copy was presented to the nurse surveyor at this 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility report #MD00168783 involving Resident #58 was reviewed on 6/12/24 at 12:16 PM. The medical record for Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility report #MD00168783 involving Resident #58 was reviewed on 6/12/24 at 12:16 PM. The medical record for Resident #58 revealed diagnosis including admission post Coronary artery bypass grafting (CABG), also known as heart bypass or bypass surgery which is a surgical procedure that improves blood flow to the heart by rerouting blood around blocked or narrowed coronary arteries. The hospital discharge was reviewed at this time and noted to practice sternal precautions for 6 weeks which included s/he could not push up out of bed or chair with [his/her] arms. Additionally, s/he was instructed to notify the office for feelings of fatigue, weakness, shortness of breath, difficulty breathing at rest or with increased activity,
On 6/17/21 while walking with physical therapy, Resident #58 suddenly verbalized feeling dizzy and lightheaded and dropped to [his] knees onto the floor.
The resident was placed on oxygen, log rolled onto a hoyer and placed in a wheelchair to recover.
This incident was reported to the facility physician, however not the resident's cardiac surgeon as noted in the discharge summary. On 6/18/24, after using the restroom, Resident #58 had another syncopal episode, required cardiopulmonary resuscitation and unfortunately did not regain consciousness.
The concern that on 6/17/21, after the first syncopal episode, the failure of the facility to notify the cardiac surgeon was reviewed with the facility Director of Nursing (DON) and Nursing Home Administrator (NHA) on 6/12/24 at 1:36 PM. As neither were working here at the time of the incident, they stated they would review for further documentation. The concern that the facility would be responsible to fulfill the instructions in the discharge summary was also reviewed at this time.
As of exit on 6/18/24 there was no further information regarding documentation related to the notification of Resident #58's status and syncopal episodes to the cardiac surgeon.
3. Review of the complaint #MD00168271 for Resident #59 on 6/11/24 at 10:16 AM revealed resident was admitted with diagnosis including respiratory failure, encephalopathy (A broad term for any brain disease that alters brain function or structure) and myeloproliferative neoplasms (MPNs) are a rare group of blood cancers that cause the bone marrow to produce too many blood cells.
Review of the complaint revealed concerns about notification of change. On, 6/1/2021 Resident #58 was transferred to the hospital for a change in condition. According to late entry progress notes from the previous social worker, the resident's emergency contacts were notified after the hospitalization. The E-interact transfer form completed by nursing staff that day failed to document that the resident emergency contacts were notified timely of the resident's transfer. According to the complaint, the family had come to the facility looking for the resident as they were not notified of the transfer and then they were unable to immediate locate the hospital that s/he was at.
This concern was reviewed with the facility DON on 6/12/24 at 1:36 PM.
Based on complaint, reviews of a closed medical record, and staff interviews, it was determined that the facility staff failed to 1. Immediately notify a resident's physician when a resident had fallen. 2. Notify the surgeon per discharge instructions or 3. Notify a residents' representatives of a change in condition and hospitalization. This was evident for 3 (Resident #8, #58, #59) of 65 residents reviewed during a complaint survey.
The findings include:
1. A review of complaint MD00198899 on 06/11/24 revealed an allegation that Resident #8 had fallen and was not assessed or treated.
A review of the facility Falls Management Program policy on 06/11/24 revealed that: The nurse will notify the resident's provider, responsible party, and/or EMS if indicated, as well as the supervisor/administrative personnel as appropriate.
A review of Resident #8's closed medical record on 06/11/24 at 11 AM revealed that Resident #8 had been admitted to the facility on [DATE] for rehab after being treated at the hospital for a fall, dementia, normal pressure hydrocephalus, upper GI bleed and thrombocytopenia. On 10/07/23 at 2:15 AM, Resident #8 was observed on the floor and was unable to describe to the nursing staff what had happened. Resident #8 denied pain or hitting his/her head.
A review of Resident #8's fall prevention care plan, dated 10/08/23, on 06/13/24 revealed 2 nursing goals for preventing Resident #8 from falling. The first fall prevention goal was that Resident #8 will be free of minor injury. The second fall prevention goal was that Resident #8 will not sustain a serious injury. Nursing interventions included: be sure the resident's call bell is within reach and encourage the resident to use it for assistance, staff to conduct frequent rounds to ensure safety.
On 10/24/23 at 3:43 PM, Resident #8 was again observed on the floor. When asked by the nursing staff what happened, Resident #8 stated that s/he was trying to walk to the bathroom and tripped.
In an interview with Resident #8's attending physician on 06/13/24 at 11:15 AM, Resident #8's attending physician stated that s/he was not immediately notified by the nursing staff of Resident #8's fall on 10/24/23. Resident #8's attending physician stated that s/he was made aware of Resident #8's 10/24/23 fall by Resident #8's family member on the morning of 10/25/23.
Cross reference F 689.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on the review of a complaint, staff and resident interview and medical record review, it was determined that the facility failed to adequately prepare a resident for discharge. This was evident ...
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Based on the review of a complaint, staff and resident interview and medical record review, it was determined that the facility failed to adequately prepare a resident for discharge. This was evident during the review of 1 of 2 complaints regarding discharges. (Resident #5)
The findings include:
Review of the complaint #MD00203025 on 6/10/24 at 9:45 AM revealed concerns regarding his/her discharge planning and preparation as well as the actual day s/he left the facility and not receiving all their personal property.
A closer review on 6/10/24 of the discharge that occurred on 2/23/24 and the completed paperwork revealed that Resident #5 had not signed any discharge paperwork, including the discharge instructions/post discharge plan review or the resident property list.
The facility DON was interviewed on 6/10/24 at 11:49 AM. The facility process on discharge was reviewed. She stated that the staff are to review the discharge planning and have the resident sign it and then it is scanned into the computer. Additionally, this is the process for the resident property list. Neither one of these processes were competed for Resident #5.
LPN staff #5 was interviewed on 6/10/24 at 1:47 PM regarding the discharge process. He reiterated the same process as the DON had just reviewed. The discharge that occurred with Resident #5 was reviewed as well as the paperwork that he had completed on 2/23/24 according to the electronic health record. He stated that he had no recollection of the discharge. He further could not explain why the paperwork was not completed as per the facility process.
On 6/12/24 at 1:36 PM the DON and NHA were notified of the identified concerns of discharge preparations secondary to the complaint and further identified lack of documentation on behalf of the facility and failure of following of the facility process related to discharge planning and preparation was reviewed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on medical record review and interview with facility staff, it was determined that the facility failed to implement a care plan related to a resident's primary diagnosis and therefore implement ...
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Based on medical record review and interview with facility staff, it was determined that the facility failed to implement a care plan related to a resident's primary diagnosis and therefore implement a plan of care related to that diagnosis. This was evident for 1 of 65 residents (#43) reviewed during a complaint survey.
The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility 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.
The findings include:
Review of the medical record for Resident #43 on 6/14/24 at 10:59 AM revealed admitting diagnosis for surgical aftercare following surgery on the circulatory system. Resident #43 had arrived at the facility after s/he went home postoperatively from right lower extremity surgery on the circulatory system. At home s/he developed cellulitis and returned to the hospital for antibiotics and required further rehabilitation services at this nursing care facility. On admission to the nursing home, s/he was noted by the wound care nurse practitioner with 3 surgical incisions on the right leg; the groin, the medial and the anterior areas of the right leg, all incisions requiring wound care and treatment daily.
A concurrent review of the residents' care plan failed to reveal a care plan in place related to wound or skin care treatment needed for the identified areas. A care plan was identified on 6/14/24 related to cellulitis and antibiotic use related only to the infection that the resident developed post-operatively. However, there was nothing in the care plan related to Resident #43's main diagnosis of surgical wound care.
The 2/8/22 MDS section M (skin conditions) identified Resident #43 as having surgical wounds and the care area assessment (CAA) triggered for care plans to be initiated related to pressure ulcer/injury. However, the care plan that was developed only referenced the residents' 'risk' for skin breakdown related to immobility and incontinence.
As there was no staff present in the facility at this time that were present at the time of the residents admission that would have been responsible for the development of the care plan, the identified concerns were reviewed with the current DON and current Nursing Home Administrator on 6/14/24 at approximately 1:00 PM and again on exit on 6/18/24 after no further information was provided to the survey team.
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 F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
2. Review of resident #21's medical record on 6/10/24 at 12:36pm revealed no evidence of a discharge summary after the resident was transferred from the facility to a local hospital on 9/2/23 and fail...
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2. Review of resident #21's medical record on 6/10/24 at 12:36pm revealed no evidence of a discharge summary after the resident was transferred from the facility to a local hospital on 9/2/23 and failed to return to the facility after the transfer.
Interview with the Director of Nursing (DON) on 6/10/24 at 1:36pm confirmed that the resident did not return to the facility after transfer to a local hospital. DON also confirmed that the facility was unable to locate a provider discharge note. The surveyor expressed concern that the facility failed to provide a provider discharge note after the resident's discharge from the facility.
3. Review of resident #36's medical record on 6/17/24 at 9:30pm revealed no evidence of a discharge summary after the resident was transferred from the facility to a local hospital on 9/17/22 and failed to return to the facility after the transfer.
Interview with the Director of Nursing (DON) on 6/17/24 at 10:52am confirmed that the resident did not return to the facility after transfer to a local hospital. DON also confirmed that the facility was unable to locate a provider discharge note. The surveyor expressed concern that the facility failed to provide a provider discharge note after the resident's discharge from the facility.
4. Review of resident #54's medical record on 6/17/24 at 9:00am revealed no evidence of a discharge summary after the resident discharged from the facility on 4/14/22.
Interview with the Director of Nursing (DON) on 6/17/24 at 10:30am confirmed that the resident discharged on 4/14/22 and the facility was unable to locate a provider discharge note. The surveyor expressed concern that the facility failed to provide a provider discharge note after the resident's discharge from the facility.
Based on medical record review and staff interview it was determined that the facility failed to ensure that residents had a discharge summary and it was complete and accurate (Resident #17, #25, #36 and #54). This was evident for 4 of 65 residents reviewed during a complaint survey.
The findings include:
1. Review of Resident #25's medical record on 6/17/24 revealed the Resident was admitted to the facility to 2/28/23 from the hospital and went to a surgery appointment on 5/19/24 at 4:15 AM.
Further review of the medical record revealed the Resident did not return to the facility following the appointment.
Further review of the medical record revealed no final summary of the resident's status at the time of discharge.
Interview with the Director of Nursing on 6/17/24 at 2:10 PM confirmed the facility staff failed to document a discharge summary in Resident #25's medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
2. On 6/12/24 at 10:13 AM a medical record review was conducted for Resident # 37. Resident # 37 has multiple wounds on both legs and is seen by the wound care team weekly. On 6/18/22, an order was gi...
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2. On 6/12/24 at 10:13 AM a medical record review was conducted for Resident # 37. Resident # 37 has multiple wounds on both legs and is seen by the wound care team weekly. On 6/18/22, an order was given to apply kerlix and ace bandage daily to left lower leg from 6/18/22 to 7/17/22. On 6/27/22 kerlix and ace bandage were not applied after wound care visit.
On 06/12/2024 an interview was completed with the Director of Nursing (DON), The DON offered no reason why the wound care had not been completed.
Based on the review of a complaint, medical record review and interview with staff, it was determined that the facility failed to implement wound care orders for a resident with a stage 3 pressure ulcer. This was evident during the review of 2 of 5 residents (#40 and #37) reviewed for wounds during a complaint survey
The findings include:
1. Review of the complaint #MD00175703 on 6/10/24 at 11:25 revealed concerns related to the treatment of Resident #40's wounds that were identified as a stage 3 sacral ulcer.
Further review at this time of Resident #40's medical record revealed that s/he had a re-hospitalization during their stay. Upon readmission to the facility, there were no wound care orders reinstated for the treatment of the sacral stage 3 ulcer until Resident #40 was seen by the wound care nurse practitioner 3 days later on 2/25/22. Prior to discharge the wound care regimen consisted of treatment 3 times a day.
A review of Resident #40's physician orders and medication and treatment administration record confirmed that there were no orders or treatments implemented during the time frame of 2/22/22-2/25/22.
This identified concern was reviewed with the facility DON on 6/12/24 at 1:36 PM along with the facility Administrator.
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** 2. Mechanical lift - also known as a patient lift is defined by the Food and Drug Administration (FDA) as being designed to lift...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Mechanical lift - also known as a patient lift is defined by the Food and Drug Administration (FDA) as being designed to lift and transfer patients from on place to another.
On 6/10/24 at 11:17 AM an observation of facility staff transferring Resident #66 from their bed to a wheelchair. Facility staff were in the Resident's room wheeling the resident out to the hallway where the wheelchair was located when the observation started. It was observed that as Certified Medicine Aide (CMA) #45 was wheeling the resident through the door the base of the mechanical lift was closed. The resident was suspended in the sling with his/her back towards CMA #45 and their head was touching the pole. Geriatric Nursing Assistant (GNA) #44 was holding the resident's feet as they came through the doorway. As they approached the wheelchair CMA #45 widened the base of the lift to fit around the wheelchair and GNA #43 tilted the wheelchair back on its back wheels with the front wheels off the ground as the resident was lowered into the chair. GNA #44 was guiding the resident into the chair. Licensed Practical Nurse (LPN) #46 was standing with the operator of the lift attempting to console the resident. Resident #66 was yelling out and said that staff had hit his/her head on the lift.
A medical record review for Resident #66 on 6/13/24 at 9:00 AM revealed a Minimum Data Set with the assessment reference date of 5/18/24 that documented in section GG the resident was dependent on staff to transfer him/her from the bed to the wheelchair.
A review of the instructions, provided by the Staff educator, titled, How to Use a Hoyer Lift was conducted on 6/10/24 at 12:00 PM. According to the manufacturer the base should be fully opened while the resident was in the lift to maximize the stability of the lift. Further review revealed that once the resident was suspended in the air and moved away from the surface, they should be turned to face the operator of the lift. Also, the resident should be lowered until they can rest their feet on the base of the lift.
The operator of the lift, CMA #45 was interviewed on 6/10/24 at 11:44 AM. She reported that the base of the lift should be closed while the resident was in the lift. The base should be opened once the resident was at the wheelchair so the legs can straddle the wheelchair while the resident was lowered.
An interview with GNA #43, who was the person holding the wheelchair, on 6/10/24 at 11:20 AM revealed that she thought the base of the mechanical lift should be closed while the resident was being transported. She stated the wheelchair should not have been tilted back but on the ground and the wheels locked.
During an interview with GNA #44, who was holding the resident's feet, on 6/10/24 at 11:23 AM she reported it was not good to transfer the resident in the hallway but there was not enough room to transfer in the room. She reported that the base of the mechanical lift should be closed while transferring the resident until the resident was being lowered then it should be opened.
An interview with LPN #46 on 6/10/24 at 11:31 AM revealed that she thought the base of the mechanical lift should be closed while moving the resident and then opened when placing them in the bed or chair. She stated the wheelchair should not have been tilted back but in an upright position with the wheels locked.
An interview with the Staff Educator on 6/10/24 at 11:53 AM revealed that they provide education regarding the safe use of the mechanical lift upon hire and the periodically. Surveyor reviewed the observation of the mechanical lift transfer and the Staff Educator stated that the base of the lifts should have been opened while the resident was in the lift. The resident should have been turned to face the operator while the GNA who was at the resident's feet should have been on their side guiding them. She stated that the wheelchair should not have been tilted back because it was not in a stable position and the resident could have fallen back.
The Director of Nursing (DON), who was the former staff educator was interviewed on 6/10/24 at 12:36 PM. She stated that she educated staff to keep the base of the mechanical lift in a closed position while transporting them due to the limited space in a room. She confirmed that the resident should be facing the operator during transport and that would keep them from hitting their heads on the lift. She also confirmed that the staff person holding the resident's feet should have been standing to the side of the resident to guide and assist them if needed. She confirmed that the wheelchair should not have been tilted back while the resident was being lowered into the chair, but should have been fully on the floor with the wheels locked. She was asked to provide a copy of the education that she had provided to staff.
Review of the education revealed it was provided to staff on 8/24/23 and there was a checklist included which included that the resident should be facing the operator of the lift. However, it did instruct staff to close the base of the lift while moving the resident between surfaces and to open the base at the chair or the bed while lowering the resident. This contradicts what the manufacturer's instructions to keep the base wide for stability of the lift. In addition, it had not included that the resident should be lowered to allow their feet to rest on the base of the lift.
A subsequent interview with the staff educator revealed that she was aware of the check list that were provided by the DON. She stated that the instructions she gave the surveyor was directly from the manufacturer and that was the safest way to use the lift. She was not aware that the resident should have been lowered until their feet touched the base of the lift. She reported that she will review the manufacturer's instructions and add that to the training.
Based on complaint, reviews of a closed medical record, and staff interviews, it was determined that the 1. facility staff failed to follow a resident's fall prevention care plan to ensure all nursing interventions were implemented. Resident #8 did not have the call light within reach and tried to walk to the restroom without assistance and fell. This was evident for 1 (Resident #8) of 65 residents reviewed during a complaint survey and 2. the facility failed to ensure that staff were using a mechanical lift to transfer residents based on the manufacturer's instructions to ensure resident's safety. This was evident for 1 of 1 observation of a resident transfer in a mechanical lift.
The findings include:
1. A review of complaint MD00198899 on 06/11/24 revealed an allegation that Resident #8 had fallen and was not assessed or treated.
A review of the facility Falls Management Program policy, on 06/11/24, listed a procedure that included but not limited to: Prevention, a Fall Risk Tool will be completed upon admission, readmission, quarterly and as needed, Discuss fall risks and interventions with patient and the responsible party, Incorporate any identified interventions into the care plan, refer the patient to PT/OT for screening, evaluation, and treatment, consult with the maintenance department for any necessary adaptations. Under Fall Occurrence, #1 - The nurse will notify the resident's provider, responsible party, and/or EMS if indicated, as well as the supervisor/administrative personnel as appropriate.
A review of Resident #8's closed medical record on 06/11/24 at 11 AM revealed that Resident #8 had been admitted to the facility on [DATE] for rehab after being treated at the hospital for a fall, dementia, normal pressure hydrocephalus, upper GI bleed and thrombocytopenia. On 10/07/23 at 2:15 AM, Resident #8 was observed on the floor and was unable to describe to the nursing staff what had happened. Resident #8 denied pain or hitting his/her head. On the morning of 10/09/23 at 11:39 AM, Resident #8's wife noted Resident #8 had left sided weakness. Resident #8 was seen by one of the facility physicians and an order was created to send Resident #8 to the hospital to evaluate a new left facial droop and left upper extremity weakness. The goal was to obtain a cat scan of the head to rule out a blocked brain shunt versus a transient ischemic attack or a stroke. Resident #8 was subsequently readmitted to the facility on [DATE]. Resident #8 was treated for generalized weakness and possible pneumonia
A review of Resident #8's fall prevention care plan, dated 10/08/23, on 06/13/24 revealed 2 nursing goals for preventing Resident #8 from falling. The first fall prevention goal was that Resident #8 will be free of minor injury. The second fall prevention goal was that Resident #8 will not sustain a serious injury. Nursing interventions included: be sure the resident's call bell is within reach and encourage the resident to use it for assistance, staff to conduct frequent checks to ensure safety.
On 10/24/23 at 3:43 PM, Resident #8 was observed again on the floor by staff. When Resident #8 was asked by the nursing staff what had happened, Resident #8 stated that s/he was trying to walk to the bathroom and tripped. A review of Resident #8's post fall review, dated 10/25/23 at 9:08 AM, staff member #5 completed all sections of the assessment and then signed the assessment. In an interview with staff member #5 on 06/13/24 at 9:23 AM, staff member #5 confirmed completing Resident #8's post fall assessment for Resident #8's 10/24/23 fall. The nurse surveyor then asked staff member #5 to review section C, Fall, question d. Question d asked the nurse was the call light within reach? Staff member #5 documented No. Staff member #8 stated that he could not recall Resident #8's 10/24/23 fall and had to go with what s/he documented at the time.
In an interview with Resident #8's attending physician on 06/13/24 at 11:15 AM, Resident #8's attending physician stated that s/he was not immediately notified by the nursing staff of Resident #8's fall on 10/24/23. Resident #8's attending physician stated that s/he was made aware of Resident #8's 10/24/23 fall by Resident #8's family member on the morning of 10/25/23. Resident #8's attending physician stated that s/he had staff member #5 assist him/her with Resident #8's physical assessment on 10/25/23. Resident #8's attending physician stated orders were given to staff member #5 to obtain x-rays on 10/25/23 at approximately 1 PM. Further review on Resident #8's closed electronic medical record failed to reveal Resident #8 had any x-rays completed on 10/25/23. On 10/26/23, X-ray results indicated Resident #8 had an L1 compression fracture.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record reviews on 6/14/24 at 9:39 AM for Resident #60 while investigating complaint #MD00165852 revealed on 3/16/2021...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record reviews on 6/14/24 at 9:39 AM for Resident #60 while investigating complaint #MD00165852 revealed on 3/16/2021 the facility staff documented his/her weight as 290 pounds (lbs.). This was documented again on 3/26/21. However, on 4/6/21 staff documented residents' weight as 181.
Resident #60 was admitted to the facility post left leg amputation above the knee.
An admission nutrition assessment was completed by the previous dietitian (RD) on 3/18/21 and noted that the resident is unable to communicate and newly admitted with a left AKA (above knee amputation), however, still documented the resident as weighing 290lbs.
On 4/7/21, the RD saw Resident #60 again.
The RD struck out the weights in the computer from 3/16/21 and 3/26/21 documenting that those weights are not the residents actual body weights. The progress note, dated 4/7/21, continued to state that the resident was weighed and noted to be 180 lbs., which is 100lbs less than what was previously documented. The resident, who can verbally communicate and noted to have capacity, stated during the 4/7/21 meeting with the RD, that his/her normal weight was between 220-230 lbs. prior to the AKA. The previous RD also stated in the same progress note that visual observation confirms this weight as well, which disputes the admission assessment where he documented the weight of 290 lbs. just 3 weeks prior.
The current facility dietitian, staff #29 was interviewed on 6/17/24 at 9:35 AM regarding the facility policy/process on meeting with residents on admission. She stated that for her it is within 72 hours. The RD progress notes were reviewed for Resident #60 with staff #29. Although there was an initial assessment on 3/18/21 it was not reflective of the actual resident including the documented weights. Additionally, according to the 4/7/21 progress note, it revealed that the previous RD had not actually visited or seen and confirmed the weights of the resident until 4/7/21 when he stated that the residents documented weight of 180 was confirmed by visual observation 3 weeks after the resident was admitted . The concern that the initial assessment had based the diet on a weight that was 100lbs. different than the resident's actual weight was also reviewed.
This concern was reviewed with the current facility RD on 6/17/24 at 9:38 AM as well as the DON on 6/17/24 and again at exit on 6/18/24.
Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to 1. discharge a resident home with all of their belongings. This was evident for 1 (Residents #53) of 65 and 2. failed to accurately monitor and assess a resident's weights on admission. This was evident for 1 of 3 residents during a complaint survey (#60)
The findings include:
1. A review of Complaint MD00173266 on 06/10/24 revealed an allegation the facility lost Resident #53's dentures after admission. Resident #53 was discharged home on [DATE] and arrived without his/her upper dentures.
A review of Resident #53's closed medical record on 06/10/24 revealed a facility Speech Pathologist progress note, dated 09/13/21, that indicated Resident #53 was in possession of a set of upper dentures with sparse dentition on the bottom.
A review of Resident #53's nutrition/dietary progress note, dated 09/15/21 at 4:56 PM, the facility dietician documented that s/he spoke with Resident #53's family member who requested that the nursing staff place Resident #53's dentures in his/her mouth during meals. Further, the facility dietician documented that s/he asked the GNA staff member to help Resident #53 place his/her dentures in the Resident's mouth for improved oral intake and speech production.
Review of Resident #53's admission MDS, with an ARD date of 09/16/21, section L, revealed Resident #53 was admitted to the facility with no dental issues.
Review of Resident #53's nursing care plan, on 06/10/24, revealed Resident #53 was identified with a nutritional problem related to the need for a pureed diet, history of a stroke, dementia and hypertension. The facility dietician initiated a nutritional care plan on 09/13/21 with a goal to maintain an adequate nutritional status as evidenced by maintaining weight within +/- 5 % consistent body weight and consuming at least 50 - 75 % of at least 2 - 3 meals daily. Nursing interventions included: monitor/document/report PRN (as needed) any signs or symptoms of dysphagia, pocketing food, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appears concerned during meals, monitor/document/report to MD PRN signs and symptoms of malnutrition, emaciation, muscle wasting, significant weight loss: 3 pounds in one week, greater than 5 % in one month, greater than 7.5 % in 3 months, and greater than 10 % in 6 months, and monitor intake and record every meal.
A review of Resident #53's GNA documentation records on 06/13/24 revealed that during Resident #53's 09/12/21 - 09/27/21 stay at the facility, the nursing staff documented that Resident #53 consumed 0-25 % for 17 of 46 meals and consumed 26-50 % for 14 of 46 meals. The nursing staff documented that Resident #53 consumed less than 50 % for 31 of 46 meals.
Upon admission, Resident #53's physician instructed the nursing staff to monitor Resident #53's weight weekly x 4 weeks. On 09/12/21, the nursing staff documented that Resident #53 weighed 125 pounds. Review of Resident #53's closed record indicated that on 09/21/21, there was a problem obtaining a weight for Resident #53 and instructed the reader to refer to the 09/21/21 nursing notes for additional information. Further review of Resident #53's closed record failed to reveal a reason why the nursing staff could not have obtained a weight for Resident #53 on 09/21/21 - 09/27/21 while Resident #53 continued to reside in the facility.
In an interview with the facility director of nurses (DON) on 06/13/24 at 12:48 PM, the DON stated the speech pathologist (SLP) that reviewed Resident #53 during the 09/12/21 admission no longer works at the facility.
In an interview with the facility director of nurses (DON) on 06/13/24 at 1:30 PM, the DON stated the dietician that reviewed Resident #53 during the 09/12/21 admission no longer works at the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected 1 resident
Based on medical record review and interview with facility staff, it was determined that the physicians failed to have their notes in the medical record timely after seeing the resident. This was evid...
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Based on medical record review and interview with facility staff, it was determined that the physicians failed to have their notes in the medical record timely after seeing the resident. This was evident for 1 of 65 (#4) Residents reviewed during a complaint survey.
The findings include:
When the medical record of Resident #4 was reviewed on 6/12/24 at 1:11 PM a physician discharge note with an effective date of 5/19/24 was the first note to appear. However, Resident #4 was discharged from the facility on 3/22/24 to the emergency room and had not returned. This physician discharge note said that it was completed on 3/14/24. However, according to the resident's census report, s/he had been in and out of the facility twice since the note was written.
This identified concern of the delay to have the physician note in the chart timely was reviewed with the DON on 6/12/24. At approximately 1:30 PM on 6/12/24 the DON was asked what the expectation and process was to have physician notes in the resident medical records. She stated that the notes are to be completed and in the charts within 30 days.
The delay of an additional 30 days to have a discharge summary in the medical record was reviewed with the DON on 6/12/24 and during exit on 6/18/24.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on the review of a facility reported incident (FRI) #MD00204392 related to an allegation of abuse, a review of employee files and interviews, it was determined that the facility failed to ensure...
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Based on the review of a facility reported incident (FRI) #MD00204392 related to an allegation of abuse, a review of employee files and interviews, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 1 out of 5 employee files reviewed for competencies and skill sets.
The findings include:
Review of the FRI #MD00204392 on 6/11/24 at 9:07 AM revealed an allegation of abuse occurring with Resident #3 at the hands of GNA #7.
A review of the facility investigation and concurrent review of the employee file for GNA #7 revealed that upon hire on 8/6/19 the Certified Nursing Assistant competency check off sheet was never completed.
The DON was interviewed on 6/11/24 at 10:10AM. This concern was brought to her attention as she was present and had completed this investigation and investigation packet. She was not aware of the blank competency check list. She was asked at this time for anything further or any education or training that was completed with staff GNA #7 since her hire. This request was followed up on every day of the survey.
As of exit on 6/18/24, no further documentation or training was provided to the survey team.
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 F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of a complaint, resident interview and interview with the facility staff, it was determined that the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of a complaint, resident interview and interview with the facility staff, it was determined that the facility failed to timely provide a resident with an established psychiatric diagnosis with therapeutic treatment to maintain his/her highest practicable well-being. This was evident during the review of 1 of 65 residents (#33) reviewed during a complaint.
The findings include:
Review of the complaints for Resident #33 on 6/17/24 at 10:17 AM, #MD00174214 and #MD00180447 revealed concerns related to general care in the facility and the fact that s/he battles with severe depression and anxiety and with the lack of care and neglect that [s/he] is not receiving, the depressive and anxiety episodes are increasing. The complaints also noted that the individual was under [AGE] years old.
Continued record review revealed that Resident #33 has been a resident of the facility since February 2020. Admitting diagnosis' included acute transvers myelitis (a rare neurological condition that causes inflammation of the spinal cord) which has caused paraplegia, additionally admission diagnosis included major depressive disorder and unspecified psychosis not due to substance or known psychological condition.
On admission in 2020, the attending physician ordered for a psychiatric consult. This order was in place from 2/26/2020 through 6/5/2020. At no time between those dates was a psychiatric consult completed.
Review of Resident #33's care plans on 6/17/24 at 12:37 PM revealed that a behavior care plan was initiated for refusal to allow skin assessments on 8/22, lab refusals, yelling and throwing items at staff occurred in the month of 9/22, and further yelling at staff and medication refusals was updated in the care plan between January and February of 2023. However, even with these changes in behaviors at no time was there an updated order or a referral for the facility psychiatrist to see the resident.
On 3/1/23 Resident #33 was seen by the facility psychiatrist for the first time to evaluate mental status and adjust medications for behavioral disturbances. Patient seen to evaluate for depression, Patient seen to evaluate for agitation, Patient seen to evaluate for anxiety.
At the time of the evaluation, Resident #33 was not on any medication and further was not prescribed any psychiatric medication, only 1:1 supportive therapy was recommended.
Surveyor met with Resident #33 on 6/18/24 at 7:45 AM. Resident #33 was verbally frustrated at the lack of attention and care that s/he receives from the staff for regular activities of daily living as s/he is dependent for care. S/he stated that the staff will argue with each other about helping with care and that there are long waits up to 45 minutes for someone to answer the call bells.
This surveyor reviewed the concerns in his/her complaint. S/he stated that until s/he came to this facility 4 years ago, his/her psychiatric well-being was ok. It wasn't until they were admitted here and had to just sit in bed because of their diagnosis (paraplegia) and have become dependent on staff that their mental health diminished.
This surveyor asked about the facility providing any mental health services. Resident #33 stated that it was limited, and nothing provided to him/her when they were first admitted to the facility when they were trying to adjust.
The facility social worker, staff #30 was interviewed on 6/18/24 at 8:40 AM. She reviewed the process of completing trauma screens on residents and stated that if nothing triggers, no care plan is completed, and they are only completed on the initial admission or if there is a significant change and even then, it may or may not trigger the facility to complete a new screen. The incidents and history of Resident #33 was reviewed including his/her multiple re-hospitalizations that had lasted for weeks. She stated that none of those incidents had triggered for a new trauma screen to be completed or for him/her to be reassessed for any behavior screening or monitoring, even the occurrences in 2022 and 2023 with the care refusals.
The DON was interviewed on 6/18/24 at 8:47 AM. The concern that there were no documented psychiatric services provided or offered to an atypical nursing home resident newly diagnosed with paraplegia related to the transverse myelitis admitted to the facility in 2020 with identified behaviors in 2022 and 2023 was reviewed at this 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
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview it was determined that the facility staff failed to administer medications according to the physician orders. This was evident for 1 out 1 resident ...
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Based on clinical record review and staff interview it was determined that the facility staff failed to administer medications according to the physician orders. This was evident for 1 out 1 resident (#51) in the complaint sample.
Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication error and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles.
Late documentation is a form of inaccurate documentation and is worsened if the documentation does not document when medications were actually given. 'Late administration' is defined as giving medication greater than 1 hour after a medication is due. 'Late documentation' is defined as not documenting immediately after administration.
The findings include:
On 6/13/24 at 11 Am, an investigation of complaint MD174252 alleges that Resident #51 was not getting his/her pain medication on time,
A review of Resident #51's medication administration record (MAR) for a period covering November 10, 2021, thru November 18, 2021, revealed a significant pattern of late documentation for the pain medication that the resident was prescribed.
The resident was prescribed:
1. Morphine Sulfate ER tablets 15mg every 12 hours for pain. (supplement). The medication was administered late for 7 out of 16 opportunities.
2. Lantus Solostar pen injector 100 units/ml inject 75 units (treats diabetes). The medication was administered late for 5 out of 15 opportunities.
3. Humalog 100 unit/ml to be dosed on a sliding scale (treats diabetes). The medication was administered late for 6 out of 16 opportunities.
Interview with the Director of Nursing on 6/14/24 at 10:15 AM confirmed the facility staff failed to ensure Resident #51's medications were given as prescribe.
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 F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to discharge a resident home with all of their belongings. This was evident for 1 (Residents #53) of 65 residents reviewed during a complaint survey.
The findings include:
A review of Complaint MD00173266 on 06/10/24 revealed an allegation the facility lost Resident #53's dentures after admission. Resident #53 was discharged home on [DATE] and arrived without his/her upper dentures.
A review of Resident #53's closed medical record on 06/10/24 revealed a facility Speech Pathologist progress note, dated 09/13/21, that indicated Resident #53 was in possession of a set of upper dentures with sparse dentition on the bottom.
A review of Resident #53's nutrition/dietary progress note, dated 09/15/21 at 4:56 PM, the facility dietician documented that s/he spoke with Resident #53's family member who requested that the nursing staff place Resident #53's dentures in his/her mouth during meals. Further, the facility dietician documented that s/he asked the GNA staff member to help Resident #53 place his/her dentures in the Resident's mouth for improved oral intake and speech production.
Review of Resident #53's admission MDS, with an ARD date of 09/16/21, section L, revealed Resident #53 was admitted to the facility with no dental issues.
In an interview with the facility director of nurses (DON) on 06/13/24 at 12:48 PM, the DON stated the speech pathologist (SLP) that reviewed Resident #53 during the 09/12/21 admission no longer works at the facility.
In an interview with the facility director of nurses (DON) on 06/13/24 at 1:30 PM, the DON stated the dietician that reviewed Resident #53 during the 09/12/21 admission no longer works at the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
2. On 6/14/24 at 11:30AM, a medical record review determined the facility staff failed to maintain complete and accurate medical records. A request was made to the Director of Nursing for the Controll...
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2. On 6/14/24 at 11:30AM, a medical record review determined the facility staff failed to maintain complete and accurate medical records. A request was made to the Director of Nursing for the Controlled Medication Utilization Record sheets for Resident #51 prn pain medications.
On 6/17/24 at 12 PM, the Director of Nursing confirmed that the Controlled Medication Utilization Record sheets was not included in Resident's #51 medical record and is unable to locate.
Based on medical record review and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #25 and #51). This was evident for 2 of 65 residents reviewed during a complaint survey.
The findings include:
A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.
1. Review of Resident #25's medical record on 6/17/24 revealed the Resident was admitted to the facility to 2/28/23 following crainiectomy surgery. A craniectomy is a major brain surgery that involves removing part of the skull to relieve pressure on the brain.
Further review of the medical record revealed a physician note on 4/4/23 that stated: Patient getting ready for his/her neurologist appt today, states doing well. Further review of the medical record revealed no documentation from the neurologist appointment.
On 6/17/24 at 1:06 PM the Surveyor asked the Director of Nursing (DON) for the documentation from the neurologist appointment on 4/4/23. The DON was unable to provide the neurologist appointment progress notes until 6/18/24.
Interview with the Director of Nursing on 6/18/24 at 11:15 AM confirmed the facility staff failed to have the 4/4/23 neurologist appointment notes in Resident #25's medical record and had to call to have them sent to the facility on 6/18/24.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected 1 resident
Based on a facility's Quality Assurance and Performance Improvement (QAPI) record review and interview, the facility failed to adequately monitor malfunctions in the facility's hot water heating syste...
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Based on a facility's Quality Assurance and Performance Improvement (QAPI) record review and interview, the facility failed to adequately monitor malfunctions in the facility's hot water heating system.
QAPI Plan
A written plan that contains the process that will guide a facility in their efforts to assure care and services are maintained at acceptable levels.
QAPI Committee
A group consisting of a facility's administration department and selected other facility staff that review the facility's process to ensure care and services are maintained at acceptable levels.
Findings include:
The State of Maryland's Department of Health Office of Health Care Quality received a complaint (MD00193286) from resident #17 which alleged that facility was having issues with providing hot water to resident's rooms.
On 6/10/24 at 11:42am, the surveyor interviewed maintenance director #2 regarding resident #17's allegations of the facility failing to maintain hot water in resident's rooms in the month of 6/2023. Maintenance Director #2 stated that he/she was unaware of hot water issues in the summer of 2023 because he/she was not employed with the facility at the time. Maintenance Director #2 stated that he/she started working for the facility in August 2023. Maintenance Director #2 provided the surveyor with a QAPI plan describing the facility's actions to repair the hot water heating system. The QAPI plan started on 11/27/23 and ended 1/3/24. Maintenance Director #2 stated that the facility's dysfunctional hot water heating system affected only resident rooms on one side of the facility. The facility contacted a repair company immediately and provided hot water from the kitchen in portable vessels for bathing.
Surveyor review of the QAPI plan and accompanied invoices for repair of the malfunctioning hot water heater system on 6/11/24 at 8:30am revealed the facility's hot water heating system was malfunctioning due to a broken circulation pump. The accompanied temperature readings revealed the 1st floor shower room recorded temperatures of 140 F from 1/3/24 - 1/5/24 and 1/9/24. Review of the QAPI plan stated that Maintenance Director #2 would take hot water temperature daily throughout the facility for 90 days. The QAPI plan also stated that the QAPI committee would review the temperatures.
During a surveyor interview with Maintenance Director #2 on 6/11/24 at 11:37am, the surveyor pointed out the 1st floor shower room temperatures from 1/3/24 -1/5/24 and 1/9/24 were 140 F. Maintenance Director #2 stated that those temperatures recorded in error. The surveyor asked Maintenance Director #2 the hot water temperature range is acceptable based on facility policy. The hot water temperature range was stated as 100 F to 120F.
During a surveyor Interview of the Administrator on 6/11/24 at 11:54am, the surveyor informed the Administrator of the 140 F hot water temperatures recorded for 1/3/24 - 1/5/24 and 1/9/24. The Administrator stated that he/she was not employed with the facility at the time of the hot water system malfunction. The Administrator also stated that he/she would expect Maintenance Director #2 to inform him/her of the temperature anomaly. The surveyor also pointed out that the QAPI plan stated that the hot water temperatures would be taken daily for 90 days. The surveyor asked the Administrator if the QAPI committee is expected to review the hot water temperatures after Maintenance Director #2 takes them. The Administrator stated that he/she would expect the QAPI committee to review the temperatures to make sure the hot water system is functioning properly. Also, the surveyor also asked if the facility informed the OHCQ of the malfunctioning hot water heating system from 11/23 to 1/24. The Administrator stated that he/she was unable to find proof that OHCQ was informed of the malfunctioning hot water heating system. The surveyor expressed concerns that the QAPI committee failed to show good faith when they failed to review the hot water temperatures as listed on the QAPI plan and the facility failed to inform OHCQ of their malfunctioning hot water heating system from 11/23/24 - 1/24/24.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. The facility staff failed to report an allegation of abuse to OHCQ (Office of Health Care Quality) for Resident #2.
During in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. The facility staff failed to report an allegation of abuse to OHCQ (Office of Health Care Quality) for Resident #2.
During interview with Resident #2's Responsible Party (RP) on 6/12/24 at 11:00 AM, the RP stated he/she felt on 3/17/24 LPN #6 was rough with Resident #2 when he/she walked into the Resident's room on 3/17/24. The RP stated he/she told LPN #6 to stop abusing Resident #2. The RP stated he/she notified the former Administrator on 3/17/24 at 10:25 AM via text of his/her concern and the former Administrator responded back on 3/17/24 at 11:36 AM he was looking into it now.
During interview with Director of Nursing (DON) on 6/12/24 at 9:42 AM, the DON stated the only Facility Reported Incident for Resident #2 in 2024 was from 4/12/24.
During interview with the DON on 6/13/24 at 8:15 AM, the Surveyor reviewed Resident #2's RP's concerns on 3/17/24 and asked what the facility did at the time. The DON stated she would get back to me.
On 6/13/24 at 8:50 AM, the DON provided the Surveyor the facility's investigation of the 3/17/24 incident with Resident #2 including staff and resident interviews. The DON was asked at that time why it was not reported to OHCQ. The DON stated because in our investigation we found it not to be abuse.
During interview with the former Administrator on 6/13/24 at 10:39 AM, the Surveyor reviewed the incident and asked why he did not report the incident on 3/17/24 to OHCQ and he stated because we found it not to be abuse.
Interview with the DON on 6/13/24 at 8:50 AM confirmed the facility staff failed to report to OHCQ on 3/17/24 an allegation of abuse for Resident #2.
7. The facility staff failed to report an allegation of abuse for Resident #7 within 2 hours of the allegation on 1/23/23.
Review of Resident #7's medical record on 6/11/24 revealed the Resident was admitted to the facility on [DATE] and was assessed to be alert and oriented.
Review of a facility reported incident for Resident #7 revealed on 1/23/23 at approximately 6:00 PM, Resident #7 called the police to report GNA (geriatric nursing assistant) #36 held his/her wrist while removing his/her dinner tray.
Further review of the facility reported incident revealed the former Administrator did not report the incident to OHCQ until 1/24/23 at 5:02 PM.
Interview of the DON on 6/14/24 at 1:08 PM confirmed the facility staff did not report Resident #7's allegation of abuse on 1/23/23 until 1/24/23.
Based on review of facility documentation and interview with staff it was determined the facility staff failed to ensure that allegations involving abuse were reported to the Administrator of the facility and the State Agency no later than 2 hours after the allegation was made and results of all investigations were reported within 5 working days. This was evident in 5 of 27 abuse allegations reviewed for Residents (#1, #2, #7, #62, #3 ).
The findings include:
1. Facility Reported Incident (FRI) #MD00186593 related to an allegation of abuse involving Resident #1 was reviewed on 6/11/24 at 12:50 PM. The Date/Time of the incident in the facility's report was 12/9/22 11:45 AM and the police report was 12/9/22 at 11:45 AM. The facility's email containing the Initial self-report was dated 12/9/22 2:36 PM. It was not sent to the State Agency within 2 hours of the allegation.
2. The facility's investigation documentation for FRI #MD00196546 was reviewed on 6/13/24 at 11:13 AM. The report indicated that the Director of Nursing (DON) received an email from Resident #1's family member on 9/5/23 alleging that a staff member was abusive toward Resident #1. The facility's initial report was submitted to the State Agency on 9/5/23. Staff statements obtained by the facility during their investigation revealed that the alleged incident occurred at approximately 3:00 AM on 8/31/23, 5 days prior to the date it was reported to the state agency. The email from the Resident #1's family member was not included in the facility's investigative documentation.
At 12:46 PM on 6/13/24, the surveyor requested and received a copy of the email from the resident's family member. The email was dated 9/5/23 10:59 AM and was addressed to numerous recipients which included but were not limited to the facility's former DON (Staff #31) and former Administrator (#24). The email indicated that 2 issues were resolved and asked that the facility fully address the 3rd issue immediately and referenced the incident on the night shift of 8/30/23 - 8/31/23. It included, It's been several days since my initial call to you about this incident.
These findings were reviewed with the current DON at that time. She agreed that the email indicated that the facility was aware of the allegation of abuse prior to the date it was reported to the State Agency on 9/5/23. She was unable to provide any additional information regarding the family's initial report to the facility staff prior to 9/5/23 as indicated in the email. The facility failed to report the incident and initiate an investigation within 2 hours of when the allegation of abuse was initially reported by Resident #1's family member.
3. Review of another FRI #MD00200889 on 6/13/24 at 1:00 PM revealed that on 12/22/23 Staff #24 the former Administrator received a text message at 10:47 AM from Resident #1's family member reporting an allegation of abuse. Per the facility's documentation, he did not read the message until 12:29 PM on 12/22/23. The facility sent the initial report of the allegation to the State Agency on 12/22/23 at 6:18 PM. It was not reported within 2 hours after the allegation was made.
4. FRI #MD00204370 involving Resident #1 was reviewed on 6/17/24 at 8:00 AM. The facility's initial report indicated that the DON and Unit Manager reported to Administrator (#24) on 4/4/24 at approximately 5:30 AM that the police had been contacted by a complainant regarding an incident of abuse that allegedly occurred on 2/13/24. The report also indicated that the incident was reported to the clinical management staff and to Resident #1's representative on 2/14/24. The investigation report revealed that the Unit Manager (#38) performed an interview with Resident #1 on 2/14/24 at approximately 10 AM, regarding the incident. In an interview on 6/17/24 at 4:16 PM the surveyor reviewed the report with Unit Manager (#38) who confirmed that the incident was not reported to the State Agency on 2/14/24 but on 4/4/24 almost 2 months later. She stated, we investigated it then reported it. She confirmed that she did not notify the State Agency and indicated that the Administrator (#24) was notified by her the same day. She stated, Once I report it to the administration, I take my hands off, they do the reporting and investigation. She confirmed that 911 was not called on 2/14/24.
5. The facility's investigation documentation related to Facility Reported Incident (FRI) #MD00205514 was reviewed on 6/11/24 at 10:15 AM. The report indicated that on 5/8/24 at approximately 11:00 AM, Resident #1 reported that a Geriatric Nursing Assistant (GNA) grabbed his/her arm and left a red mark. The facility reported an allegation of abuse to the State Agency within 2 hours and conducted an investigation. Per the Follow-up Investigation Report Form, the final report was sent to the State Agency on 5/16/24. This was more than 5 business days after the alleged incident.
The Administrator and Director of Nursing were made aware of these findings on 6/18/24 at 9:04 AM.
8. Facility reported incident #MD00164917 related to an allegation of abuse involving Resident #62 and a facility employee was reviewed on 6/12/24 at 11:50 AM. The incident was documented as occurring on 3/10/21. According to the facility investigation report documentation that was sent to the Office of health care quality, the 5 day follow up was not received until 3/17/21.
This documentation was confirmed with the current facility DON and Administrator on 6/12/24 at 1:36 PM.
9. A. Review of the facility reported incident #MD00204392 on 6/11/24 at 9:07 AM revealed an allegation of abuse that occurred on the early morning of 4/5/24 with the night shift staff that worked from 4/4/24 into 4/5/24. The nurse failed to report the allegation to the supervisor timely.
According to the facility reported incident, Resident #3 reported to the night shift nurse LPN, staff # 6, about an allegation of inappropriate behavior and interaction between him/her and the GNA providing activities of daily living (ADL) care at around 2:00 AM. This information was not passed on to any supervisor and GNA #3 continued to work her entire shift.
Resident #3 reported the interaction again to the charge nurse on the day shift and Resident #3 was assessed for injuries. The resident was found to have an injured thumb requiring pain medication 3 times a day for the next 5 days.
B. Further, according to the facility investigation, the facility did not complete the interviews and investigation for the abuse incident until 7 days on 4/12/24 not the required 5 days.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
7. Review of Resident #17's facility reported incident (MD 00195075) on 6/10/24 at 11:30am revealed the resident alleged that facility nursing staff grabbed the resident's legs roughly after the resid...
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7. Review of Resident #17's facility reported incident (MD 00195075) on 6/10/24 at 11:30am revealed the resident alleged that facility nursing staff grabbed the resident's legs roughly after the resident complained of pain from an arthritic hip. The resident also alleged facility nursing staff slapped the resident in the face when the resident asked nursing staff to stop treating him/her roughly.
Review of the facility's investigation on 6/10/24 at 11:00 revealed that Resident #17 made the abuse allegation on 8/2/23. The facility report was missing interviews from nursing staff scheduled on the day of the allegation.
Surveyor interview with the Director of Nursing (DON) on 6/11/24 at 9:00am revealed that the facility was unable to locate the missing staff interviews and he/she was unable to confirm that staff interviews were conducted when the abuse allegations were being investigated.
The surveyor expressed concerns that the facility investigation of the allegation of abuse toward Resident #17 was not a thorough investigation on 6/11/24 at 9:30am.
4. On 6/11/24 at 10:38 AM a review of the facility's investigation file for the facility reported incident #MD00186435 revealed a self-report form that documented on 12/5/22 at 2:25 PM the resident reported that Housekeeper #20 had pushed him/her which resulted in a fall.
Interviews were conducted with the witnesses, by the previous Administrator #24, on 12/7/22 however the interview information was confined to 2- 3 questions. The interview with Housekeeper #20 revealed the 3 questions were: 1) where was the resident standing when you approached them, 2) How did the resident fall, and 3) Did you ask the resident not to enter the housekeeping closet? The facility failed to obtain a written, narrative statement from the housekeeper to allow him to put in his own words what had happened.
A review of the interview conducted with Unit Clerk (UC) #26 on 12/6/22, by the previous Administrator #24 revealed her questions were: 1) What did you witness in regard to [Resident #29] fall incident yesterday and 2) Did you hear loud voices prior to the fall? The facility failed to obtain a written statement from the UC to allow her to fully explain what she had witnessed about the incident.
A review of the staff statements obtained from Registered Nurse (RN) #22, and RN #21, revealed that RN #22 stated the resident was laying on their back in the hallway and Resident #21 stated the resident was sitting in the hallway. Facility staff failed to reconcile these differences in their investigation.
RN #22 wrote in his statement that he when he saw Resident #29 laying on the floor, he went to them to assess and assist them off the floor. He did not write that the resident said anything to him at the time but stated that he asked Housekeeper #20 if he had pushed the resident to which the housekeeper replied he had pushed the resident because they were attempting to come into the housekeeping closet. The surveyor was unable to interview RN #20 because the facility had no contact information available, therefore it was uncertain if he was the staff member that Resident #29 had reported they were pushed by the housekeeper as stated on the self-report form.
Further review of facility's investigation file revealed that they failed to obtain statements or interview other staff who may have had knowledge of how this housekeeper interacted with other residents. The housekeeper's supervisor was not interviewed.
A medical record review for Resident #29 on 6/11/24 at 11:34 AM revealed a discharge summary from the local hospital dated 12/3/22 that documented the resident had open heart surgery on 11/18/22. The resident was sent to the facility for rehabilitation services. Review of the therapy notes for an evaluation conducted on 12/5/22 revealed therapy had not ambulated the resident due to safety concerns.
An interview conducted over the phone with the previous Administrator #24 on 6/13/24 at 10:12 AM revealed that he had not determined through his investigation that Housekeeper #20 was abusive towards Resident #29. However, when asked if the actions of the employee were willful without intention to harm the resident was considered abuse and if it was abusive for the housekeeper to go about his duties without assisting the resident after they fell, he stated that he could see where it could be perceived that it was abuse. There was no evidence that housekeeping staff were educated on what to do if a resident was attempting to enter a housekeeping closet to prevent further incidents of abuse.
The concerns were reviewed with the current Administrator and Director of Nursing on 6/13/24 at 12:34 PM.
Based on review of facility documentation and interview with staff it was determined the facility staff failed to investigate, prevent, and correct alleged abuse violations. This was evident for 6 of 27 abuse allegations reviewed related to Residents (#1, #24, #29, #3, #61 and #17).
The findings include:
1. Facility Reported Incident (FRI) #MD00186593 was reviewed on 6/11/24 at 12:50 PM. The report alleged that on 12/14/22 Staff #37, a Geriatric Nursing Assistant (GNA) photographed Resident #1 while he/she was sitting on the toilet. The facility's investigative documentation included a typed statement from Staff #37. It did not include the date and time the statement was written nor when the events described in the statement took place. The statement was not signed by the person providing the statement to indicate it was their statement. The facility's report indicated that the incident occurred on 12/9/22 at 11:45 AM and the police were notified on 12/9/22 at 11:45 AM. However, review of GNA #37's time punch record on 6/12/24 at 11:46 AM revealed that GNA #37 worked from 6:54 AM - 3:00 PM on 12/9/22. She was not removed from duty at the time of the report and was allowed to work the entire shift. There was no evidence that GNA #37 received education related to resident abuse after the incident.
2. The facility's investigation documentation for Facility Reported Incident (FRI) #MD00196546 was reviewed on 6/13/24 at 11:13 AM. The report indicated that the Director of Nursing (DON) received an email from Resident #1's family member on 9/5/23 alleging that a staff member was abusive toward Resident #1. In the email, the family member described a woman with yellow hair as the perpetrator. There was no indication that the facility identified or attempted to identify the woman with yellow hair during their investigation. A statement from Staff #32, a night shift nursing supervisor indicated that a Certified Medication Aide (CMA) interacted with Resident #1 during the night in question. However, he did not identify the CMA and the investigation did not include a statement from a CMA. During an interview on 6/12/24 at approximately 11:00 AM the Director of Nursing was asked to identify the CMA who was working the night of 8/30/23. She indicated that the facility had no CMA's working night shift. The facility did not attempt to identify the person that Staff #32 was identifying as the CMA, during their investigation or obtain a potential witness statement from that person.
Abuse Prevention Measure Interviews were documented with additional staff. Staff #33 a GNA answered yes to the question: Have you recently witnessed a resident being abused, neglected or treated rudely or harshly? There was no explanation or details documented in the space provided. There was no indication that the Administrator reviewed the response and further investigated.
The facility's documentation included sign in sheets for Abuse education dated 9/5/23. The sheets included signatures of 29 staff. However there was no evidence that education was provided to Staff #32, or GNA's #34 and #35 who were the staff working with Resident #1 on the night of the alleged incident. Review of the time punch cards for the accused GNA #34 revealed she was not suspended until 9/5/23 and had worked 11pm - 7am on 9/1/23.
3. FRI #MD00204370 involving Resident #1 was reviewed on 6/17/24 at 8:00 AM. The facility's initial report revealed the DON and Unit Manager reported to Administrator (#24) on 4/4/24 at approximately 5:30 AM that the police were contacted by a complainant regarding an incident of abuse that occurred on 2/13/24. The report also indicated that the incident was reported to the clinical management staff and to Resident #1's representative on 2/14/24. The investigation report indicated that the Unit Manager (#38) performed an interview with Resident #1 on 2/14/24 at approximately 10 AM, regarding the incident. In an interview on 6/17/24 at 4:16 PM the surveyor reviewed the report with Unit Manager (#38). She confirmed that the incident was not reported to the State Agency on 2/14/24 when it occurred, but on 4/5/24 almost 2 months later. She stated, we investigated it then reported it.
The facility report revealed that in an investigation interview the night shift supervisor (#32) indicated that Resident #1 did not inform him of any alleged abuse or mistreatment by GNA #35. Interviews with other staff who worked during the 11pm - 7 am shift on 2/13/24 indicated that they did not know of any concerns. However, Unit Manager #38, the Administrator #24 as well as the clinical management staff were aware of the resident's allegation but failed to report and immediately investigate the allegation of abuse. An investigation was not conducted until 4/5/24.
The facility's report revealed GNA #35, the alleged perpetrator, was relocated to other room assignments and taken off Resident #1's assignment effective 2/13/24. GNA #35 was suspended for 3 days pending the investigation outcome after 4/5/24. The facility failed to remove GNA (#35) from duty at the time of the alleged incident. No documentation was found to indicate that GNA (#35) received education related to abuse after the allegation.
The DON was made aware of these findings on 6/17/24 at 2:00 PM. She was asked to provide evidence that the staff involved in the above allegations of abuse were provided with education related to the allegations. On 6/17/24 at 2:50 PM the DON returned with the ADON (Assistant Director of Nursing). The ADON indicated that she was not able to find documentation that education was provided to the staff accused of abuse of Resident #1. She indicated that they were interviewed regarding the incidents, statements were written, and they were sent off duty, however, there was no evidence that they were provided with education. The Administrator and Director of Nursing were made aware of these findings on 6/18/24 at 9:04 AM.
5. Review of the facility reported incident (FRI) and investigation packet for #MD00204392 on 6/11/24 at 7:39 AM revealed an allegation of abuse between a GNA #3 and Resident #3 occurring at approximately 2:00 AM on 4/5/24.
The staffing schedule for 4/5/24 was in the packet, the schedule form 4/4/24 into 4/5/24 was not available. This surveyor asked for the schedule from that time on 6/11/24 at 9:07 AM from the DON.
Continued review of the facility investigation packet reviewed on 6/11/24 at 9:10 AM, the staff from the day shift of 4/5/24 was interviewed regarding the incident and allegation from the nightshift of 4/4/24 into 4/5/24. However, not all the staff from the 4/4/24-4/5/24 shift were interviewed.
Additionally, 3 of the staff that were interviewed were not interviewed until 7 days after the incident. The DON was asked about the statements in the packet as they were dated 4/12/24 and there was no other signature noting who was conducting the interview. The DON stated that the 'the date is just when the administrator typed up the interview.' This surveyor tried to confirm who did the interview, when it was done and the time. However, she was unable to confirm when it occurred, but stated that it was the previous Administrator that had conducted the interviews
The concern that the facility failed to interview all the potential employees that were present at the time of the allegation and further document on the interviews who completed them, and the actual date and time of the interview was reviewed on 6/11/24 at 10:10 AM.
6. On entrance to the facility on 6/10/24 a list of facility reported incidents was emailed to the Administrator and requested for review, including for Resident #61.
The surveyor began reviewing the facility reported incident #MD00165609 on 6/11/24 at approximately 11 AM revealed an allegation from Resident #61 alleging s/he was abused from 'a gang of hooligans.'
The investigation into this allegation was requested again on 6/11/24. A small packet was provided that only contained progress notes and psychiatric notes from the time of the event.
There were no interviews or other investigation details.
This concern was reviewed with the DON on 6/12/24 at 1:36 PM and she stated that she was aware since the incident had occurred in 2021 and they did not have the investigation file.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
Based on medical record review and interview with staff it was determined the facility staff failed to accurately complete resident assessments reflective of the resident's status. This was evident fo...
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Based on medical record review and interview with staff it was determined the facility staff failed to accurately complete resident assessments reflective of the resident's status. This was evident for 5 of the last 5 assessments for 1 (Resident #1) of 65 resident's reviewed for during the survey.
The findings include:
The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.
The Brief Interview for Mental Status (BIMS) is a 15-point cognitive screening test that evaluates memory and orientation. 0-7 points: Severe cognitive impairment, 8-12 points: Moderate cognitive impairment and 13-15: Intact cognition.
A PHQ (Patient Health Questionnaire) is a nine-item questionnaire that can be used to assess the severity of depression.
A brief interview was conducted on 10/11/24 at 10:39 AM with Resident #1. He/She was able to communicate verbally however he/she had difficulty forming words clearly and communicated his/her thoughts and questions to the surveyor by writing on a piece of paper.
Resident #1's record was reviewed on 6/12/24 at 2:05 PM. The most recent MDS assessment was a quarterly assessment with an ARD (assessment reference date) 4/24/24.
Section C Cognitive Patterns C0100 asked the question: Should Brief Interview for Mental Status (BIMS) (C0200-0500) be Conducted? A dash (-) was marked in the space provided. It was not coded to indicate 0. No or 1. Yes as indicated in the instructions. Staff Assessment for Mental Status (C0600-C1000) also contained dashes. Resident #1's cognitive pattern was not assessed.
Section D Mood D0100 Should Resident Mood Interview be Conducted? Was coded 1. Yes - Continue to D0150, Resident Mood Interview (PHQ-2 to 9). The spaces provided for the mood interview answers all contained a dash (-). They were not answered 0. (No), 1. (Yes) or 9. (No response), as indicated in the instructions. Staff Assessment of Resident Mood (D0500) was not completed. Resident #1 was not assessed for depression.
Review of section's C and D for the quarterly MDS assessments with ARD's 3/1/24, 10/13/23, and 4/12/23 and the most recent Annual MDS assessment with an ARD of 7/13/23 also contained dashes or were left blank. They were not coded as per the instructions. The surveyor was unable to find that Resident #1's Cognitive Status and Mood were assessed quarterly for the past year.
An interview was conducted on 6/12/24 at 12:55 PM with Staff #23 Registered Nurse/MDS Supervisor. She indicated that she has worked in the facility since 8/2017 and was familiar with Resident #1. She was asked why Section C and D were not completed in Resident #1's MDS assessments. She indicated that lately Resident #1's BIMS has not been done. She then indicated that the resident and family have requested that no assessments be done and added also PHQ-9. She indicated that a staff assessment could be done but the other MDS nurse attempted it in the past and Resident #1's family had a fit. She stated I went to my top people - corporate management. She was asked if the requirement for the MDS assessments was discussed with the family. She indicated yes, and that they did not provide rationale for refusal. She indicated that Resident #1 had a Plan of Care for refusing assessments and laboratory tests.
Further review of Resident #1's medical record on 6/13/24 at 8:00 AM failed to reveal a plan of care addressing assessments or the resident/family refusal.
Review of the RAI (Resident Assessment Interview) Manual Version 3.0 instructions, revealed specific instructions for properly coding MDS Sections C and D when the resident refuses to answer. It included the proper codes to use when the resident refused and guidance for the Assessor to proceed to item D0700, Social Isolation in the case of resident refusal or unwillingness to participate.
These instructions were not followed by the facility staff.
The Administrator and Director of Nursing were made aware of these findings on 6/18/24 at 9:04 AM.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 6/11/24 at 12:42 PM, a medical record review was conducted for Resident # 20. Resident # 20 has a diagnosis of Congestive ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 6/11/24 at 12:42 PM, a medical record review was conducted for Resident # 20. Resident # 20 has a diagnosis of Congestive Heart failure, and other diagnosis.
There were multiple orders for obtaining weights for Resident # 20. On 5/4/23 order stated to weigh resident every day shift for 7 days. On 5/4/23 there was a second order to weigh resident every day shift every Tuesday and on 5/5/23 there was a third order to weigh Resident # 20 every day. There were no weights taken on 12 dates in 05/23 and 18 dates in 06/23, as well as 3 dates in 07/23.
The Director of Nursing (DON) was interviewed on June 11, 2024, regarding multiple orders for obtaining weights. The DON stated the orders for 5/4/23 should have been discontinued or clarified with the doctor regarding frequency of weights for Resident # 20.
2. The facility staff failed to assess and provide care to a scalp wound for Resident #25.
Review of Resident #25's medical record on 6/17/24 revealed the Resident was admitted to the facility to 2/28/23 following craniectomy surgery. A craniectomy is a major brain surgery that involves removing part of the skull to relieve pressure on the brain.
Review of the Neurosurgeon's progress notes from a follow up appointment on 4/4/23 revealed the Neurosurgeon documented, I am concerned about his/her scalp healing. Discussed wound with wound care, Recommendations are to apply Medihoney daily, and cover with dressing. Medihoney needs to be applied at a minimum every three days, and covered.
Further review of Resident #25's medical record revealed no assessment of the Resident's post surgical scalp wound on admission to the facility and no treatment of the wound until 4/6/23. The wound was not documented it was assessed by the wound team until 4/7/23.
Interview with the Director of Nursing on 6/17/24 at 2:10 PM confirmed the facility staff failed to assess Resident #25's scalp wound on admission and provide treatment until 4/6/23.
3. Review of a Facility Reported Incident (FRI) on 6/13/24 at 1:00 PM revealed that Resident #1 alleged that that a Phlebotomist (Laboratory technician) and a nurse held his/her arms and legs during an attempted blood draw on 12/21/23 at approximately 6:30 PM. The facility's investigative documentation revealed that in response to this allegation, on 12/28/23 staff were educated to have 2 people present at all times when providing any care or procedures to Resident #1. Resident #1's medical record revealed a verbal order written by a Nurse Practitioner (NP) on 12/29/23 at 15:02 for Resident is a two person assist with ADL's (Activities of Daily Living), Transfers, and any procedures every shift.
A care plan intervention: Answer resident's call light and enter room with another person was initiated on 1/22/24 to Resident #1's plan of care for behaviors.
A plan of care was initiated on 5/15/24 for: (Resident #1) will have 2 Caregivers/2 Nurses at bedside at all time during ADL Care and when Caring for the resident needs. It was initiated on 5/15/24. The surveyor was unable to find how the NP's order was consistently communicated to all staff and providers that provide care for Resident #1 between 12/29/23 and when the plan of care was developed on 5/15/24.
Review of another FRI on 6/17/24 at 9:36 AM revealed that Resident #1 made an allegation on 6/10/24 at 7:20 PM that he/she was slapped during the prior night shift by a GNA (#39).
A statement from GNA #39 indicated that in the evening on 6/9/24 she provided ADL care and left the resident in bed asleep. She indicated that she returned to the room at approximately 1:30 AM on 6/10/24 with a nurse (#40) to assist the resident to the bathroom. When they returned to assist him/her back to bed, GNA(#39) left the room at Resident #1's request and the nurse (#40) assisted the resident back to bed from the bathroom.
A statement from the Registered Nurse (RN) (#40) indicated that he and the GNA (#39) assisted the resident to the bathroom on 6/9/24. He indicated that the GNA was in the bathroom with Resident #1 and after about 2 minutes, the GNA (#39) opened the door and indicated (Resident #1) needs you. The resident then stated to him I don't want to work with (GNA#39) anymore. When Nurse #40 asked about any specific reasons the resident did not provide a reason. The statements by GNA #39 and RN #40 indicated that neither staff member ensured that 2 staff were present when care was provided for Resident #1 during the night of 6/9/24 as per Resident #1's Plan of Care and the NP order.
On 6/17/24 at 2:00 PM the DON was asked to provide documentation of where the NP order written on 12/29/23 for 2 person assist was transcribed/communicated to staff. None was provided.
An interview was conducted on 6/17/24 2:50 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON).
The DON indicated that an order for 2 person assist with ADL's, transfers, and any procedures every shift is a nursing order not a physicians order. She was made aware that on 12/29/23 15:02, a NP provided a telephone order for 2 staff to assist. She was asked how this order on 12/29/23 would have been transcribed or otherwise communicated to ensure that it was consistently implemented by all staff. She explained that it should not have been ordered. She added that the information would be passed on verbally during the change of shift report.
She was made aware that it is on the resident's current plan of care (initiated 5/15/24 - 2 caregivers/2 nurses at bedside at all time during ADL Care and when Caring for the resident needs.) However, it was not added until 5/15/24. She was made aware that statements the facility obtained from staff during abuse investigations indicated that staff were providing care for the resident alone. She was made aware of the most recent incident in the early morning of 6/10/24 in which GNA #39 assisted the resident in the bathroom alone. She indicated that the Nurse that was on duty (RN #40) was a male, so the GNA needed to provide care alone. She was asked if the GNA soul have gotten another female staff for assistance. She replied that if another female staff is not available, then staff are to provide care to the resident alone to maintain dignity.
An interview was conducted with Staff #32 a Registered Nurse on 6/18/24 at 6:57 AM. He confirmed there should be 2 staff at all times when caring for Resident #1 and that it was implemented about 2 months ago and there was a lot of he said/she said going on.
During an interview on 6/18/24 at 7:08 AM GNA (#35) confirmed that there should be 2 people at all times when caring for Resident #1 and indicated the intervention was started about 6 months prior. She stated we always go with 2 because he/she always complains. 2 people to always have a witness. The Administrator and Director of Nursing were made aware of these findings on 6/18/24 at 9:04 AM.
Based on the review of a complaint, medical record review and interview with staff, it was determined that staff failed to provide all treatment and care to residents in accordance with professional standards of practice by failing to follow practitioner orders and established care plans. This was evident for 4 of 65 (#43, #1, #25 and #20) residents reviewed during a complaint survey.
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
The findings include:
1. Review of the medical record for Resident #43 on 6/14/24 at 10:59 AM revealed admitting diagnosis for surgical aftercare following surgery on the circulatory system. Resident #43 had arrived at the facility after a short stay at home with 3 areas, the groin, the medial and the anterior areas of the right leg all noted as surgical incisions requiring wound care and treatment by the wound care nurse practitioner on admission.
A review of the physician orders failed to reveal orders in place for the treatment of 2 of the 3 wounds, only wound care for the groin wound was addressed.
A review on 6/14/24 of the physician history and physical documented as completed on 2/5/22, also failed to reveal any review or identification of the surgical wounds or plan for the care of the wounds.
The hospital discharge summary, also reviewed at this time, did not have care instructions for the surgical wounds; however, the wound nurse practitioner saw the resident on admission on [DATE] and had recommendation to apply dry dressing daily and clean with normal saline on all the identified wounds. According to the medication and treatment administration record the only orders in place were for wound care for the groin wound and to 'monitor the surgical site (staples) to the right lateral and medial lower leg every shift.'
This identified concern was reviewed with the DON on 6/14/24 at approximately 1:00 PM and again during exit on 6/18/24 after no further documentation related to wound care treatment was provided.
Sept 2019
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
3. On 09-23-19 at 08:30 AM, 12:10 PM, 3:45 PM and on 09-24-19 at 07:30 AM and 09:20 AM, surveyor observation of resident #219 revealed a Foley catheter (a flexible tube which passes through the urethr...
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3. On 09-23-19 at 08:30 AM, 12:10 PM, 3:45 PM and on 09-24-19 at 07:30 AM and 09:20 AM, surveyor observation of resident #219 revealed a Foley catheter (a flexible tube which passes through the urethra and into the bladder to drain urine) hanging from the side of the bed with no dignity bag (a bag which covers the Foley catheter's drainage bag from plain sight) present. The resident's door was left open most of the time and the Foley bag could be seen by anyone walking in the hallway.
On 09-24-19 at 11:22 AM, the resident was observed in his/her wheelchair being pushed by the physical therapist in the hall way with the Foley bag hanging on the wheelchair with no dignity bag.
On 09-24-19 at 1:30 PM, surveyor interview with the DON revealed there should be a dignity bag covering the Foley catheter's drainage bag to preserve dignity. No additional information was provided.
Based on surveyor observations and interview with facility staff, it was determined that the facility failed to ensure the dignity of residents. This finding was evident for 3 of 4 residents selected for the Dignity review. (#26, #58, #219) The findings include:
1. On 09-23-19 at 10:30AM, surveyor observed signage posted on the wall over resident #58's bed that indicated Swallowing Precautions were in place for the resident. The sign detailed steps necessary to assist the resident during meals. The posted steps included: the resident taking small, single bites and sips, eating at a slow rate, every 1-2 bites a liquid wash was necessary, the resident should be in an upright position during eating as well as be maintained upright 20-30 minutes afterwards, and that the resident requires assistance with set up of meals (i.e. cutting food).
Surveyor interview with resident #58 on 09-24-19 at 3:52PM revealed that the Swallow Precautions signage was posted by the facility's speech therapist some time ago without the resident's permission.
On 09-25-19 at 1:30PM and 5PM, surveyor interview with the Director of Nursing revealed no additional information.
2. On 09-23-19 at 11:30AM and 09-24-19 at 1:30PM surveyor observations revealed a posting of signage over resident #26's bed that indicated A & D ointment after each change on Buttocks-- Thanks. A & D ointment is a skin protectant that moisturizes and seals the skin, and aids in skin healing.
Record review revealed resident #23 is alert to name only and totally dependent on staff assistance in meeting his/her daily personal care needs. Further review revealed physician orders that were initiated on 02-25-19 for the application of the A & D ointment after each incontinent care for every shift.
On 09-25-19 at 1:30PM and 5PM, surveyor interview with the Director of Nursing revealed no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0603
(Tag F0603)
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 records, and resident 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 records, and resident and facility staff interview, it was determined that the facility staff failed to prevent involuntary seclusion during the treatment of a resident's medical condition. This finding was identified in 1 of 5 residents with infections not UTI related during the survey. (#99). The findings include:
On 09-23-18 at 09:10 AM, during initial tour of the facility, surveyor observed an isolation cart (One of several measures that can be taken to prevent contagious diseases from being spread from a patient to other patient, healthcare workers, visitors and outsiders) set up at the entrance of resident #99's room with a visible sign indicating that the resident was on an isolation. Per Center for Disease Control, (CDC) different measures are taken to prevent the spread of diseases: Examples include standard precautions and contact precautions.
Surveyor review of the clinical records revealed that resident #99 was re-admitted to the facility on [DATE] after a brief hospital stay following a medical procedure. Additional record review revealed that resident #99 was on isolation precautions for a sacral wound infection of (Methicillin-resistant staphylococcus aureus) MRSA. (A bacterium that causes infections that is tougher to treat because its resistant to commonly used antibiotics).
On 09-23-19 at 10:22 AM, surveyor interview with the unit manager revealed that resident #99 was not permitted to leave his/her room because he/she was on contact isolation/precaution. (series of procedures/measures designed to minimize the transmission of infectious organisms by direct contact with an infected patient. Contact precautions are often used with patients who have wound or skin infections due to the infection in his/her wound).
The unit manager further stated that the resident's infection was restricted to his/her sacral wound and the wound was always covered except during treatment.
According to CDC updates on Multidrug-Resistant Organism Management released in July 2019, residents on Contact Precautions should be restricted to their rooms only when the wound is not contained. If the patient's wound is contained by a dressing, then the precaution can be changed from contact precaution/isolation to Enhanced Barrier Precaution.
However, although resident #99's source of infection was isolated to his/her sacral wound and the wound was contained by a dressing, the facility still restricted resident #99 to his/her room from 09-06-19 to 09-25-19.
On 09-25-19 at 09:15 AM, surveyor interview with resident #99 revealed that he/she had been on contact isolation since he/she returned from the hospital following a procedure. Resident #99 denied being depressed and stated he/she understood what the facility did, although resident would have appreciated being allowed to at least go to church.
On 09-25-19 at 09:15 AM, surveyor interview with the Director of Nursing and the infection control nurse revealed no new information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to report an incident of suspected elopement of a resident from the faci...
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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 report an incident of suspected elopement of a resident from the facility to the State Survey Agency. This finding was identified in 1 of 2 residents reviewed for accidents. (#222). The findings include:
Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.
This finding was identified during the investigation of complaint #MD00142298.
On 09-23-19 at 09:30 AM, surveyor review of the closed clinical record revealed that resident #222 was admitted to the facility's rehabilitation unit on 07-01-19 after a brief hospital stay. Further record review revealed that the resident was alert and oriented to self, place and time and that the resident was self-represented. Further record review revealed the facility's elopement risk assessment which indicated that the resident was a low risk for elopement.
Additional record review revealed that on 07-03-19 at around 2 PM, facility staff observed that resident #222 was not in the building. The facility initiated a search and notified the police and the resident's niece who was listed as resident's second contact person. Further record review revealed that the resident was brought back to the facility by the local police who stated the resident was found at a local bar. Surveyor review of the facility interview with the resident upon return revealed that the resident stated, I called Uber to meet with a few of my friends at the local bar.
Although the facility investigated the incident and put plans in place to prevent similar incidents, the facility failed to report this incident to the State Survey Agency as required.
On 09-25-19 at 4:10 PM, surveyor interviewed the Administrator and the Director of Nursing. The administrator stated that the incident was not reported because: 1. The resident had capacity and was able to make his/her own decisions and therefore had the right to go wherever he/she wanted to go. 2. The resident returned to the facility and was not out of the facility for more than 24 hours. No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 09-23-19 at 2:05 PM, interview with resident #68 revealed that resident received pain medication 2 hours earlier and that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 09-23-19 at 2:05 PM, interview with resident #68 revealed that resident received pain medication 2 hours earlier and that he/she still had pain on the left rotary cuff.
On 09-25-19 at 4:40 PM, surveyor review of resident's clinical records revealed the resident had an order for acetaminophen-codeine #3 tablet 300-30MG 1 tablet every 4 hours as needed for pain and another order for Morphine Sulfate 15 MG every 6 hours as needed for severe pain.
Further record review revealed that resident had received as needed pain medications on
09-01-19,
09-03-19 to 09-06-19,
09-08-19 to 09-10-19,
09-12-19 to 09-13-19,
09-15-19 to 09-21-19, and
09-23-19 to 09-24-19.
However, record review revealed no evidence that the nurses documented a re-evaluation of resident #68's pain after medication administration.
According to the Maryland Nurse Practice Act 10.27.10.02 F(f) Standard of Care -The RN shall evaluate the client's progress toward attainment of outcomes-The responses to interventions shall be documented and communicated to the client and other members of the health care team
Based on surveyor review of clinical records and staff interviews, it was determined that the facility staff failed to ensure that services provided by the facility met professional standards of quality. This finding was evident in 2 of 34 residents selected for review (#68 and #99). The findings include:
1. On 09-23-18 at 09:10 AM during initial tour of the facility, surveyor observed an isolation cart (One of several measures that can be taken to prevent contagious diseases from being spread from a patient to other patient, healthcare workers, visitors and outsiders) set up at the entrance of resident #99's room with a visible sign indicating that resident was on an isolation.
Surveyor review of the clinical records revealed that resident #99 was re-admitted to the facility on [DATE] after a brief hospital stay after a medical procedure. Additional record review revealed that resident #99 was isolated for an infection MRSA (Methicillin-resistant staphylococcus aureus) in the wound. (MRSA is a bacterium that causes infections that is tougher to treat because of its' resistance to commonly used antibiotics).
On 09-23-19 at 10:22 AM, surveyor interview with the unit manager revealed that resident #99 was on contact isolation due to the infection in his/her wound.
On 09-25-19 at 09:15 AM, surveyor interview with resident #99 revealed that he/she had been on contact isolation since returning from the hospital following a medical procedure.
However, surveyor review of resident #99's Physician Order sheet (POS) for September and hospital transfer orders, there was no evidence of a physician's order to isolate resident #99.
As a standard of nursing practice, licensed nurses are required to perform according to doctors' orders and if an order is not clear, they are required to notify the primary physician for clarification as indicated in section 10.27.09.01 of the Nurse practice act under collaboration of care.
On 10-25-18 at 1:40 PM, surveyor interview with the Director of Nursing (DON) revealed no additional information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 09-23-18 at 09:10 AM, during an initial tour of the facility, surveyor observed an isolation cart (One of several measures...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 09-23-18 at 09:10 AM, during an initial tour of the facility, surveyor observed an isolation cart (One of several measures that can be taken to prevent contagious diseases from being spread from a patient to other patients,healthcare workers, visitors and outsiders) set up at the entrance of resident #99's room with a visible sign indicating that the resident was on isolation precautions.
Surveyor review of the clinical records revealed that resident #99 was re-admitted to the facility on [DATE] after a brief hospital stay. Additional record review revealed that resident #99 was isolated for an infection in the wound categorized as MRSA (Methicillin-resistant staphylococcus aureus) a bacterium that causes infections that is tougher to treat because of its resistance to commonly used antibiotics.
On 09-23-19 at 10:22 AM, surveyor interview with the unit manager revealed that resident #99 was on contact isolation due to the infection in his/her wound.
On 09-25-19 at 09:15 AM, surveyor interview with resident #99 revealed that he/she had been on contact isolation since he/she returned from the hospital following a medical procedure.
However, additional review of resident #99 clinical record, revealed no evidence that a care plan with interventions to address the contact isolation was developed.
On 09-25-19 at 1:40 PM, surveyor interview with the director of nursing (DON) revealed no additional information.
3. On 09-26-19 at 10:12 AM, surveyor review of the clinical record for resident #61 revealed that the resident had a medical condition that prevented the resident from being able to urinate on his/her own. Further review of the physician order sheet (POS) and Treatment Administration Record for the months of August and September 2019, revealed a physician specific order to catheterize (is a process of placing a flexible hollow tube in the body to drain and collect urine from the bladder) the resident once every 8 hrs.
On 09-26-19 at 10:40 AM, surveyor interview with resident #61 revealed that facility catheterized him/her once every shift.
However, there was no evidence in resident #61's clinical record that the facility staff initiated a plan of care for this medical procedure, which was being performed daily.
On 09-26-19 at 1:40 PM, surveyor interview with the director of nursing (DON) revealed no additional information.4. On 09-27-19, surveyor review of the clinical record revealed that resident #30 was admitted to the facility with 4 pressure ulcers.
Further review of the clinical record revealed no evidence that facility staff developed a care plan to address resident #30's pressure ulcers.
On 09-27-19, surveyor interview with the Director of Nursing provided no additional information.
Based on surveyor review of the clinical record, surveyor observation and interview with facility staff, it was determined that the facility failed to develop comprehensive plans of care for residents. This finding was evident for 4 of 34 residents selected during the survey (#30, #61, #64, #99). The findings include:
1. a. On 09-23-19, surveyor review of the clinical record for resident #64 revealed the resident was alert and oriented and able to verbalize his/her own needs. Further review revealed that an admission smoking evaluation was completed on 07-23-19, and that the resident was assessed as safe to smoke with staff supervision.
Surveyor observations on 09-23-19 at 10:15 AM, and on 09-24-19 at 2 PM, revealed resident #64 outside the facility, in the designated smoking area, smoking and conversing with staff and other residents.
However, further record review revealed no documented evidence of a comprehensive plan of care that addressed resident #64's smoking behavior as well as the need for supervison while smoking, until surveyor intervention on 09-25-19.
Interview with the facility's Director of Nursing on 09-25-19 at 6:30 PM revealed no additional information.
b. Additionally, further record review revealed that the attending physician ordered on 07-23-19 that resident #64 was to be on a fluid restriction of 1500 ml (milliliters) in a 24 hour period. This amount included the fluids to be consumed at meals and during medication administration.
Surveyor observation on 07-23-19 at 12:15 PM revealed a water pitcher sitting on the resident's bedside table and a half filled bottle of soda. During an interview with resident #64, s/he denied being on any type of fluid restrictions.
Interview on 09-25-19 at 5 PM with the facility's dietician revealed that resident #64 was on a 1500 ml per day fluid restriction, and the fluid amounts are divided both between dietary and nursing. Further interview revealed the dietician was aware that the physician had ordered the fluid restriction, but was unaware of the reason for the restriction. No additional information was provided.
However, review of the comprehensive plans of care for resident #64 revealed no documented evidence of a plan of care that addressed the resident's fluid restriction until surveyor intervention on 09-25-19.
Interview with the Director of Nursing on 09-25-19 at 6:30 PM 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** Based on surveyor observations, review of the facility's policy and procedure, interview with residents, maintenance contractors...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observations, review of the facility's policy and procedure, interview with residents, maintenance contractors and facility staff, it was determined that the facility failed to ensure that water temperatures were maintained in residents' rooms at a safe temperature below 120 degrees Fahrenheit (F). The findings include:
a. On 09-23-19 at 12:00PM, surveyor observation revealed the following initial hot water temperature results for residents' bathrooms sinks:
room [ROOM NUMBER] = 123.8 F
room [ROOM NUMBER] =127.9 F
room [ROOM NUMBER]= 126.8 F
room [ROOM NUMBER] =125.5 F
room [ROOM NUMBER] = 128.8 F
room [ROOM NUMBER] = 128.7. F
b. Further observations on 09-23-19 at 12:30PM revealed the following hot water temperatures obtained at residents' bathroom sinks:
room [ROOM NUMBER] = 123.8 F
room [ROOM NUMBER] = 128 F
room [ROOM NUMBER] = 126.5 F
room [ROOM NUMBER] = 128.1 F
room [ROOM NUMBER] = 128.1 F
c. Observations of follow up hot water temperatures obtained at the following 2nd floor residents' bathrooms sinks:
1:46 PM room [ROOM NUMBER] = 126.7 F
1:47 PM room [ROOM NUMBER] = 125.9 F
1:48 PM room [ROOM NUMBER] = 127.4 F
1:50 PM room [ROOM NUMBER] = 127.2 F
1:52 PM room [ROOM NUMBER] = 127 F
1:56 PM room [ROOM NUMBER] = 124.5 F
2 PM room [ROOM NUMBER] = 127 F
d. In addition, temperatures were obtained from the following 1st floor residents' rooms:
1:56 PM room [ROOM NUMBER] = 124.7 F
1:58 PM room [ROOM NUMBER] = 123.9 F
1:56 PM room [ROOM NUMBER] = 124.4 F
1:50 PM room [ROOM NUMBER] = 125.2 F
1:52 PM room [ROOM NUMBER] =124 F
1:55 PM room [ROOM NUMBER] = 123.1 F
2:04 PM room [ROOM NUMBER] = 127 F
2:07 PM room [ROOM NUMBER] = 127.2 F
e. Surveyor interview on 09-23-19 at 1:56 PM with the resident in room [ROOM NUMBER] revealed that the resident felt the hot water from the bathroom sink was too hot, but the resident mixed the cold water with the hot to cool it down prior to using the water. Many of the residents observed, during the hot water temperature checks, were capable of independently mixing the cold water with the hot water, while other observed residents required the assistance of staff to retrieve water from the bathroom sinks.
On 09-23-19 at 3:05 PM, surveyor interview with the facility maintenance director and administrator revealed that water temperatures were obtained weekly, on Wednesdays, of randomly selected resident rooms. Both the maintenance director and/or the maintenance assistant obtained water temperatures from the residents' bathrooms sinks as well as shower rooms on the 1st and 2nd floor. The temperature results were documented on a weekly temperature log sheet.
Review of the facility's last 3 months of water temperature logs revealed the last documented reading was obtained on 09-18-19. At that time, temperatures were taken from 3 residents' rooms on the 1st floor and 3 residents' rooms on the 2nd floor, as well as both the 1st and 2nd floor shower rooms. Further review of the 09-18-19 log revealed that water temperature results were documented at 118 F for all 6 rooms and showers.
During an interview with the maintenance director and the administrator at 3:15 PM on 09-23-19, surveyor requested that hot water temperatures be obtained from some of the selected rooms on the 09-18-19 temperature log.
On 09-23-19, surveyor reviewed the following water temperatures (checked by the maintenance director of residents' rooms that were randomly selected on 09-18-19)
3:04 PM room [ROOM NUMBER] =124.6 F
3:10 PM room [ROOM NUMBER] =123.6 F
3: 12 PM room [ROOM NUMBER] =125.2 F
3:15 PM room [ROOM NUMBER] =126.8 F
f. Further surveyor observation on 09-23-19 at 3:36 PM revealed a hot water temperature in room [ROOM NUMBER] = 126.3 F, while at 3:45 PM a hot water temperature result in room [ROOM NUMBER] of 124.9 F. Interview at that time with the resident in room [ROOM NUMBER] revealed that the hot water had been quite hot since the resident was admitted a week ago, but he/she was capable of mixing the hot water with the cold prior to its use.
Observation and interview with the maintenance director and administrator of the facility's boiler room revealed that the hot water heater, which supplies residents' areas, was currently set at 125 F. Two maintenance contractors were observed working in the boiler room
Surveyor interview with maintenance contractor #4 on 09-23-19 at 6 PM revealed that when he initially arrived at the facility on this day around 10 AM, the maintenance request was due to hot air temperatures within the facility. Contractor #4 stated that he was not aware of any issues involving the hot water temperature until he was informed by the facility's maintenance director in the afternoon. Also he was unaware that the facility had 2 existing hot water heaters (1 for kitchen usage and 1 for residents areas), since neither had been labeled. Further interview revealed no issues with the mixing valve at the water tank. (The mixing valve is a device that prevents excessively hot water from reaching resident areas). The hot water heater setting supplied to the residents' areas was lowered and current water temperatures checked in randomly selected rooms for both the 1st and 2nd floors had readings between 101-115 F at present. The facility maintenance director will continue to maintain checks of the hot water temperatures.
On 09-25-19 at 1:15 PM, surveyor interview with maintenance contractor #5 and the facility administrator revealed that a replacement of a valve was completed, with the mixing valve adjusted. Further interview with contractor #5 revealed that, not until surveyor intervention on 09-23-19, had the workers been aware that there was an issue with the water temperatures. The initial call repair request was for elevated air temperatures within the facility. Hot water temperatures have been monitored and maintained below 120 F since intervention on 09-23-19, while the hot water tank for residents' use has been set at 120 F. The facility has been instructed to monitor the hot water tanks settings daily and to utilize a clipboard at the tanks for documentation and have a plan for intervening if the setting registers above 120 F.
Interview with administrator and the Director of Nursing on 09-25-19 at 2 PM revealed no additional information.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on surveyor observation, review of clinical records, facility policy and procedures and interview with facility staff, it was determined that the facility failed to ensure infection control prac...
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Based on surveyor observation, review of clinical records, facility policy and procedures and interview with facility staff, it was determined that the facility failed to ensure infection control practices to prevent development and transmission of communicable disease and infections for resident #221. This finding was evident for 1 of 3 residents reviewed for the respiratory care area.
Additionally, based on surveyor observations and interview with facility staff, it was determined that the facility staff failed to ensure appropriate hand hygiene practices between residents' contacts during meal distribution. This finding was evident for 2 of the 2 floors within the facility of resident units. The findings include:
1. On 09-23-19 at 10:30 AM, surveyor tour to resident #221's room revealed oxygen tubing connected to an oxygen concentrator (a device which concentrates the oxygen from the surrounding air). The tubing was observed on the floor under the resident's bed. The tubing and the humidifier bottle were not dated.
Additional observation revealed a nebulizer treatment (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) set up on the resident's bedside lamp table. The tubing and the canister (plastic container that holds the medication) were left on the bare table with tubing still attached to the canister and were not dated.
Surveyor review of the clinical records for resident #221 revealed a physician order that stated Change and date oxygen tubing every week and as needed.
On 09-24-19 at 09:12 AM, surveyor interview with Director of Nursing (DON) 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, facility staff failed to store the oxygen tubing in a plastic bag. In addition, there was no evidence that the tubing was changed as indicated in the physician order sheet.
2. On 09-27-19 at 5:30 PM, surveyor review of facility infection control program and policies with the infection control nurse revealed that the infection control team meets monthly and discusses ongoing infection related issues.
However, review of the facility's infection control program policy and procedures revealed that the policy had not been reviewed since 2016. Additionally, there was no evidence that the antibiotic stewardship program has been reviewed since 2016.
On 09-27-19 at 5:40 PM, surveyor interview with the director of nursing revealed no new information.
Oct 2018
16 deficiencies
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 surveyor review of the clinical records and facility staff interview, it was determined that facility staff failed to notify families and the physician of residents' significant weight loss. ...
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Based on surveyor review of the clinical records and facility staff interview, it was determined that facility staff failed to notify families and the physician of residents' significant weight loss. This finding was evident for 2 of 3 residents selected for nutrition review during the survey. (#60 and #63) The findings include:
1. a. On 10-11-18, surveyor review of the clinical record revealed that resident #60 had lost 14 pounds (greater than 5% of body weight) between 04-16-18 and 05-14-18.
Further review of the clinical record revealed that resident #60 had lost 37 pounds (greater than 16% of body weight) in the 6 months between 03-15-18 and 09-07-18.
However, there was no evidence that the family of resident #60 was notified of the significant changes in the resident's weight.
On 10-11-18 at 5 PM, surveyor interview with the nurse practice educator/infection control nurse provided no additional information.
On 10-15-18 at 11 AM, follow up interview with the Director of Nursing provided no additional information.
b. On 10-11-18, further review of the clinical record for resident #60 revealed a weight loss of 10 pounds between 09-07-18 and 10-02-18. There was no evidence that the physician was notified of resident #60's continued weight loss. On 10-11-18 at 5 PM, surveyor interview with the nurse practice educator/infection control nurse provided no additional information.
On 10-15-18 at 11 AM, follow up interview with the Director of Nursing provided no additional information.
2. On 10-11-8, surveyor review of the clinical record revealed that resident #63 had lost 12 pounds (greater than 7% of body weight) between 06-21-18 and 07-10-18. In addition, the resident lost 11 more pounds (greater than 8% of the resident's body weight) between 08-24-18 and 09-10-18.
Further review of the clinical record revealed that resident #63 had lost 32 pounds (greater than 20% of the resident's body weight in the 6 months between 04-29-18 and 10-02-18. However, there was no evidence that the family of resident #63 was notified of the significant changes in the resident's weight.
On 10-11-18 at 5 PM, surveyor interview with the nurse practice educator/infection control nurse provided no additional information.
On 10-15-18 at 11 AM, follow up interview with the Director of Nursing provided 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 observation, review of the clinical records, and interview of facility staff, it was determined that the facility failed to develop comprehensive care plans to address the medical ne...
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Based on surveyor observation, review of the clinical records, and interview of facility staff, it was determined that the facility failed to develop comprehensive care plans to address the medical needs of residents . This finding was evident for 2 of 5 residents selected for the unnecessary medication review during the survey. (#40 and #61) The findings include:
1. On 10-15-18, surveyor review of the clinical record revealed that resident #40 had a diagnosis of deep vein thrombosis and was receiving a blood thinner.
Further review of the clinical record revealed no evidence that a care plan was developed to address the needs of resident #40 having a deep vein thrombosis and being administered a blood thinner.
On 10-16-18 at 11 AM, surveyor interview with the Director of Nursing provided no additional information.
2. On 10-15-18, surveyor review of the clinical record for resident #61 revealed that the resident had a history of breast cancer, was receiving an anti-cancer medication, and required routine follow up with the oncologist.
Further review of the clinical record revealed no evidence that a care plan was developed to address the needs of resident #61 related to the history of breast cancer, medication management, and follow-up treatment.
On 10-16-18 at 11 AM, surveyor interview with the Director of Nursing provided no additional 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 record and interview with facility staff, it was determined that the facility staff failed to revise a comprehensive plan of care to reflect the needs of resid...
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Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility staff failed to revise a comprehensive plan of care to reflect the needs of resident #53. This finding was identified for 1 of 31 residents selected for the care plan review during the survey. The findings include:
On 10-15-18, surveyor review of the clinical record for resident #53 revealed a comprehensive plan of care, initiated on 08-29-18, regarding the resident's potential to develop pressure ulcers related to incontinence and immobility. On 09-11-18, staff revision of the plan of care included interventions by licensed staff that included the use of barrier skin creams, daily skin checks, use of a pressure reducing mattress and a wheel chair cushion.
Further record review revealed licensed staff documentation on 09-06-18 of a facility acquired sacral wound area, with a treatment plan to cleanse with saline, apply Hydrogel ointment and cover with a dry dressing daily.
On 09-20-18, the treatment plan for the sacrum area wasamended to include the use of Santyl ointment and a dressing once daily. On 10-11-18, the treatment to the sacral area was modified again to include the use of silver alginate twice daily with a dressing.
However, there was no documented evidence that facility staff revised the comprehensive plan of care for resident #53 to reflect the changes in the treatment plan for the actual skin breakdown after 09-06-18.
On 10-16-18 at 3:30PM, surveyor interview with the Director of Nursing revealed no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical records, surveyor observations and interview with facility staff, it was determined that the facility failed to ensure standards of nursing practice in medicat...
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Based on surveyor review of the clinical records, surveyor observations and interview with facility staff, it was determined that the facility failed to ensure standards of nursing practice in medication administration for residents. This finding was identified for 4 of 31 residents selected for review during the survey. (#12, #15, #61, #84) The findings include:
1. On 10-11-18, surveyor review of resident #12's clinical record revealed 9AM medications that were scheduled for administration. However, on 10-11-18 at 12:10 PM, RN (Registered Nurse) #13 was observed entering resident #12's room for administration of 9AM medications. Further review of the October 2018 MAR (Medication Administration Record) revealed that RN #13 documented the 9AM medications as administered at 9AM.
On 10-11-18 at 12:20 PM, surveyor interview with the Infection Control Nurse/Nurse educator revealed no additional information.
2. On 10-11-18, surveyor review of resident #15's clinical record revealed scheduled 9 AM medications for administration. However, on 10-11-18 at 12:06 PM surveyor observation revealed RN (Registered Nurse) #12 was observed entering resident #15's room for administration of 9AM medications. Further review of the October 2018 MAR revealed RN #13 documented the 9AM medications as administered at 9AM.
On 10-11-18 at 12:20 PM, surveyor interview with Infection Control Nurse/Nurse educator revealed no additional information.
3. On 10-11-18, surveyor review of resident #61's clinical record revealed scheduled 9AM medications for administration. However, on 10-11-18 at 12:06PM surveyor observation revealed RN (Registered Nurse) #13 was observed entering resident #61's room for administration of 9AM medications. Further review of the October 2018 MAR revealed that RN #13 documented the 9AM medications as administered at 9AM.
On 10-11-18 at 12:15 PM, surveyor interview with resident #61 revealed that the resident had just received his/her morning medications a few minutes prior to the surveyor's inquiry.
On 10-11-18 at 12:20 PM, surveyor interview with Infection Control Nurse/Nurse educator revealed no additional information.
4. On 10-11-18, surveyor review of resident #84's clinical record revealed 9AM medications that were scheduled for administration. However, on 10-11-18 at 12:10 PM, RN (Registered Nurse) #13 was observed entering resident #84's room for administration of 9 AM medications. Further review of the October 2018 MAR revealed that RN #13 documented the 9AM medications as administered at 9AM.
On 10-11-18 at 12:20 PM, surveyor interview with Infection Control Nurse/Nurse educator revealed no additional information.
According to the Maryland Nurse Practice Act 10.27.09.02E (1) (2), the RN shall implement the interventions, identified in the plan of care. The interventions shall be implemented recognizing the rights of the client, family and significant others: consistent with the established plan of care; implemented in a competent, safe, and appropriate manner consistent with knowledge of scientific principles; and documented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical record, surveyor observations, and interview with facility staff, it was determined that the facility staff failed to ensure consistent pain management for res...
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Based on surveyor review of the clinical record, surveyor observations, and interview with facility staff, it was determined that the facility staff failed to ensure consistent pain management for resident #30. This finding was identified for 1 of 3 residents selected for the Pain Management Care Area investigations during the survey. The findings include:
On 10-10-18, surveyor review of the clinical record for resident #30 revealed scheduled medications for pain management that included: Gabapentin 400 mg three times a day for peripheral neuropathy, Ultram (Tramadol) 50 mg every 8 hours for pain, Tylenol 650 mg every 8 hours as needed for pain and Ultram 50 mg 2 tablets every 6 hours as needed for pain.
Further review revealed that resident #30 received current wound treatment to multiple pressure ulcers that include his/her bilateral heels and the left posterior thigh.
On 10-11-18 at 2:02 PM, the surveyor observed the wound treatment to resident #30. The resident complained of intermittent pain to the left lower extremity as LPN (Licensed Practical Nurse) #11 was cleansing the left posterior thigh wound with saline soaked gauze. When asked by LPN #11, if the resident wanted to continue, the resident's response was yes. At 2:10 PM , during positioning of the resident on his/her back to perform wound treatment to the heels, the resident cried out that the pain was a 10 (with a score of 1 being the lowest and 10 is at the highest). Upon surveyor intervention, the wound treatment was stopped secondary to the resident's level of pain. LPN #11 informed the resident he/she would go check physician's orders for the administration of an as needed pain medication.
On 10-11-18 at 2:27 PM, surveyor observed LPN #11 administer Tylenol 650 mg to resident #30. LPN #11 stated they needed to resume the wound treatment when the medication was effective.
Review of the October 2018 MAR (Medication Administration Record) on 10-11-18 at 2:30 PM revealed documentation that the 9 AM Gabapentin was administered, while the 1 PM dose had not been signed as administered for 10-11-18. Further review revealed that the Ultram on 10-11-18 at 6 AM was documented as not available for administration, while the 2 PM dose was not signed as administered for 10-11-18 as of 2:30 PM.
On 10-11-18 at 4:21 PM, surveyor observed the resumed wound treatment to resident #30's bilateral heel wounds. The resident complained of some pain when the heel wounds were touched, but stated the pain was tolerable and treatment could be completed.
Surveyor interview on 10-11-18 at 4:15 PM with LPN #11 and the facility's nurse educator/infection control nurse revealed that, prior to the wound treatment of the heels, the attending physician was notified and an order for Oxycodone 5 mg was obtained and the medication was administered 15 minutes prior to the start of the treatment.
On 10-12-18, surveyor review of the October 2018 MAR revealed documentation on 10-11-18 at 8AM by RN (Registered Nurse) #12 that the Ultram 50 mg every 8 hours for pain (6AM dose) was awaiting delivery from the pharmacy and was not administered. On 10-11-18 at 22:41, documentation by LPN #11 revealed that Ultram 50 mg every 8 hours (10PM dose) for pain was awaiting pharmacy delivery and was not administered, while the 10-11-18 2,PM dose was documented as administered by LPN #11.
However, on 10-15-18 at 1:30 PM surveyor review of the Controlled Substance log for the Ultram 50 mg for resident #30 revealed that a pharmacy delivery of 60 tablets was documented as received by facility staff on
10-12-18 at 7 AM, with 50 tablets remaining as of 10-15-18. Staff documentation revealed the following administration of the 10-12-18 Ultram 50mg supply:
10-12-18 at 2 PM, 8 PM,
10-13-18 at 6 AM, 2 PM, 10 PM,
10-14-18 at 6 AM, 2 PM, 10 PM
and 10-15-18 at 6 AM.
Further review revealed that the last dose of available Ultram tablet for resident #30, prior to the 10-12-18 delivery, was signed as available and administered on 10-10-18 at 9 PM.
Additionally, on 10-15-18 at 3 PM, surveyor review of the 10-11-18 transactions from the facility's interim medication supply revealed no evidence that staff removed Ultram 50 mg for resident #30 on 10-11-18 either for scheduled doses, or any as needed doses. Ultram 50 mg was available in the interim supply for removal and administration.
On 10-15-18 at 4 PM, surveyor interview with the Director of Nursing revealed no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical record and facility staff interview, it was determined that the attending physician failed to evaluate and address changes in resident #63's nutritional status...
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Based on surveyor review of the clinical record and facility staff interview, it was determined that the attending physician failed to evaluate and address changes in resident #63's nutritional status. This finding was evident for 1 of 3 residents selected for nutrition review during the survey. (#63) The findings include:
On 10-11-18, surveyor review of the clinical record revealed that resident #63 had lost 12 pounds (greater than 7% of body weight) between 06-21-18 and 07-10-18. In addition, the resident lost 11 more pounds (greater than 8% of the resident's body weight) between 08-24-18 and 09-10-18.
Further review of the clinical record revealed that resident #63 had lost 32 pounds (greater than 20% of the resident's body weight in the 6 months between 04-29-18 and 10-02-18.
However, there was no documented evidence that the physician evaluated or addressed the changes in resident #63's nutritional status.
On 10-11-18 at 5 PM, surveyor interview with the nurse practice educator/infection control nurse provided no additional information.
On 10-12-18 at 12 PM, after surveyor intervention on 10-11-18, surveyor interview with the dietician revealed that the dietician had spoken with the physician on 10-12-18, and the physician ordered further testing to evaluate nutritional status.
On 10-15-18 at 11 AM, follow up interview with the Director of Nursing provided no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on surveyor review of the clinical record and facility staff interview, it was determined that the pharmacy failed to report irregularities from medication reviews. This finding was identified f...
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Based on surveyor review of the clinical record and facility staff interview, it was determined that the pharmacy failed to report irregularities from medication reviews. This finding was identified for 1 of 5 residents selected for the unnecessary medication review during the survey (#66). The findings include:
On 10-15-18, surveyor review of the physician's orders revealed that resident #66 was prescribed an antipsychotic medication that was indicated as used for dementia. Antipsychotic medications are not indicated for dementia.
Further review of the clinical record for resident #66 revealed that the pharmacist had reviewed the resident's medication regimen on 06-14-18, 07-16-18, 08-13-18, and 09-11-18.
Surveyor review of the monthly medication regimens revealed that the pharmacist did not identify that Risperdal was administered for dementia, was an irregularity, and failed to report it to the physician.
On 10-16-18 at 11 AM, surveyor interview with the Director of Nursing provided no additional information.
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 surveyor review of the clinical record and facility staff interview, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications. T...
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Based on surveyor review of the clinical record and facility staff interview, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications. This finding was evident for 1 of 5 residents selected for the unnecessary medication review during the survey. (#66) The findings include:
On 10-15-18, surveyor review of the clinical record for resident #66 revealed that on admission, the resident was ordered 2 antipsychotic medications, Seroquel for dementia and Risperdal for dementia. Dementia is not an appropriate indication for antipsychotic medications.
In addition, the Seroquel was ordered to be discontinued on 05-24-18. However, this medication continued to be administered to resident #66 until 06-06-18.
Further review of the clinical record revealed that, on 08-03-18, the order for the Risperdal was rewritten with the indication as antipsychotic/antimanic agent. Antipsychotic indicates the type of medication Risperdal is, however, it does not indicate the clinical need for the medication.
In addition, there was no evidence in the clinical record that indicated the continued use of an antipsychotic medication for resident #66.
On 10-16-18 at 11 AM, surveyor interview with the Director of Nursing provided no additional information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on surveyor review of the clinical records, and interviews with facility staff and the Ombudsman, it was determined that the facility staff failed to provide written notification to the Ombudsma...
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Based on surveyor review of the clinical records, and interviews with facility staff and the Ombudsman, it was determined that the facility staff failed to provide written notification to the Ombudsman and the resident representatives when a resident was transferred to a hospital. This finding was evident for 6 of 6 residents selected for hospitalization review during the survey (#298, #27, #4, #30, #6 and #245). The findings include:
1. On 10-12-18 at 10:00AM, surveyor review of the clinical record revealed that resident #298 was transferred to the hospital in September 2018. However, there is no documented evidence that a notice of transfer was provided to the facility's State Ombudsman as required. On 10-12-18 at 9:10AM interview with the Ombudsman representative for the facility confirmed that they had not received any notification regarding transfers from the facility as required.
On 10-12-18 at 10:30 AM, interview with the daytime unit manager of the second floor, revealed that there is no documented evidence that the facility sent a copy of the transfer notice to the Ombudsman and the facility was unaware of the requirement to do so.
On 10-12-18 at 12:10PM, interview with the Director of Social Services, revealed that the facility did not send a copy of the notice to the Ombudsman and were unaware of the requirement to do so.
2. On 10-12-18 at 10:15AM, surveyor review of the clinical record revealed that resident #27 was transferred to the hospital in September 2018. On 10-12-18 at 9:10AM interview with the Ombudsman confirmed that they had not received any notification regarding transfers from the facility as required.
On 10-12-18 at 10:30 AM, interview with the daytime unit manager of the second floor, revealed that there is no documented evidence that the facility sent a copy of the transfer notice to the Ombudsman and the facility was unaware of the requirement to do so.
On 10-12-18 at 12:10PM, interview with the Director of Social Services, revealed that the facility did not send a copy of the notice to the Ombudsman and were unaware of the requirement to do so.
5. On 10-10-18 at 11:30 AM, surveyor review of the clinical record revealed that resident #6 was transferred to the hospital in September 2018. Review of a nurse's note written on 09-26-18 at 12:02 PM, revealed the resident representative was called and made aware of the transfer.
On 10-10-18 at 12:45 PM, surveyor interview with the unit manager on the first floor revealed that nurses send a facesheet, physician's orders sheet, acute care transfer assessment, pertinent diagnostic results, a Maryland orders for life-sustaining treatment form (MOLST), facility bed hold policy, and physician progress notes with residents upon transfer to the hospital. However, there was no evidence that written notification was provided to resident #6 or his/her representative, nor was there evidence of notifying the Ombudsman in writing about the transfer to the hospital.
On 10-10-18 at 1:12 PM, surveyor interview with the social worker revealed that he/she was not aware that the facility was required to notify the ombudsman in writing when a resident was discharged to a hospital.
On 10-16-17 at 1:22 PM, surveyor interview with the ombudsman revealed that he/she was not notified about the hospital transfer.
On 10-16-18 at 2:15 PM, surveyor interview with the Director of nursing (DON) revealed no new information.
6. On 10-12-18 at 11:30 AM, surveyor review of the clinical record revealed that resident #245 was transferred to the hospital in October 2018. Review of a nurse's note, written on 10-12-18 at 10:30 AM, revealed that the resident representative was called and made aware of the transfer.
On 10-12-18 at 1:45 PM, surveyor interview with staff #1 revealed that nurses send a facesheet, physician's orders sheet, acute care transfer assessment, pertinent diagnostic results, a Maryland orders for life-sustaining treatment form (MOLST), facility bed hold policy, and physician progress notes with residents upon transfer to the hospital. However, there was no evidence that written notification was provided to resident #245 or his/her representative, nor was there evidence of notifying the Ombudsman in writing about the transfer to the hospital.
On 10-12-18 at 2:12 PM, surveyor interview with the social worker revealed that he/she was not aware that the facility was required to notify the ombudsman in writing when a resident was transferred to a hospital.
On 10-15-18 at 1:15 PM, surveyor interview with the Director of nursing (DON) revealed no new information.
3. On 10-12-18 surveyor review of the clinical record for resident #4 revealed that the resident was transferred to the hospital in September 2018.
However, further review revealed no documented evidence that the facility had sent a copy of the notice for the hospital transfer to the Ombudsman.
On 10-16-18 at 1:07PM surveyor interview with the Ombudsman revealed there has been no notification, either verbal or in writing, received from the facility of a hospital transfer for resident #4.
On 10-16-18 at 3PM surveyor interview with the Director of Nursing revealed no additional information.
4. On 10-10-18 surveyor review of the clinical record for resident #30 revealed that the resident was transferred to the hospital in August 2018. However, further review revealed no documented evidence that the facility sent a copy of the notice for the hospital transfer to the Ombudsman.
On 10-16-18 at 1:07PM surveyor interview with the Ombudsman revealed there has been no notification, either verbal or in writing, received from the facility of a hospital transfer for resident #30.
On 10-16-18 at 3PM surveyor interview with the Director of Nursing revealed no additional information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 10-11-18, surveyor review of the clinical record for resident #46 revealed an admission MDS, dated [DATE], and in section ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 10-11-18, surveyor review of the clinical record for resident #46 revealed an admission MDS, dated [DATE], and in section M Skin Conditions, the resident had 1 unstageable pressure sore. However, review of the admission assessment revealed that the resident had 2 unstageable pressure sores, as well as a stage 2 pressure sore on admission.
A stage 2 pressure ulcer is a wound with a partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough (yellow, tan, gray, green or brown tissue), and may also present as an intact or open/ruptured fluid filled blister.
An unstageable pressure ulcer is a wound with full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined.
In addition, an MDS, dated [DATE], was coded in section M Skin Conditions, that resident #46 had 1 unstageable pressure sore. However, review of a nurse practitioner's progress note, written on 07-24-18, revealed that the resident had 2 unstageable pressure ulcers.
Further review of the clinical record revealed the MDS assessment was completed on 08-08-18. Under section M Skin Conditions, it was coded that resident #46 had 1 unstageable pressure sore. However, review of the treatment records for the month of August 2018 revealed the resident continued to be treated for the same two areas the resident had in July.
In addition, an MDS, dated [DATE], was coded in section M under Skin Conditions, that resident #46 had 1 unstageable pressure sore. However, review of a wound physician's progress note written on 09-07-18 revealed that the resident had 2 stage 3 pressure ulcers.
A Stage 3 pressure ulcer is a wound with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.
On 10-11-18 at 5:15 PM, surveyor interview of the nurse practice educator/infection control nurse provided no additional information.
On 10-15-18 at 11 AM, follow up interview with the Director of Nursing provided 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 accurate MDS assessments for residents. This finding was identified for 3 of 31 residents selected for review during the survey. (#30, #85, #46) 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.
1. a. On 10-10-18, surveyor review of the clinical record for resident #30 revealed that, on 06-13-18, staff documented on the admission skin assessment form that the resident had bilateral posterior thigh pressure wounds and a skin tear on the left lower anterior leg.
However, review of the MDS admission assessment section M (Skin), with an ARD (Assessment Reference Date) of 06-20-18, revealed that staff indicated only 1 unstageable pressure ulcer.
According to the National Pressure Ulcer Advisory Panel (NPUAP), an unstageable pressure sore is defined as, full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
b. Additionally, review of the MDS section M, with an ARD of 06-27-18, revealed an assessment that indicated a total of 2 unstageable pressure ulcers and 1 unstageable Deep Tissue Injury (DTI) ulcer. However, review of the wound documentation by licensed staff as of 06-27-18, revealed that resident #30 had a total of 2 bilateral thigh wounds, 1 left heel wound and 1 right heel DTI . The National Pressure Ulcer Advisory Panel defines a deep tissue injury (DTI) as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise.
On 10-16-18 at 3PM, surveyor interview with the MDS coordinator #8 revealed that resident #30's MDS assessment had been completed based solely on review of the staff documentation in the clinical record and that direct observations of the resident's wounds had not been completed by staff #8. No additional information provided.
On 10-16-18 at 3:30PM, interview with the Director of Nursing revealed no additional information.
2. On 10-15-18 surveyor review of the clinical record for resident #85 revealed that on 08-02-18, staff documentation, on the weekly wound evaluation, identified wounds on the resident's bilateral lower extremities (BLE) as stasis ulcers.
Additionally, review of the facility's wound physician documentation dated 08-02-18, revealed an assessment of the resident's BLE as venous wounds with a duration of greater than 30 days and a treatment plan of Vaseline gauze once daily for 30 days. A stasis ulcer is a breakdown of the skin (ulcer) caused by fluid build-up in the skin from poor vein function (venous insufficiency).
Further review of the wound physician's documentation on 08-30-18, revealed an assessment of resident #85's BLE wounds as venous etiology and greater than 57 days in duration, with deterioration in the wounds progress. In addition, the treatment plan was changed to alginate calcium with silver dressing once daily for 30 days.
However, review of resident #85's MDS assessment section M (Skin Conditions), with an ARD (Assessment Reference Date) of 08-14-18, revealed documentation of 0 for the number of venous and arterial ulcers, and an indication of a surgical wound.
On 10-16-18 at 3PM, surveyor interview with MDS coordinator #8 revealed that resident #85's MDS assessment was completed based on review of the documentation in the clinical record and that direct observation of the resident's wounds was not completed by staff #8. No additional information was provided.
On 10-16-18 at 3:30PM, interview with the Director of Nursing revealed no additional information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on surveyor review of the clinical records, surveyor observation, and interview with facility staff, it was determined that the facility staff failed to ensure that residents receive treatment a...
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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 ensure that residents receive treatment and care in accordance with the professional standards of practice. These findings were identified for 2 of 31 residents selected for review during the survey. ( #63, #75 ) The findings include:
1. On 10-11-18, surveyor review of the clinical record for resident #63 revealed a physician's order, dated 08-30-18, for a dermatology consult for severe eczema. However, there was no evidence that resident #63 was seen by the dermatologist as ordered or that an appointment was scheduled.
Further review of the clinical record for resident #63 revealed physician's orders for hydrophor 42% to bilateral lower extremities twice a day, white petroleum to rash twice a day, Amlactin lotion to rash twice a day, petroleum 100% to whole body twice daily, and ace wrap over kerlix to the bilateral lower legs in the morning.
In addition there was an order for Kenalog aerosol spray to be applied to the bilateral lower extremities rash as needed for itching. However, review of the medication administration record revealed the order was transcribed as Kenalog aerosol spray to be applied to bilateral lower extremities rash.
On 10-11-18 at 11 AM surveyor observation of the treatments that were applied to resident #63 revealed the following:
LPN #9, with the assistance of RN #10, applied AmLactin to all areas of eczema rash on arms, abdomen, hips, thighs, knees and buttocks of resident #63. During the observation, the resident was scratching and complaining of itching.
After the application of the AmLactin, as staff were repositioning resident #63 in the bed, surveyor asked LPN #9 and RN #10 if they had completed the treatment. RN #10 responded that they also needed to apply hydrophor to resident #63's lower legs. RN #10 then left the room to get the hydrophor.
After 5 minutes, RN #10 returned to the door and handed LPN #9 two packets of white petroleum. LPN #9 applied the white petroleum to resident #63's lower legs and feet. LPN #9 said the treatment was completed and that the resident had a medication that could be given by mouth for itching.
On 10-11-18 at 11:30 AM, surveyor interview with GNA #2 revealed that the GNAs do not apply treatments to resident #63 during personal care.
On 10-11-18 at 12 PM, surveyor review of the medication administration record revealed that LPN #9 had signed that all ordered treatments were completed. However, Hydrophor was not applied to the lower legs, the petroleum 100% pure jelly was not applied to the entire body, and the lower legs were not wrapped with kerlix and ace wraps as ordered.
On 10-11-18 at 5:30 PM, surveyor interview with nurse practice educator/infection control nurse provided no additional information.
2. On 10-16-18, surveyor review of the clinical record of resident #75 revealed an order, dated 09-10-18, for the administration of the antibiotic Invanz 1 gram IV (intravenously) once daily for 14 days.
Further review revealed that the resident had a PICC for the IV administration. A PICC line, or peripherally inserted central catheter is a long, soft, flexible tube or catheter, that is inserted through a vein in the arm. The PICC catheter is designed to reach one of the larger veins located near the heart. The PICC catheter can generally remain in place from five days to several months and in some cases up to a year. It is usually used for administration of antibiotics and chemotherapy. The standard for care includes determining and recording the internal and external length of the catheter in case of dislodgement. A baseline arm circumference is measured, recorded, and routinely assessed to determine if swelling associated with a blood clot has occurred. Flushes of the catheter are done at various intervals to prevent the catheter from becoming occluded from a blood clot.
Further review revealed physician's orders, dated 09-10-18, for licensed staff to do weekly PICC line dressing changes and for the admission measurement of the PICC line on 09-10-18.
However, further review revealed no evidence of physician's orders for the standard of care in the flushing of the PICC line before and after the administration of medications via the PICC line. The standard of care includes the use of saline and/or heparin flushes via the PICC line to maintain patency.
Additionally, record review revealed no documented evidence by licensed staff of the PICC flushes for resident #75 while the resident was receiving the IV antibiotic via the PICC.
On 10-16-18 at 4 PM, surveyor interview with the Director of Nursing revealed no additional information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 and facility staff interview, it was determined that facility staff failed to pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of the clinical record and facility staff interview, it was determined that facility staff failed to provide necessary treatment and services to promote the healing of pressure ulcers. This finding was evident for 2 of 6 resident selected for pressure ulcer review during the survey. (#46, #30). The findings include:
1. On 10-11-18, surveyor review of the clinical record for resident #46 revealed an initial clinical assessment, dated 07-11-18 at 3:16 PM, that documented the resident had multiple pressure sores which included an unstageable pressure ulcer on the left medial knee, an unstageable pressure ulcer on the right upper hip, and a stage 2 pressure ulcer on the coccyx.
A stage 2 pressure ulcer is a wound with a partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough (yellow, tan, gray, green or brown tissue) . May also present as an intact or open/ruptured fluid filled blister.
An unstageable pressure ulcer is a wound with full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined.
Further review of the physician's orders revealed that, on admission, the pressure ulcers on the right hip and the coccyx had orders for treatment. However, there were no orders to treat the left knee pressure sore until 07-24-18.
In addition, there was no evidence of any assessment or monitoring of the left knee pressure sore from 07-12-18 until 07-24-18. Further review of the weekly skin assessments revealed that the weekly skin assessments were not completed for the left knee or right hip pressure sores from 08-01-18 until 08-23-18.
On 10-11-18 at 5:15 PM, surveyor interview of the nurse practice educator/infection control nurse provided no additional information.
On 10-15-18 at 11 AM, follow up interview with the Director of Nursing provided no additional information.
2. Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility failed to accurately assess and provide timely treatment of pressure ulcers for resident #30. The findings include:
On 10-10-18, surveyor review of the clinical record for resident #30 revealed that the hospital's nursing condition of Discharge summary, dated [DATE], revealed that, at the time of discharge, the resident had a stage 2 sacral ulcer, right and left posterior thigh DTI (Deep Tissue Injury) areas and Moisture Associated skin damage to the left inner leg . A Stage 2 ulcer occurs when the skin usually breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin.
The National Pressure Ulcer Advisory Panel defines a DTI as a pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise.
Further review of the the facility's nursing initial admission assessment, dated 06-13-18, revealed that resident #30's skin condition included: bilateral posterior thigh wounds, a left anterior lower leg wound area and rash/redness noted in the skin folds on the groin and under the breast area.
Surveyor review of the initial admission physician orders revealed wound care treatment for the right and left posterior thigh wounds, as well as the applications of a barrier cream at the time of incontinence. However, there was no documented evidence by the facility's staff of an assessment of resident #30's sacral ulcer or treatment to the area as identified in the 06-13-18 hospital transfer summary.
Further review of the June 2018 TAR (Treatment Administration Record) revealed a wound treatment to the resident's coccyx area, which was a pressure area, but had not been documented as assessed or treated until 06-28-18.
On 06-27-18, facility staff documentation revealed an assessment of a pressure area on the left heel as unstageable, while the right heel was assessed as a DTI. Further review revealed wound treatment of skin prep to the right and left heel to be completed daily. However, review of the 06-27-18 skin and wound assessment revealed staff documentation that the left heel area was identified as externally (hospital ) acquired even though there was no hospital information that identified the pressure areas on the heels at the time of transfer to the facility. In addition, the heel areas were not identified at the time of initial admission to the facility and no treatment was ordered by the facility until 06-28-18.
On 10-10-18, surveyor review of the MDS (Minimum Data Set) admission assessment section M (Skin), with an ARD (Assessment Reference Date) of 06-20-18, revealed that staff had only identified 1 unstageable pressure ulcer on the MDS, which was inaccurate. (Refer to F684 for additional information)
On 10-16-18 at 3 PM, surveyor interview with MDS coordinator #8 revealed resident #30's MDS assessment was completed based on the review of staff documentation located within the clinical record. Further interview revealed that direct observations of the resident's wounds are not completed by MDS coordinator #8. No additional information provided.
On 10-16-18 at 3:30 PM, interview with the Director of Nursing revealed no additional information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on surveyor review of the clinical records, review of facility infection control policies and staff interviews, it was determined that the facility staff failed to maintain an infection control ...
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Based on surveyor review of the clinical records, review of facility infection control policies and staff interviews, it was determined that the facility staff failed to maintain an infection control program to help prevent the spread of a multi-drug resistant organism This finding was evident for 1 of 2 residents selected for infection control during the survey (#297). The findings include:
On 10-10-18 at 11:30 AM, surveyor review of the clinical record for resident #297 revealed a hospital discharge summary on 09-24-18, which was originally prepared on 09-21-18. The summary included an assessment plan which informed staff that the resident needed strict contact and droplet precautions at all times including SAR (sub-acute rehabilitation) on discharge. The discharge summary was printed by the facility's Admissions Director and provided to the first floor nursing station on the afternoon prior to resident #297's arrival.
Review of resident's #297 discharge summary revealed that the resident was found to have CRE Pseudomonas and CRE Klebsiella and ESBL in the urine. (CRE, Carbapenem-resistant Enterobacteriaceae, is a family of germs that are difficult to treat because they have high levels of resistance to antibiotics. ESBLs are Gram-negative bacteria that produce an enzyme; with the ability to break down commonly used antibiotics). The summary further revealed that strict contact and droplet precautions were maintained at all times and recommended that these be continued indefinitely.
Further review of the clinical record for resident #297 revealed an admission note which recorded the arrival of the resident from the acute care hospital at 10:51PM on 09-24-18 by private ambulance However, there was no documented evidence that contact and droplet precautions were in place in preparation for the arrival of the resident from the acute care hospital. The first order for contact precautions, were entered at 7:00AM on 09-25-18. Contact and droplet isolation at all times indefinitely every shift for CRE sepsis.
On 10-10-18 at 12:00 PM, surveyor reviewed email correspondence written on 09-25-18 between the Maryland Department of Health and the facility's Nursing Practice Educator that the facility communicated to the State that the resident had not been placed on contact precautions overnight as a result of a break in communication from the transferring facility. The email also revealed that resident #297 was found to be colonized with Candida auris (Candida auris is often multidrug-resistant). In consultation with CDC (The Centers for Disease Control and Prevention), the State Department of Health provided specific recommendations for care to this resident to prevent transmission of Candida auris. The recommendations included: having the resident in a private room, on contact precaution, and using EPA-approved disinfectant cleaning agents effective against Candida auris.
On 10-10-18 at 1:15 PM, interview with the first floor unit manager revealed that he/she was the staff member who admitted the resident to the facility on the evening of 9-24-18 and was scheduled to work the 11-7 shift that night. The nurse revealed that they had initiated contact precautions after reading through the transfer summary from the discharging facility. He/she revealed that he/she discovered that the resident was to be on contact and droplet precautions after reading the discharge summary. The nurse said he/she began working with the resident after their shift started at 11PM. He/she was made aware of the resident's arrival by the daytime unit manager from whom he/she had taken report. The resident was placed in a private room with a private bathroom.
On 10-10-18 at 1:25 PM, interview with the Nurse Practice Educator revealed that he/she had been in contact with the Maryland Department of Health concerning the resident's status and recommendations. He/she acknowledged that the resident arrived at the facility with no precautions in place and was unclear of the exact length of time that precautions were not in place.
On 10-10-18 at 3 PM interview with Admissions Director, revealed that he/she prepared an admissions packet on 09-24-18, originally printed for the resident on 09-21-18, and left it at the first floor nursing station. The document contained the ordered isolation precautions for resident #297. He/she was uncertain if he/she had left it unattended or had handed it off to a facility staff member.
On 10-10-18 at 5 PM, follow up interview with the first floor unit manager, revealed that he/she documented during their shift that the resident was on contact/droplet precaution and that he/she instructed staff to wear PPE when entering the room. The unit manager added that they had put precautions in place as soon as he/she had discovered that the patient was on precaution status based on their review of the transfer/discharge summary. The unit manager was unclear as to when exactly that was initiated. However, there was a lack of documented evidence to support that precautions were put in place prior to 7 AM.
On 10-10-18 at 5:30 PM, interview with Director of Nursing added no additional information.
On 10-10-18 at 5:45 PM, interview with the Administrator added no additional information.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0730
(Tag F0730)
Minor procedural issue · This affected multiple residents
Based on surveyor review of the Geriatric Nursing Assistants' (GNA) employee files and interview of staff, it was determined that the facility failed to complete performance reviews every 12 months an...
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Based on surveyor review of the Geriatric Nursing Assistants' (GNA) employee files and interview of staff, it was determined that the facility failed to complete performance reviews every 12 months and to provide training based on the outcomes of these reviews. This finding was evident for 2 of 2 nurse aide files reviewed during the survey. (#2 and #3) The findings include:
On 10-16-18, surveyor review of the nurse aide employee files revealed that the facility had not completed a performance review of GNA #2 or GNA #3 in the past 12 months.
On 10-16-18 at 11:15 AM, surveyor interview with the administrator confirmed that GNA performance reviews had not been completed.
MINOR
(B)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on surveyor observations and interview with the facility staff, it was determined that the facility failed to post the total number and the actual hours worked by the licensed nursing staff at t...
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Based on surveyor observations and interview with the facility staff, it was determined that the facility failed to post the total number and the actual hours worked by the licensed nursing staff at the beginning of the shift. This finding was evident for 2 of 2 nursing units in the facility. The findings include:
On 10-08-18 at 8:23 AM and 1:03 PM, surveyor observations of the 2nd floor nursing unit revealed no evidence of the posting of the total number and the actual hours worked by the registered nurses, licensed practical nurses and certified geriatric nursing assistants at the beginning of and during the 7-3 shift. Further observation at 3:30 PM revealed no evidence of the posting of the total number and the actual hours worked at the beginning of the 3-11 shift.
In addition, surveyor observation at 3:45 PM of the 1st floor nursing unit revealed no evidence of the posting of the total number and the actual hours worked by the licensed nurses and the certified geriatric nursing assistants at the beginning of the 3-11 shift.
On 10-08-18 at 5:30 PM, surveyor interview with the facility administrator and the Director of Nursing revealed no additional information.
MINOR
(C)
Minor Issue - procedural, no safety impact
Food Safety
(Tag F0812)
Minor procedural issue · This affected most or all residents
Based on surveyor observation and staff interviews, it was determined that the facility staff failed to store food under sanitary conditions. This finding was evident for the facility's kitchen during...
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Based on surveyor observation and staff interviews, it was determined that the facility staff failed to store food under sanitary conditions. This finding was evident for the facility's kitchen during the surveyor's initial tour. The findings include:
On 06-04-18 at 08:20 AM, surveyor tour of the kitchen revealed the following:
Observation of the walk-in refrigerator revealed:
a. Tuna salad with no label or date
b. Half rotten celery among fresh vegetables
c. Four boiled eggs wrapped in plastic with no date
d. Swiss, American and provolone cheese wrapped in plastic with no date.
e. Molded Swiss cheese observed in plastic wrap with no date.
f. Ham and sliced turkey breast wrapped in plastic with no date.
g. Rotten, half used tomatoes and onions wrapped in plastic with no date.
Additional observation of the walk-in freezer revealed:
a. A half bag of meat balls left open and on the freezer floor.
b. A half bag of frozen chicken breast observed on the floor under the shelf.
On 02-26-18 at 8:30 AM, surveyor interview with the Dietary Manager revealed no further 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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 45% turnover. Below Maryland's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), Special Focus Facility, 2 harm violation(s), $153,596 in fines, Payment denial on record. Review inspection reports carefully.
- • 93 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $153,596 in fines. Extremely high, among the most fined facilities in Maryland. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Layhill's CMS Rating?
CMS assigns LAYHILL NURSING AND REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Layhill Staffed?
CMS rates LAYHILL NURSING AND REHABILITATION CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 45%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Layhill?
State health inspectors documented 93 deficiencies at LAYHILL NURSING AND REHABILITATION CENTER during 2018 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 87 with potential for harm, and 3 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Layhill?
LAYHILL NURSING AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LIFEWORKS REHAB, a chain that manages multiple nursing homes. With 129 certified beds and approximately 126 residents (about 98% occupancy), it is a mid-sized facility located in SILVER SPRING, Maryland.
How Does Layhill Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, LAYHILL NURSING AND REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (45%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Layhill?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Layhill Safe?
Based on CMS inspection data, LAYHILL NURSING AND REHABILITATION CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Maryland. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Layhill Stick Around?
LAYHILL NURSING AND REHABILITATION CENTER has a staff turnover rate of 45%, 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 Layhill Ever Fined?
LAYHILL NURSING AND REHABILITATION CENTER has been fined $153,596 across 2 penalty actions. This is 4.4x the Maryland average of $34,615. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Layhill on Any Federal Watch List?
LAYHILL NURSING AND REHABILITATION CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.