How many inspection deficiencies does HOLLY HILL HEALTHCARE CENTER have?

HOLLY HILL HEALTHCARE CENTER has 83 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at HOLLY HILL HEALTHCARE CENTER?

HOLLY HILL HEALTHCARE CENTER has a two-star staffing rating from CMS with 0.80 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is HOLLY HILL HEALTHCARE CENTER located?

HOLLY HILL HEALTHCARE CENTER is located in TOWSON, MD. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does HOLLY HILL HEALTHCARE CENTER have?

HOLLY HILL HEALTHCARE CENTER has 75 certified beds.

Who owns HOLLY HILL HEALTHCARE CENTER?

HOLLY HILL HEALTHCARE CENTER is a for profit - corporation facility and is part of the COMMUNICARE HEALTH chain.

How does HOLLY HILL HEALTHCARE CENTER compare to other nursing homes?

HOLLY HILL HEALTHCARE CENTER has a 2-star overall rating, which is below average compared to other nursing homes in MD. Families should carefully review inspection findings and consider alternatives.

HOLLY HILL HEALTHCARE CENTER

Name: HOLLY HILL HEALTHCARE CENTER
Address: 531 STEVENSON LANE, TOWSON, MD, 21286, US
Telephone: (410) 823-5310
Rating: 2.0

531 STEVENSON LANE, TOWSON, MD 21286 · (410) 823-5310

For profit - Corporation 75 Beds COMMUNICARE HEALTH Data: November 2025

Trust Grade

35/100

#166 of 219 in MD

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Last Inspection: March 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Holly Hill Healthcare Center has received a Trust Grade of F, indicating significant concerns and a poor overall rating. It ranks #166 out of 219 facilities in Maryland, placing it in the bottom half of nursing homes in the state, and #32 out of 43 in Baltimore County, meaning there are only a few local options that are better. The facility is worsening, with issues increasing from 14 in 2023 to 32 in 2024. Staffing is a concern here, with a rating of 2 out of 5 stars and a high turnover rate of 55%, which is above the Maryland average of 40%. Notably, while there are no fines recorded, there are serious deficiencies, such as a lack of a full-time qualified Food Service Director and the use of chipped and cracked food trays, which could pose health risks for residents. Additionally, the laundry process is not adequately preventing cross-contamination, as doors between clean and soiled laundry areas were left open, potentially increasing the risk of infection.

Trust Score: F
In Maryland: #166/219
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Maryland facilities.
Skilled Nurses: Each resident gets 48 minutes of Registered Nurse (RN) attention daily — more than average for Maryland. RNs are trained to catch health problems early.
Violations: 83 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★★

5.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2023: 14 issues

2024: 32 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below Maryland average (3.0)

Below average - review inspection findings carefully

Staff Turnover: 55%

Near Maryland avg (46%)

Higher turnover may affect care consistency

Chain: COMMUNICARE HEALTH

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 83 deficiencies on record

Mar 2024 32 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

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Based on observation and staff interviews, it was determined that the facility failed to maintain the residents' dignity, by staff standing over residents while assisting them to eat. This was evident for 2 Residents (Resident #38 and #42) observed in one dining area out of the three dining areas in the facility. The findings include: On 02/20/24 at 12:49 PM, the surveyor observed Staff #7 (Occupational therapist) feeding resident # 38 while standing and Staff #8 ( Staffing Coordinator) feeding resident # 42 while standing. On 02/29/24 at 01:22 PM, during the surveyor's interview with staff # 8, they confirmed that they were feeding the resident on 02/20/24 while standing. When asked if she/he was ever instructed to sit with a Resident while feeding, they indicated that the educational course/ training offered to them did not cover the topic. Staff # 8 then stated, I'm a stander. On 03/04/24 at 03:30 PM, during an interview with the Director of Nursing (DON): When asked about expectations of where staff should be when feeding residents, DON indicated that staff should be sitting down when feeding residents. Surveyor then reviewed the concern that several staff were observed standing while feeding residents, including staff #8. The surveyor also reviewed the report from Staff #8 that her training did not cover sitting down with the residents while feeding. DON reported that Staff #8 was a nursing assistant.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on record review and interviews, it was determined that the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to residents who were discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 2 (#51, #57) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification. The findings include: Residents with Medicare Part A have certain rights and protections related to financial liability and appeals. The financial liability, appeal rights, and protections are communicated to beneficiaries through notices given by providers to residents who are being discharged from Medicare services but have Medicare benefit days remaining. The notices include: Notice of Medicare Non-Coverage (NOMNC): This must be issued at least two calendar days before the last day of Medicare coverage. Skilled Nursing Facility Advance Beneficiary Notice (SNFABN): This notice must be issued far enough before delivering potentially noncovered services to allow sufficient time for the beneficiary to consider all available options. On 2/22/24 at 8:47 AM, the facility provided the survey team with NOMNCs for three residents discharged from Medicare services with benefit days remaining in the last six months. A review of those resident records revealed that Residents #51 and #57 remained in the facility after the last day of their Medicare coverage. However, the review did not show that Residents #51 and #57 were issued SNFABNs. On 2/28/24 at 12:49 PM, an interview was conducted with staff #15, Social Services Director, in the presence of the Nursing Home Administrator. During the interview, Staff #15 was asked about what notification residents received when Medicare services were ending while they had benefit days remaining and planned to continue to stay in the facility. Staff #15 stated that she only issued NOMNCs. The facility's Non-coverage and Advanced Beneficiary Notices Policy was reviewed on 3/1/24 at 12:20 PM. The review revealed these statements in the policy: If a resident is currently covered under Medicare and coverage is ending, and the resident will remain in the SNF, the SNFABN must be provided to the resident notifying them that someone else will need to pay for the SNF stay after Medicare ends. This would be in addition to the NOMNC already provided. On 3/1/24 at 4:01 PM, during an interview with Staff #15, she indicated that they discussed in their weekly meetings which beneficiary notifications would be issued to residents whose Medicare services were ending. However, she failed to provide evidence that SNFABNs were issued to Residents #51 and #57 when their Medicare A services ended, but they had benefit days remaining and continued to stay in 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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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2) On 2/24/24 at 10:19 AM, review of the facility Investigation for #MD00200432 revealed documentation that Resident # 23 & Resident # 53 alleged a complaint that included an allegation that they were left wet all night. Continued review of the facility investigation revealed a statement of the alleged perpetrator signed by ADON. However, the statement failed to reveal that the concern of the residents of not being changed was addressed. Further review of the facility's investigation failed to reveal any investigation to substantiate the concern that the residents were left wet all night. On 3/4/24 at 11:17AM, the ADON was interviewed, and she reported that she interviewed the alleged perpetrator regarding the complaint. After reviewing the interview, she confirmed that the interview failed to contain any inquiry into whether the residents received incontinent care on the evening in question. On 3/4/24 at 11:50 AM, during an interview with the Administrator, he reported that since it was an abuse allegation, they investigated under abuse with questions pertaining to abuse. Based on record review and interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse.This was evident for 3 (Resident #68, # 23, and # 53) of 12 residents reviewed for abuse during a survey. The findings include: 1) On 2/28/24 at 10:37 AM, a review of the facility's investigation for the self-report, MD00201824, was conducted. The facility's initial self-report documented that, when Resident #68 was transferred to the hospital due to a fall, EMS (emergency medical systems) personnel alleged the resident appeared to be abused or neglected by the facility. Continued review of the documents included with the facility's investigation failed to reveal evidence that staff interviews had been completed during the facility's investigation, and there were no interviews of staff assigned to the resident at the time of the alleged event. On 2/29/24 at 1:50 PM, during an interview, the Nursing Home Administrator (NHA) was made aware there were no staff interviews included with documentation of the facility's investigation of the self-reported incident. The NHA responded, stating that staff interviews had been conducted and he would look for them. On 3/1/24 at 10:15 AM, the Director of Nurses (DON) reported to the surveyor that evidence of staff interviews conducted as part of the facility's investigation could not be found.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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Based in record review and interview, it was determined that the facility failed to communicate the residents comprehensive care plan goal to the receiving healthcare institution to ensure safe and effective transition of care. This was evident for 1 (Resident #33) of 4 residents reviewed for hospitalization. The findings include: Resident #33 has been residing in the facility since 2019. On 2/21/24 at 3:09 PM, Resident #33's medical record was reviewed and revealed that s/he was sent out to the emergency department in January of 2024. On 2/28/24 at 1:40 PM, Resident #33's transfer form, with a reference date of 1/21/24, completed by Licensed Practical Nurse (LPN Staff #21) was reviewed and revealed section E, item number 5 as emergency department or outpatient transfer checklist. The items listed in this checklist were as follows: a) X-Ray b) Medication list c) Lab results d) Care plan goals e) MOLST f) Face sheet g) Other info h) Bed Hold i) Notice of Transfer, with an instruction to print these documents in this order and include with the transfer form to send with the patient to the hospital. A check mark in a boxed area before each item indicated which document was printed and sent with the resident. Staff #21 did not put a check mark next to item D for care plan goals. On 3/01/24 at 12:09 PM, Registered Nurse (RN Staff #10) working on the 2nd floor was interviewed about the process when a resident needed to be sent out to the hospital. Staff #10 reported that, after having the Physician or Nurse practitioner evaluate the resident and getting an order to send the resident to the hospital, she would print the necessary documentation for transfer and call 911. Staff #10 stated each document that they would print, but failed to mention the residents comprehensive care plan goals as one of them. On 3/01/24 at 1:46 PM, a nurse working on the 1st floor (RN Staff #22) was also interviewed about her process when a resident had an order to be sent out to the hospital. Staff #22 indicated that the process would be individualized for each resident, but also failed to report the residents comprehensive care plan goals as part of the information and documents they would print and send to the hospital with the resident. On 3/01/24 at 5:44 PM, the surveyor discussed the concern with the Director of Nursing (DON) about the transfers and discharge requirements, where there was no evidence of the comprehensive care plan goals of the resident being provided to the receiving healthcare institution. The DON confirmed that this was the responsibility of the nurse and indicated that a transfer form is used by the nurses and that it had a portion where the nurse would mark all the required documents that were printed and sent with the resident. The surveyor reviewed with the DON the transfer form for Resident #33, with a reference date of 1/21/24, and revealed the portion that the DON was referring to was section E, and confirmed the surveyor finding that the care plan goal was not marked as printed and sent with the resident when they were transferred to the hospital.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

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Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (Resident #27) of 4 residents reviewed for hospitalization. The findings include: On 2/27/24 at 11:00 AM, a review of Resident #27's electronic health record (EHR) revealed that Resident #27 was transferred to an acute care facility on 2/2/24. In a SBAR Summary for Providers note, on 2/2/24 at 12:24 PM, the nurse documented Resident #27 had a change in condition, the primary care provider was notified, and recommended that Resident #27 be sent to the hospital. Continued review of the medical record failed to reveal any documentation to indicate that Resident #27 was oriented and prepared for the transfer or received an explanation as to why s/he was being transferred to the hospital, in a manner that the resident could understand and there was no documentation of the resident's potential response or understanding of the transfer. The above concerns were discussed with the Director of Nurses (DON) and Assistant Director of Nurses (ADON) on 3/5/24 at 1:30 PM and they both indicated they understood the concerns at that time.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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3) On 2/21/24 at 9:51 AM, the surveyor observed a contracture of Resident #6's hands. Contracture is defined as a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff, as defined by the National Cancer Institute. This prevents normal movement of a joint or other body part. A medical record review revealed an MDS, with an Assessment Reference Date of 02/01/2024, which coded that the resident did not have an upper extremity impairment in range of motion. Range of Motion (ROM) is movement how far someone can move or stretch a part of their body. On 02/26/24 at 12:16 PM, a medical record review of Resident # 6 revealed that the resident had resided at the facility for more than 2 years. A review of Nurse Practitioner notes from 10/03/2023 reveals both hands severely contracted with fingers stuck in a bent position towards [his/her] palm. Care plan notes, dated 10/06/2023, revealed, Resident has contracture for bilateral hands and is currently on caseload with OT [occupational therapy] for splinting, but contractures are too advanced for splinting. On 02/26/24 at 01:09 PM, the MDS Nurse (Staff #16) reported that, when evaluating for ROM, you should read the evaluation notes, if currently or recently on therapy, and actually go to the resident to observe, assess, and talk to the staff. The surveyor then reviewed the concern that Section GG (Section GG: Self-Care: Coding the resident's usual performance for each activity using the 6-point scale - Defined in RAI manual) revealed no impairment in the upper extremity. MDS Nurse indicated she would investigate. On 2/26/24 at 2:20 PM, the MDS Nurse confirmed that the ROM was coded in error and that she had submitted a correction modification. On 02/26/24 at 12:16 PM, a Medical record review revealed that resident #6 did not have a current physician's order for intermittent catheterization. Further review failed to reveal documentation to indicate the resident had received intermittent urinary catheterization during the assessment period. On 2/26/24 at approx 02:30 PM, interview with employee # 16, the MDS coordinator confirmed intermittent catheterization in MDS was an error and a modification had been submitted. On 2/26/24 at 02:40 PM, interview with the Registered Nurse (#5) confirmed that staff do not perform Intermittent catheterization for resident #6. On 03/04/24 at 3:30 PM, the surveyor reviewed concerns with the Director of Nursing (DON) regarding the failure to assess contractures and the coding of intermittent catheterization when it was not completed. 2) Resident #33 was admitted to the facility in 2019 following a stroke and weakness on the right side. On 2/20/24 at 10:47 AM, the resident was observed sitting in his/her wheelchair outside her room with no activity being provided. The surveyor attempted to interview Resident #33 but was unable to understand his/her speech. On 2/28/24 at 8:55 AM, a review of Resident #33's MDS assessment, with an assessment reference date (ARD) of 2/21/24, indicated that the resident's speech was unclear, but the ability to make self-understood and understand others was coded as sometimes understood and sometimes understand. Further review of this assessment revealed section C0100 (Should Brief Interview for Mental Status (C0200-C0500) be Conducted?) and was coded as YES, however, the succeeding questions (C0200 - C0500) were coded as not assessed. Section C0600 (Should the Staff Assessment for Mental Status (C0700-C1000) be Conducted?) was also coded as a YES, however the succeeding questions (C0700 - C1000) indicated that the resident was not assessed. In an interview with the MDS coordinator (Staff #16) on 2/28/24 at 3:44 PM, she indicated that an interview must be attempted for all residents, but in cases where the resident was non-interviewable, the system forced you to do the staff assessment instead. The MDS assessment with an ARD of 2/21/24, section C, was reviewed with Staff #16 and revealed that it was done and signed by herself, and she stated, in that instance it was a missed interview. I can't remember why. That was an oversight on my part. Based on observation, medical record review and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (#15, #33, #6) of 44 residents reviewed during the survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. A Discharge-return anticipated MDS assessment is completed when a resident is temporarily admitted for acute care in the hospital, or a hospital observation stay lasts more than 24 hours, but the resident is expected to return to the nursing facility. 1) On 2/20/24 at 1:12 PM during an initial rounding of the facility, Resident #15 was observed sitting in his/her room receiving oxygen at 2 Liters (L)per minute via nasal cannula. A record review completed for Resident #15 on 2/21/24 at 10:00 AM revealed that Resident #15 was admitted to the facility in August 2014 and had diagnoses including Heart Failure. On 2/27/24 at 3:49 PM, a subsequent medical record review completed for Resident #15 showed a nursing note, dated 1/27/24, that stated resident complained of difficulty breathing, was given oxygen at 4L per minute and transferred to the hospital for evaluation per the attending provider's instruction. A continued review revealed a Discharge return anticipated MDS assessment, dated 1/27/24, that had answered No for Shortness of Breath in section J. On 2/28/24 at 3:18 PM, an interview was completed with staff #16, a corporate mobile MDS coordinator and staff #37, an MDS coordinator. During the interview, staff #16 confirmed that Resident #15's complaint of difficulty breathing during the observation period for his/her discharge MDS assessment, dated 1/27/24, was omitted 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

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Based on record review and staff interview, it was determined that the facility failed to ensure that the Level II Preadmission screening and resident review (PASARR) screen was completed by Adult Evaluation and Review Services (AERS) before the resident's admission. This was evident for 1 (Resident #9) of 1 resident reviewed for PASARR compliance. The findings include: On 02/21/24 at 11:53 AM, the medical record review of Resident #9, revealed that a scanned copy of PASARR level one, dated 05/06/2020, was available from electronic medical records. PASARR form page 2 indicated that If questions 1.2.or three checked yes or if all answers in part D are No the individual must be referred to AERS for level two evaluation. Page 2, Part D, questions 1,2,3,4, and 5 had answers checked as No. Thus indicating a referral to AERS was required. Further review of the medical record failed to reveal the evidence that PASARR, dated 5/6/2020, was referred to AERS for level two evaluation. The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders, intellectual disabilities, and related conditions. This initial screening was called Level I Identification of individuals with MD or ID (§483.128) and is completed before admission to a nursing facility. The Level I pre-admission screening aims to identify individuals who have or may have a mental disorder (MD) intellectual disability (ID) or a related condition, who would then require PASARR Level II evaluation and determination before admission to the facility. The state mental health or intellectual disability authority must conduct a Level II resident review within 40 calendar days of admission. On 02/28/24 at 12:58 PM, an interview with staff #15 (Social Service Director) confirmed understanding the process of positive residents for PASARR level one would be sent to AERS for level two evaluation and determination. However, Resident #9 did not have a PASARR level two evaluation. On .02/28/24 12:58 PM, surveyor requested that staff #15 bring a copy of the PASAAR level two screening from 05/06/2020, and was told that they would check, however, copies were not received.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on the review of medical records, and staff interviews, it was determined that the facility failed to provide the resident and or their representative with a summary of the baseline care plan. This was evident for 1 (Resident # 119 ) of 33 residents reviewed for baseline care plans. The findings include: On 02/28/24 at 04:17 PM, a review of Resident #119's medical record revealed that the resident was initially admitted to the facility in February 2024. Further review of medical records failed to reveal that a copy of the baseline care plan was offered to the resident or the resident's representative. On 3/4/24 at 11:10 AM, facility provided a copy of the Interdisciplinary Care Conference attendance record for an initial care conference held on 2/6/24 that revealed neither the resident nor the Resident Representative attended the meeting. Further review of the Interdisciplinary Care Conference Attendance Record form revealed the following statement Resident and/or Resident Representative will be invited to all Interdisciplinary Care Conferences. In instances where the Resident and/or Resident representative do not attend, a member of the Interdisciplinary team will review the Care Plan and the details of the Care Conference with appropriate individuals. Copies of current care plans will be provided to a resident representative via electronic email or sent via mail, including the interdisciplinary care conference summary. On 03/04/24 at noon, (Staff #15) Social Services Director was interviewed. The Social service Director reported that a copy of the baseline care plan, including the list of the medications, would be offered to family members or residents attending the care plan meeting. If family members could not attend the care plan, staff # 15 would continue to try and reach out to them, and every attempt that was made to contact them would be documented. Staff #15 confirmed that they had spoken with Resident #119's representative, but when asked if she had offered to send the baseline care plan information to the Resident's representative, Staff #15 stated: I did not. The Social Service Director went on to report that she had, on occasion, emailed care plan information when requested by family/resident representative On 03/04/24 at 3:30 PM, the surveyor reviewed concerns with the Director of Nursing (DON) regarding the failure to provide baseline care plan information to Resident #119 or their representative.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. On 2/20/24 at 1:13 PM, during an initial tour of the ground-floor unit, Resident #15 was observed with no teeth or dentures and eating lunch with his/her gums. A subsequent observation was made of Resident #15 on 2/23/24 at 8:07 AM, eating breakfast by his/her bedside and having no dentures. When asked if s/he wore dentures, stated, I used to wear dentures, and it was good, but they disappeared. A medical record review, done on 2/20/23 at 1:30 PM for Resident #15, revealed an attending provider's orders 1) to remove dentures at night and keep in water at bedtime, initiated on 5/23/2019 and discontinued on 1/29/24 2) to perform oral hygiene twice daily every day and evening shift, initiated on 5/24/19 and discontinued on 1/29/24. A continued review noted a Minimum Data Set (MDS) assessment, dated 12/22/23, documenting that Resident #15 had moderately impaired cognitive functioning. The MDS assessment recorded that Resident #15 required supervision or touching assistance from staff to perform oral hygiene. The review also noted an annual dental exam report, dated 1/18/24, which indicated that the Resident was completely edentulous (lacking teeth) and used upper and lower dentures. Further review showed that Resident# 15 was briefly hospitalized on [DATE] and readmitted to the facility on [DATE]. However, the above orders for daily oral hygiene and denture care were not re-initiated upon Resident #15's return to the facility. On 2/26/24 at 3:51 PM, during an interview with staff #28, a licensed practical nurse and evening supervisor, she indicated that she found Resident #15's dentures. On 2/27/24 at 8:12 AM, Resident #15 was observed with his breakfast tray in front of him and wearing his dentures. When asked about the food, Resident #15 stated, I'm finished eating. I have my dentures on. It takes time to get used to wearing them again. On 2/27/24 at 8:55 AM, during an interview with staff #3, a licensed practical nurse (LPN), she stated she was unaware that Resident #15 used dentures before the surveyor's intervention. She also stated that she called the attending provider and had been instructed to restart the orders for Residen#15's denture/oral care. A subsequent interview was conducted on 2/27/24 at 2:59 PM with staff #34, a Geriatric Nurse Aide (GNA). During the interview, she stated she usually worked with Resident#15 and was unaware that he used dentures until the surveyor's intervention. On 2/28/24 at 7:20 AM, during an interview with the Director of Nursing (DON), she stated that she expected the nurses to take out Resident #15's dentures at night and put them back in the morning for meals during oral care unless there was a refusal. Based on interviews, record review and observation, it was determined that the facility failed to 1) provide a resident with the amount of assistance needed during meals, according to the facility's assessment of the resident ability to feed himself, and 2) ensure that a resident who required assistance with activities of daily living (ADL) was assisted with putting his/her dentures in their mouth during meal times. This was evident for 1 (Resident #23) of 2 residents reviewed for Activities of Daily Living (ADLs) and for 1 (#15) of 5 residents reviewed for Dental. The findings include: 1) On 2/26/24 at 8:25 AM, Resident # 23, a long-term resident was interviewed. During the interview the resident reported s/he was unable to eat all their breakfast that morning. They reported that s/he had kept dropping their food and was only able eat a couple pieces of bacon. On 2/29/24, the GNA tasks documentation was reviewed. For the question regarding the Resident #23's ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident, the resident was documented to be dependent in this category (helper does all the effort) on 2/26/24 at 2:16 PM and 2/26/24 at 4:42PM. On 2/27/24 at 8:59 AM, a review of MDS section GG0130, self-care quarterly assessment dated [DATE], revealed a section regarding the Resident #23's ability to use suitable utensils to bring food to the mouth and swallow once the meal is presented on a table tray. The above sections was documented that the resident was dependent on the staff and the helper did all the effort and Resident # 23 does none of the work to complete the activity. The MDS is a set of assessment screening items employed as a part of a standardized, reproducible, and comprehensive assessment process that ensure 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 the resident. On 2/27/24 at 8:53 AM, Residents #23's care plan under the focus (activities of daily living (ADL) Self performance deficit, with an initiated date on 11/29/23, was reviewed. The review revealed documentation that Residents #23 was totally dependent on staff assistance for eating, that the helper does all the effort, and the resident does none of the effort. On 2/27/24 at 10:54 AM, during an Interview Nurse RN Staff # 33 reported that Resident #23 was able to eat without assistance. On 2/27/24 at 12:32 PM, an observation of the resident eating lunch was made from the hallway in front of Resident #23's room. The observation revealed Resident # 23 eating in bed without assistance. Resident #23 was positioned low in the bed with the bedside table higher than his shoulders. The residents lunch tray was on the bedside table. Resident #23 was observed to have spilled food (biscuit or breadcrumbs). Resident # 23 picked up the crumbs with his fingers off his blanket and sheets and put them in his mouth. Further observation revealed Resident # 23 trying to take off the lid of a small brown cup on his lunch tray. Resident tried several times and was unable to open the lid. On 2/27/24 at 12:38 PM, the resident was interviewed. The resident reported that he did not know what was in the little brown cup and he was not able to open it. The surveyor asked the resident if he would like me to get him assistance in opening the lid of the small brown bowl. The resident responded yes. The surveyor then went into the hall and asked the ADON for assistance. At 12:40 PM, the ADON came in the room and opened the lid for the resident. The resident began to eat the fruit cocktail (the contents of the small brown bowl. On 2/29/24, the GNA tasks were reviewed under the question for Resident #23's ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident. The review revealed that the resident was documented to be dependent with eating (helper does all the effort) for the following dates and times, 2/27/24 at 1:33 PM and 2/27/24 at 9:48PM. 02/29/24 08:35 AM, the above concerns regarding Resident #23 receiving the feeding assistance that he was assessed by the facility to need for eating, was discussed with the Administrator and DON. The Administrator reported that the resident was receiving assistance in eating today. On 3/04/24 at 12:53 PM, an observation was made from the hall of Resident #23 attempting to eat from his lunch tray. The observation revealed the resident lying in bed in a low reclined position with his shoulder lower than the bed table. Resident was observed reaching up for her/his food with her/his hands and got food on her/his arm. The resident then attempted to wipe the food off his arm with a towel. Continued observation at 1:00 PM, revealed the Resident #23 attempted to use a fork, but was unsuccessful and again used his hands to eat. On 3/04/24 1:02 PM, Nurse # 31 entered the resident room and began to adjust the resident to a higher position in bed. A second staff member enter the room and closes the door as the resident shouted, where is my water?

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, it was determined that the facility failed to ensure the administration of a complete course of antibiotics as ordered. This was evidenced for 1 (Resident #118) out of 5 residents reviewed for un necessary medication. The findings include: On 02/29/24 at 4:00 PM, a record review for Resident #118 revealed that, on 02/06/2024 at 3:13 PM, a new order was placed for an antibiotic to be given every 12 hours for 7 days for Urinary Tract Infection (UTI). On 02/29/2024 at 11:10 AM, review of Resident #118's Medication Administration Record (MAR) indicated that the first two doses of the antibiotics, scheduled to be given on 02/06/2024 at 8 PM & 02/07/2024 at 8 AM were not administered, resulting in only 12 of 14 doses of the antibiotic being administered. A nurse's progress note with a date of 2/06/24 at 11:10 PM indicated, pending pharmacy delivery for Resident #118's antibiotic. A review of Resident #118 ' s medical record failed to reveal documentation indicating that Resident #118's physician was made aware, nor that there was any change to the start date of the antibiotics. On 02/29/24 at 04:29 PM, the surveyor reviewed the concern with the Director Of Nursing (DON) that based on the review of the MAR, resident # 118 received 12 of the ordered 14 doses of antibiotics. No documentation was found to indicate the order was changedor that MD was notified. The facility failed to provide any additional supportive documentation that the resident received a complete course of ordered antibiotics, as of the time, survey exit on 03/05/24 at 5:30 PM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and staff interview, it was determined that the facility failed to ensure and check the functionality of the wander guard, as ordered. This was evident for 1 (Resident # 119) of 1 Resident reviewed for potential elopement during the survey. The findings include: On 02/22/24 at 08:44 AM, Surveyor observed that Resident #119 had a wander guard on the resident's ankle. A Wander guard bracelet is a technology to safegurd residents at risk of wandering. It has a a sensor that monitors doors and a technology platform that sends safety alerts in real-time when residents get close to the doors. On 02/26/24 at 09:18 AM, a medical record review revealed that the physician ordered to monitor the wander guard device function and placement every shift, dated 02/05/24. Monitoring to ensure the placement of the wander guard and to check the function of the wander guard orders were combined and it was signed on the treatment administration record (TAR). A review of the February 2024 TAR revealed that monitoring and the function of the wander guard order was signed by licensed Nurses every shift from 02/05/2024 - 02/29/24. On 02/27/24 at 10:26 AM, during an interview with staff #5, Registered Nurse (RN), it was revealed that the function of the wander guard was not checked by Nursing, but checked every once in a while by Maintenance staff.Staff #5 also confirmed that the Nursing unit does not have the device to check the function of the wander guard. Staff #5 reported that the previous maintenance staff used to check the function of the wander guard, but s/he had not seen the new Maintenance staff checking it. Staff #5 was not aware of the wander guard function checking schedule of the maintenance department. When maintenance completed the checking of the wander guard function, they would inform the Nurses on the unit. On 02/28/24 at 05:26 PM, the Director of Nursing (DON) reported that the wander guard function was checked by the Maintenance department. DON didn't know that the Maintenance staff was not checking the function of Wanderguard and that Nursing was signing that they were checking. On 02/29/24 at 11:08 AM, the Maintenance Director (staff#19) reported that he/she started working recently at this facility and that they had not checked any wander guards or function of wander guards.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0691 (Tag F0691)

Could have caused harm · This affected 1 resident

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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 ensure that colostomy care was provided to a resident with a colostomy. This was evident for 1 (#15) of 1 resident reviewed with a colostomy. The findings include: The Minimum Data set (MDS) assessment is a federally mandated assessment tool that nursing home staff use to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. A medical record review done on 2/23/24 at 10:20 AM for Resident #15 revealed a care plan, initiated on 8/24/14 and revised on 3/9/22, that recorded that Resident #15 had a colostomy use status. A continued record review showed a progress note, dated 12/14/23,that the Resident had a diagnosis of cognitive impairment, completed by Resident #15's attending provider. A subsequent record review completed on 2/23/24 at 10:51 AM revealed an order summary report of January 2024 that revealed an attending provider's orders for 1) colostomy care every shift, initiated on 10/31/17 and discontinued on 1/29/24, 2) Monitor ostomy site for discoloration, change ostomy every shift and as needed, initiated on 10/31/2017 and discontinued on 1/29/2024. A continued review showed a discharge MDS assessment, dated 1/27/24, which revealed that Resident#15 depended on staff for toilet hygiene. Resident #15's MDSs showed that Resident #15 was hospitalized briefly on 1/27/24 and readmitted to the facility on [DATE]. However, the above orders for the colostomy care were not restarted upon Resident #15's return to the facility. On 2/23/24 at 10:27 AM, an interview conducted with staff #4, a geriatric nurse aide (GNA), revealed that Resident#15 used to take care of the colostomy by themselves, but was no longer able, due to confusion. On 2/23/24 at 11:59 AM, during an interview with staff #3, a licensed practical nurse (LPN), she stated that the attending orders for Resident #15's colostomy care were not restarted upon his/her return to the facility on 1/30/24 so there was no record of a nursing assessment of the colostomy site every shift. On 2/26/24 at 2:09 PM, an interview was conducted with the Director of Nursing (DON). During the interview, she said she expected the nurses and the Geriatric nurse aides (GNAs) to provide colostomy care that included assessment of the colostomy site every shift to ensure it was not irritated or infected.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview, it was determined that the facility failed to follow physicians' orders for the administration of oxygen. This was evident for 1 (Resident # 17) of 4 residents reviewed for respiratory care during a survey. The findings include: On 2/21/24, review of records revealed that Resident #17 was a long-term care resident of the facility. On 2/28/24 at 9:13 AM, a review of orders revealed an order with a start date of 2/20/24 for oxygen at 2 LPM (liters per minute) via NC (nasal cannula) as needed. May titrate to maintain O2 sats above 92% every 24 hours as needed for SOB, (Shortness of Breath). Supplemental Oxygen is a prescribed drug and is normally delivered by a nasal cannula. A nasal cannula is a thin, flexible tube that wraps around your head, typically hooking around your ears. On one end, it has two prongs that sit in your nostrils and deliver oxygen. The other end of the tube connects to an oxygen supply. There are several different types of oxygen supply delivery systems. The type of oxygen delivery system you use depends on your condition and what your healthcare provider recommends the oxygen saturation to be. Oxygen saturation is generally detected by the pulse oximeter. Your healthcare provider also determines how much oxygen you need to satisfy the oxygen saturation. The flow rate is how many liters of oxygen per minute your device delivers. For example, patients commonly use a flow rate of 2 liters per minute, but the flow rate varies by each patient's needs. On 2/28/24 at 9:39 AM, an observation was made in Resident #17's room. The observation revealed that resident had an O2 nasal cannula connected, running at a flow rate of 3 liters per min. On 2/28/24 at10:34 AM, an observation in Resident # 17's room with the DON was made. The DON confirmed that the oxygen level was at 3 L/min. On 2/28/24 at10:38 AM, an observation was made of Nurse Staff # 12 who entered the room and changed the flow rate to 2 liters per minute. During the observation Resident # 17 reported to the Nurse #12 and the surveyor that s/he did not touch his oxygen flow rate. On 2/29/24 at 8:17 AM, the surveyor discussed the concerns with Administrator and DON. The Administrator reported that the resident may have administered the oxygen himself/herself. On 3/4/24 at 4:00 PM, review of vital signs revealed that the documented oxygen saturation (02 sats) rates were as follows: 2/26/24 at 4:04 AM O2 sats 98% on room air 2/26/24 at 1:08 PM O2 sats 97% via nasal cannula 2/26/24 at 7:20 PM O2 sats 97% on room air 2/27/24 at12:28 AM O2 sats 98% on room air 2/27/24 at 6:09 PM O2 sats 97% on room air 2/28/24 at 5:16 AM O2 sats 98% on room air 2/28/24 at 12:36 PM O2 sats 98% via nasal cannula 2/28/24 at 10:09 PM O2 sats 97% via nasal cannula 2/29/24 at 6:06 AM O2 sats 98% on room air 3/01/24 at 12:41 AM O2 sats 98% on room air On 3/04/24 at 4:02 PM, the above concerns were discussed with the Director of Nursing. She replied that the oxygen administration of either 2 or 3 liters did not matter. On 3/04/24, progress notes for Resident #17 were reviewed for the dates 2/3/24 to 3/5/24. The review failed to reveal documentation that the resident complained of or experienced shortness of breath. In addition, the review failed to reveal any education regarding the resident's self-administration of oxygen. On 3/05/24 at 10:06 AM, Physician Staff # 29 was interviewed via phone. During the interview he reported that his expectations were that if the residents oxygen saturation fell below 92 percent, the nurses would titrate the oxygen to maintain the oxygen level at 92%, increase monitoring of the resident, document the low oxygen saturate rate and notify the provider.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on records review and interviews, it was determined that the facility failed to ensure that pain managementwas provided to the resident that was consistent with professional standards of practice. This was evident for 1 (Resident #16) of 3 residents reviewed for pain management. The findings include: Resident #16 was admitted to the facility in late 2023. On 2/21/24 at 1:12 PM, the resident was interviewed about pain management and reported that there had been several occasions where his/her pain medications were administered late or the dose was skipped. On 2/23/24 at 9:22 AM, a review of Resident #16's medical record indicated that the resident was sent to the hospital in November of 2023 due to a fall that resulted in a fractured hip and was readmitted in December 2023. On 2/26/23 at 10:38 AM, Resident #16's pain medication orders were reviewed. The review revealed an order for Oxycodone 10MG to be administered every 4 hours starting on 12/13/23 at 9 PM to 1/12/24 at 5 PM and restarted on 1/13/24 at 1 PM to 2/12/24 at 9 AM. On 2/13/24, the order for the 10MG Oxycodone was changed to be administered every 6 hours as needed for pain. On 2/26/24 at 2:10 PM, the Director of Nursing (DON) was interviewed about her expectations from nursing staff when administering controlled medications. The DON reported that all nurses are expected to document in the narcotic sheet binder after pulling the medication, and then documenting in the resident's electronic medication administration record (eMAR) after giving the medication. Later that day at 3:58 PM, a licensed practical nurse supervisor (LPN Staff #28) was also asked about her process when administering controlled medications. She reported that, after making sure that the resident had an order for the medication, she would pull the medication, administer the medication, make sure the resident took it, and then mark the narcotic sheet binder and eMAR. Staff #28 confirmed that this was the order of her process of administering a controlled medication like Oxycodone to a resident. On 2/28/24 at 9 AM, the DON provided copies of Resident #16's narcotic sheets for review. The review revealed that the 10MG Oxycodone was pulled 5 times on 1/20/24 (at 5AM,10AM, 2PM, 5PM, 9PM), 1/21/24 (at 3AM, 9AM, 2PM, 5PM, 9PM), and 1/27/24 (at 4AM, 9AM, 1PM, 5PM,10PM). A review of Resident #16's eMAR indicated that the nursing staff had documented administration of the medication 6 times on 1/20/24, 1/21/24, and 1/27/24 as scheduled for 1AM, 5AM, 9AM, 1PM, 5PM, and 9PM. On 2/28/24 at 11:36 AM, the findings were discussed with the DON that for multiple days, staff had been documenting administration of a narcotic pain medication without evidence of getting the medication from the supply. The concern was discussed again with the DON on 3/5/24 at 12:11 PM, to this date, no documentation had been provided to reconcile the difference between the eMAR and the narcotic sheets.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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Based on the surveyor's observation, record review, and interview with facility staff, it was determined that the facility failed to assess safety or obtain a physician's order before initiating the usage of side rails, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent. This was evident for 2 (Residents #6, and #9) of 2 residents reviewed for side rails. The findings include: 1) On 02/21/24, a record review revealed that Resident #6 had resided at the facility for more than a year. On 2/21/24 at 12:33 PM, observed the resident in bed with the bed rail up on the left side of the bed. On 2/21/24, medical record review failed to reveal a physician order, a safety screening, a consent either from the resident or from family, or a care plan reflecting the bed rail usage. The facility provided a copy of informed consent for the installation of a bed rail or assist bar not used as a restraint, dated 02/22/2024. A review of the policy # NS1293-01Safe use of bed rails procedure revealed that step VI a) physician order is required b) completion of bed safety evaluation c) Consent obtained for bed rail use, d) Education provided to the resident or, if applicable, resident representative,e) Care plan for the use/ need for bed rails. On 02/27/24 at 09:22 AM, an interview with Employee # 18, the Rehab Director, revealed that Nursing does an initial assessment upon admission. Then, the therapist does the safety screening and nursing will make a final decision whether to use the bed rails or not. Nurses will obtain a physician's order and get consent either from the Resident or from the family. Consent is placed in a hard chart. 2) On 02/21/24 at 12:21 PM surveyor observed a bed rail on right hand side of resident # 9's bed. A review of the medical record revealed that Resident # 9 was admitted in 2023. Further review failed to reveal a current physician's order or consent to use the bed rail. The facility provided a Device Decision Tree form addressing the use of the quarter rails to assist with activities of daily living and bed mobility. This form was signed by the responsible representative on 2/22/24 and the nurse on 2/23/24. No other documentation was provided to indicate that an informed consent was obtained prior to the initiation of the bed rails. On 03/04/24 at 3:30 PM, the surveyor reviewed concerns with the Director of Nursing (DON) regarding the failure to evaluate and obtain informed consent before bed rail initiation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

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Based on records review, interviews, and observations, it was determined that the facility failed to develop a care plan that reflects an individualized, person-centered approach with measurable goals and specific interventions to care for and treat a resident with dementia. This was evident for 1 (Resident #38) of 1 resident reviewed for dementia care.The findings include: Resident #38 was admitted to the facility in late 2023. The resident's medical records indicated active diagnoses of, but not limited to, non-traumatic brain dysfunction, dementia, depression, impairment in both sides of the lower extremity, and sever cognitive impairment. During the survey, 3 of the 4 times Resident #38 was observed, no activity was being provided. On 3/01/24 at 3:33 PM, the residents care plan was reviewed and indicated that the resident had specific health practices, beliefs/values, cultural needs/preferences, and/or linguistic needs/preferences. On the same day at 4:16 PM, the activity preference interview signed by the Activities Director (AD Staff #27) on 12/29/23 was reviewed and revealed the resident's answer to all interview questions were either resident refused to answer or resident could not answer. On 3/4/24 at 4:50 PM, the AD was interviewed about Resident #38. The AD reported that the resident's family had called after she completed the activity preference interview and was able to interview the family, however, there was no evidence of the information she gathered from the family member. Furthermore, there was no evidence that the AD updated the care plan after the family interview. The AD was also asked if the resident had any specific health practices, beliefs/values, cultural needs/preferences, and/or linguistic needs/preferences, and she indicated not to her knowledge. The concern was discussed with the AD that the resident's activities care plan was not revised based on the interview that she conducted, and developed interventions that were specific to the resident. On 3/5/24 at 12:11 PM, the concern was discussed with the Director of Nursing that care plans for a resident with a diagnosis of dementia did not reflect an individualized, person-centered approach with specific interventions to care for and treat the resident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on review of medical records and narcotic count sheets, and interviews, it was determined that the facility failed to keep an accurate record of controlled substances. This was found to be evident for 1 of 2 medication carts reviewed during a facility recertification survey. The findings include: On 3/04/24 at 11:30 AM, the narcotic count sheet binder for the ground floor was provided by the Registered nurse on duty (RN Staff #12). The narcotic count sheet revealed columns for the amount, date and time, amount used, amount wasted, administered by, and amount remaining. A count of all the narcotics in the ground floor medication cart was conducted with Staff #12, but before initiating the count, Staff #12 reported to the surveyor that there were medications that they had already administered to several residents but had not signed off from the narcotic count sheets. The count with Staff #12 revealed 1) Resident #1, had 6 Pregabalin capsules but the narcotic count sheet indicated 7; had 25 Oxycodone tablets but the narcotic count sheet indicated 26. 2) Resident #50 had 24 Oxycodone tablets but the narcotic count sheet indicated 25. 3) Resident #41 had 18 Tramadol tablets but the narcotic count sheet indicated 19. And 4) Resident #18 had 11 Pregabalin capsules but the narcotic sheet indicated 12. On 3/4/24 at 11:43 AM, the medication administration record (MAR) for the residents identified with inaccuracy of the narcotic count sheets were reviewed and revealed all were documented as administered except for Resident #1's Oxycodone. The order stated to give 1 tablet of Oxycodone 10MG every 4 hours as needed for severe pain. at 3:16 PM after the end of Day shift on 3/4/24, the MAR for Resident #1 was again reviewed and the Oxycodone 10MG order was still not marked as administered by Staff #12. On 3/4/24 at 3:41 PM, the Director of Nursing (DON) was interviewed about her expectation from the nursing staff when they administer controlled medications. DON reported that she expected staff to document in the narcotic count sheet as soon as the medication was pulled and document in the residents MAR as soon as the medication was administered. a review of the facility's Chain of custody for Controlled Substances procedure section III (e), stated Nurse will sign both the MAR and the Drug Count sheet when administering a controlled substance to a resident. On 3/5/24 at 12:11 PM, the concern was discussed with the DON that 1) narcotic count sheets were found to be inaccurate after being reviewed and confirmed by Staff #12, and 2) after reviewing the residents MAR twice (at the time of discovery and at the end of the shift), the nurse had not documented that the medication was administered. The DON indicated that she would investigate the concern.

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

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Based on pertinent documentation and interview, it was determined that the facility failed to implement the pharmacy and physician recommendations. This was evident for 1 (Resident # 17) out of 5 residents reviewed for unnecessary medication during a survey. On 2/21/24, review of records revealed that Resident #17 was a long-term care resident at the facility. On 2/23/24 at 12:26 PM, a review of the monthly pharmacy review, dated 1/1/24, for Resident #17 revealed the following pharmacist recommendation: Please consider monitoring a fasting lipid panel on the next convenient lab day and annually thereafter. On 2/23/24 at 12:30 PM, review of Resident # 17 physician orders failed to reveal an order for an annual lipid panel. On 2/23/24, the surveyor requested pharmacy reviews for Resident #17 and the physician or providers response to the recommendations. On 3/01/24 08:15 AM, a review of the physician prescriber/response to the pharmacist recommendation revealed a physician/prescriber signature, dated 2/5/24, and a handwritten OK. On 3/01/24 at 9:13 AM, a review of physician orders revealed an order for annual lipid panel, dated 2/27/28/24, 57 days after the recommendation by the pharmacist and 22 days after the physician reviewed and commented on the recommendations. 03/01/24 09:52 AM, a review of Resident #17's recent laboratory results provided by the DON revealed a laboratory result reported for lipid panel collected on 2/28/24 and the results were available the same day. 3/01/14 at 6:00 PM, the Director of Nursing was interviewed. She reported that the pharmacy reviews were emailed to the nursing department. The pharmacy reviews are then printed out and the hard copy is provided to a physician or nurse practitioner. A provider is at the facility 2 to 3 days a week. Nursing then follows up on the physicians' recommendations/orders. The DON continued that labs technicians come daily, Monday through Friday to collect specimen's laboratory orders. The DON confirmed that the order and laboratory results were late.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on records review and interviews, it was determined that the facility failed to document adequate monitoring and indication after administering pain medication. This was evident for 1 (Resident #16) of 6 residents reviewed for unnecessary medications. The findings include: Resident #16 was admitted to the facility in late 2023. During the initial pool process interview, the resident raised some concerns about pain management. On 2/26/23 at 10:38 AM, a review of the resident's pain medication orders revealed the resident was on 10MG Oxycodone to be administered every 6 hours as needed for pain with a start date of 2/13/24. Oxycodone is used to relieve pain severe enough to require opioid treatment and when other pain medicines do not work well enough or cannot be tolerated. It belongs to the group of medicines called narcotic analgesics (pain medicines). Narcotic pain medications have significant side effects and the potential for abuse. As a result, it is a standard of nursing practice to administer narcotic medication only from sources that can be both accounted for and reconciled. This practice discourages the diversion of abusable medication and ensures that narcotic medication is tracked according to federally mandated standards. On the same day at 10:52 AM, the Director of Nursing (DON) was asked to make copies of Resident #16's narcotic count sheets for the surveyor to review. The narcotic count sheet revealed columns for the amount, date and time, amount used, amount wasted, administered by, and amount remaining. The Narcotic count sheets were compared to the resident's medication administration record (MAR) and revealed multiple dates and times where the medication was pulled from the resident's supply, but were not documented in the resident's MAR as administered. The dates and times identified were 2/15 6AM, 2/17 9:30AM, 2/17 6PM, 2/18 5PM, 2/19 12PM, 2/20 12AM, 2/20 8PM, 2/21 1AM, 2/21 8AM, 2/21 4PM, 2/22 2AM, 2/22 2PM, 2/23 12AM, 2/23 6AM, 2/23 6PM, 2/24 12AM, 2/24 12:30PM, and 2/24 6:30PM. On 2/26/24 at 2:10 PM, the DON was interviewed about her expectations for staff when they administer controlled pain medication. The DON reported that all nurses were expected to document in the narcotic sheet binder after pulling the medication, and then document in the resident's MAR after giving the medication. The concern was discussed with the DON that there were multiple dates and times where staff had documented pulling the medication from the resident's supply, but had not documented in the MAR as administering the medication. The MAR and narcotic count sheets for Resident #16 was reviewed with the DON and she reported that the resident is getting her medication and understands the concern of the surveyor and stated, You can ask the resident if she is getting her medication, she's capable, she can tell you. The DON indicated that she would talk to the unit manager to see if she has any information regarding the administration of narcotics. On 3/5/24 at 12:11 PM, the concern was discussed with the DON that staff had failed to document adequate monitoring and indication for the pain medications that were administered. At the time of exit, no additional information was provided for the 18 doses identified.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observations, records review, and interviews, it was determined that the facility failed to have a medication administration error of less than 5%. This was evident for 2 of 3 nurses observed for medication administration. The findings include: 1) An observation of the Registered Nurse (RN Staff #31) on 3/1/24 at 9:42 AM, of her preparation and administration of Resident #18's medications revealed several items on her computer that appeared bright pink. Staff #31 reported these items were the orders for the resident's lidocaine patches that were behind schedule. Staff #31 proceeded to pull Resident #18's medications one by one in a medicine cup as she verified each one from the computer on the medication cart. Included with the medications she prepared were, but not limited to, mucus relief DM guaifenesin and dextromethorphan HBr extended-release 600mg/30 Mg, and redness reliever eye drops (active ingredient tetrahydrozoline HCL 0.5%). After the medication administration observation of Staff #31, at 10:23 AM, she reported that she was done signing the electronic medication administration record (eMAR) but indicated that she still needed to get the lidocaine patches from the medication storage room and apply cream on the resident's sacral area and was just waiting for the nursing aid to finish cleaning the resident. While waiting for Staff #31 to come back from the medication storage room, Resident #18's lidocaine patch orders were reviewed and revealed 4% patches were indicated for the resident's knees and 5% was indicated for the lower back. A few moments later at 10:39 AM, when the surveyor saw Staff #31, she reported that she had applied the lidocaine patches on Resident #31 and revealed the packaging of the 4% lidocaine patches that she used. Staff #31 was asked about the 5% indicated for the resident's lower back and she stated, Oh we don't have 5% here so I just used the 4% patch. On 3/01/24 at 10:56 AM, Resident #18's eMAR was reviewed and revealed that 4% lidocaine patches had 2 separate orders, 1) was for the old patch to be removed at 7:59 AM, which Staff #31 documented as removed at 10:09 AM, and 2) to apply the new patches at 8 AM, whereas Staff #31 documented the application at 10:10 AM. The 5% lidocaine patch was to be applied at 7 AM on the lower back, but was documented as applied at 10:18 AM to which Staff #31 also confirmed they used a 4%, rather than the 5% lidocaine patch. Resident # 18 had an order for Guaifenesin ER Tablet Extended Release 12 Hour 600MG, however, Staff #31 administered guaifenesin with dextromethorphan 600mg/30 Mg. Lastly, Resident # 18 had an order for Systane Ultra Ophthalmic Solution 0.4-0.3 % (Polyethylene Glycol-Propylene Glycol) but Staff #31 administered redness reliever eye drops (active ingredient tetrahydrozoline HCL 0.5%) that had a different active ingredient in both eyes. 2) On 3/4/24 at 10:02 AM, the surveyor began a medication administration observation with RN Staff #22 for resident #24. Staff #22 prepared all the resident's medication and placed it in a medicine cup. One by one, the meds were verified by Staff #22 from the resident's medical record on the computer then handing the packaging to the surveyor for note taking, after each medication was pulled. Included in the medications that were prepared was Vitamin B1-thiamine mononitrate 100mg tablet. Staff #22 was observed administering all the medications that she had prepared for the resident with no concern identified at that time. At 10:33 AM, Staff #22 reported that she was done signing the eMAR for the medication administration that she had done. On 3/04/24 at 11:02 AM, Resident #24's eMAR was reviewed and revealed an order for Vitamin B12 (Cyanocobalamin) Oral Tablet 100 MCG, which Staff #22 marked as administered, but gave Vitamin B1-thiamine mononitrate 100mg tablet instead. The concerns identified with medication administration were discussed with the DON on 3/5/24 at 12:11 PM. A total of 3 RN's were observed for medication administration from each floor and the total medication error rate was 17%.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview, it was determined that the facility failed to ensure expired medications were disposed of properly. This deficient practice was found to be evident for 1 of 1 medication storage room and 2 of 2 medication carts observed during medication storage and labeling inspection. The findings include: On 3/4/24 at 11 AM, an observation of the facility's medication storage room on the ground floor, in the presence of a Registered Nurse (RN Staff #12), revealed an unopened bottle of Vitamin C that expired on 1/24, on the shelf with other unexpired Vitamin C bottles. Staff #12 removed the bottle and indicated that it would be disposed of. On 3/04/24 at 1:31 PM, an observation of the medication cart on the 2nd floor, in the presence of an RN (Staff #5), revealed 1) a bottle of Vitamin B12 100mcg expired on 6/23, 2) Magnesium Chloride with Calcium expired on 11/23, 3) Zinc 50 MG expired on 1/24, and 4) Bisacodyl 5MG expired on 2/24. As the surveyor was inspecting the medication cart, at 1:42 PM, the Director of Nursing (DON) arrived and saw the bottles of medicine that was put aside with identified concern and indicated that there should not be anything in the medication carts that are expired. The DON confirmed the bottles of medicine present were passed the expiration dates. On 3/4/24 at 2:31 PM, an observation of the medication cart on the Ground floor, in the presence of Staff #12, revealed a bottle of Bisacodyl expired on 2/24 on the top drawer. Staff #12 indicated that he would discard the medication. On 3/5/24 at 12:11 PM, the above findings were discussed with the DON that all 3 areas (medication storage room and 2 medication carts) inspected for medication storage and labeling were observed with expired medications.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0914 (Tag F0914)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined that the facility failed to provide full visual privacy for residents in non-private rooms. This was evident for 6 beds of the 2 floors observed during the recertification survey. The findings include: On 2/20/24 at 1:19 PM, an observation was made of room [ROOM NUMBER]. Bed A did not have suspended curtains to provide visual privacy and bed B had a curtain but only covered one side of the bed. On 2/28/24 at 2:43 PM, the resident's family member who occupied bed A in room [ROOM NUMBER] was interviewed and s/he indicated that there had not been a curtain to provide full visual privacy for several months. On 3/1/24 at 5:34 PM, a tour of the 1st and 2nd floor was conducted to identify other beds with the same concern. The observation revealed room [ROOM NUMBER] bed A and B; room [ROOM NUMBER] bed A and B; room [ROOM NUMBER] bed A; and room [ROOM NUMBER] bed B, did not have curtains that extended around the bed or in combination with adjacent walls and curtains to provide total visual privacy. On 3/04/24 at 12:02 PM, a tour of the rooms with identified concerns was done with the Maintenance Director (Staff #19) and he confirmed the above findings. The concern was discussed with Staff #19 that for residents occupying non-private rooms, each bed must have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains. Staff #19 indicated that he would check if he had curtains in stock and would order them if not.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, it was determined that the facility failed to provide reasonable accommodations to maintain residents' independence by failing to provide adequate bed side lighting that was accessible to residents with decreased mobility. This was evident for 14 rooms out of 16 rooms, observed during a survey. The findings include: On 2/21/24 at 10:30 AM, during an Interview, Resident #269 reported that s/he had recently been admitted to the facility. Resident #269 reported that s/he liked to read, however, s/he was unable to get out of bed without assistance and was unable to turn on or off their overhead bed light from their bed. On 2/21/24 at 10:31 AM, an observation in Resident #269's room revealed a light switch on the wall behind the resident bed, which was out of reach of the resident. On 2/23/24 at 10:18 AM, an interview with Occupational Therapist Staff #7 reported that the resident was unable to get out of bed safely without assistance. On 2/21/24 at 7:08 AM, an observation was made in Resident #37s room. Observation revealed the resident in bed with the call bell out of reach of Resident # 37. On 2/21/24 at 7:10 AM, the surveyor alerted Assistant Director of Nursing (ADON), regarding the call bell being out of reach of Resident #37. ADON reported the issue had already been taken care of. On 2/21/24 at 7:24 AM, during an interview, Resident # 37 reported s/he had been recently admitted to the facility. S/he reported that s/he enjoyed coloring, and s/he showed the surveyor several pictures s/he was currently coloring. In addition. Resident #37 stated she was unable to turn on her overhead light while in bed. On 2/21/24 at 7:24 AM, an observation in Resident #37's room revealed a light switch for the overhead bed lighting on the wall that was behind the bed, out of reach of the resident. The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems 02/23/24 12:08 PM, a review of Minimum Data Set (MDS) dated [DATE], section F0800, staff assessment of daily activity preferences, 1/27/23, revealed that the Resident #37 liked reading books, newspapers, or magazines. Continued review of MDS under mobility, revealed s/he was dependent on staff to transfer from a bed to a chair/wheelchair. On 1/28/24 at 2:00PM, the Maintenance Director Staff # 19 and surveyor began a tour of the residents' rooms on the first floor. The following room observations and brief interviews were as follows: During a room tour with Maintenance Director Staff #19 on 1/28/24 at 2:01PM, an observation of Resident #17 in their room revealed a private room with the light switch, for overhead bed lighting, that was on the wall behind the head of bed, out of reach for the resident. Continued observation revealed the resident was awake and sitting up in bed. On 1/28/24 at 2:02 PM, during an interview, Resident # 17 reported that s/he was able to turn on and off their over the bed light. First, s/he used the remote bed control and reclined the bed to a flat position, then they scoot up toward the head of the bed. Next, s/he reached their right arm above their head and used a back scratcher to turn the light on. S/he repeated this procedure to turn the light off. Resident reported that if the light switch was on the left side of the bed, they would be unable to operate the light switch due to pain in their left shoulder. On 3/4/24, a review of the physical therapy discharge notes,dated 2/8/24, revealed that the resident required minimal assistance for transfers. Minimal Assistance. The patient can perform 75% of the mobility task while the caregiver assists with 25%. During the continued room tour with the Maintenance Director Staff #19, an observation was made in Resident # 10's room. Observation revealed that a light switch, for the over the bed light, was on the wall behind the bed, out of reach of the resident. Continued observation revealed a grabber sitting on top of a dresser on the opposite wall from the light switch. 0n 1/28/24 at 2:02 PM, Resident #10 was interviewed. During the interview s/he reported that s/he could only turn on and off the light switch with the help of her/his grabber device. S/he continued that s/he did not currently have her/his grabber. In a subsequent interview with Resident #10 on 3/01/24 at 9:29 AM, s/he reported that s/he sometimes liked to do activities at night, and they had made a request to their family, to bring them a head lamp for light. On 3/01 /24 at 9:30 AM, an observation of Resident #10 room revealed a grabber lying on the dresser on the wall opposite the over the bed light and out of reach of Resident #270 On 3/4/23 review of Residents #10's MDS SECTION C, dated 2/27/24, revealed the resident had a BIMS of 15, indicating the resident did not have a cognitive decline. Continued review of medical records revealed the following under the section, Transfer -self performance, (How resident moves between surfaces, including to or from: bed, chair, wheelchair, standing position. Between the dates of 2/1/24 and 2/27/24, residents' self performance ability was documented 79 times during this period. On 9 occasions their ability was documented as total dependance, (full staff performance). On one occasion, extensive assistance was documented, and on one occasion independent (no help or staff oversight at any time) was documented. On 2/28/24 at 2:05PM, a continued room tour revealed the following: RM 114- over head light switch on the wall, not within reach from the resident's bed. RM 113 - over head light switch on the wall, not within reach from the resident's bed. RM 111 -over head light switch on the wall, not within reach from the resident's bed. RM 110 -over head light switch on the wall, not within reach from the resident's bed. Rm 119 -over head light switch on the wall, not within reach from the resident's bed. On 2/28/24 at 2:10 PM, a brief interview with Maintenance Director Staff #19 revealed that rooms 1 through 12 on the ground floor, rooms 110 through 122 on the first floor, and rooms 210 through 222 on the second floor all have over the bed lighting that must be turned on by a switch on the wall. On 2/28/24 at 2:11 PM, continued room tour with Maintenance Director Staff #19 revealed the following: RM 105 - pull cord was available to use for overbed lighting, no issue. RM 106 - pull cord was available to use for overbed lighting, no issue. RM 107- Bed A had a pull cord that the resident could reach, however the light did not turn on. room [ROOM NUMBER] -The light cord is short and at the foot of the bed. On 3/01/24 at 5:48 PM, the concerns regarding the lack of access to adequate overhead bed lighting for residents, the inability to transfer out of bed without assistance, were discussed with the administrator. The administrator reported that when a resident needed assistance, they should use the call bell and staff would assist them.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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3) Resident #33 had been residing in the facility since 2019. On 2/21/24 at 3:09 PM, Resident #33's medical record was reviewed and revealed that s/he was sent out to the emergency room in January of 2024. On 2/28/24 at 1:40 PM, Resident #33's transfer form with a reference date of 1/21/24, completed by Licensed Practical Nurse (LPN Staff #21) was reviewed and revealed section E, item number 5 as emergency department or outpatient transfer checklist. The items listed in this checklist were as follows: a) X-Ray b) Medication list c) Lab results d) Care plan goals e) MOLST f) Facesheet g) Other info h) Bed Hold i) Notice of Transfer with an instruction to print these documents in this order and include with the transfer from to send with the patient to the hospital. A check mark in a boxed area before each item indicated which document was printed and sent with the resident. Staff #21 did not put a check mark next to item (i) for Notice of Transfer. On 3/1/24 at 11:52 AM, the Social Service Director (SSD Staff #15) was interviewed about her process when a resident is transferred or discharged to the hospital. Staff #15 reported that she would send the notification to the Ombudsman and indicated that sending the notification to the family member or RP was the nurse's responsibility. On 3/01/24 at 12:09 PM, Registered Nurse (RN Staff #10) working on the 2nd floor was interviewed about her process when a resident needed to be sent out to the hospital. Staff #10 reported that, after having the Physician or Nurse practitioner evaluate the resident and getting an order to send the resident to the hospital, she would print the necessary documentation for transfer and call 911. Staff #10 stated each document that she would print and then call the family and/or resident representative (RP) to inform them of the resident's situation and which hospital the resident would be transferred to. If the incident were to happen after hours, then she would call the on-call provider and repeat the same process. The surveyor asked Staff #10, is there anything else you would do or provide the resident and family or RP with? Staff #10 answered No, and added, if the resident is not coming back immediately, then she would update the family on the treatment and development of the resident in the hospital. On 3/01/24 at 1:46 PM, a nurse working on the 1st floor (RN Staff #22) was also interviewed about her process when a resident had an order to be sent out to the hospital. Staff #22 indicated that the process would be individualized for each resident but also failed to note that she would provide a written notice of transfer to the resident and/or RP. When Staff #22 was asked if there was anything else she would provide the resident or RP with, she reported that she would also inform the family of any personal belongings that went with the resident. On 3/01/24 at 5:44 PM, the surveyor discussed the concern with the Director of Nursing (DON) about the notice requirements before transfers, where there was no evidence of the written notice of transfers being provided to the resident and/or RP in a practicable time. The DON confirmed that this was the responsibility of the nurse and indicated that a transfer form is used by the nurses and that it had a portion where the nurse would mark all the required documents that were printed and sent with the resident. The surveyor reviewed with the DON the transfer form for Resident #33, with a reference date of 1/21/24, and revealed the portion the DON was referring to was section E and confirmed the surveyor finding that the notice of transfer was not marked as printed and sent with the resident when s/he was transferred to the hospital or provided to the RP in a practicable time. 2) Review of Resident #15's medical record on 2/21/24 at 12:15 PM, revealed a change in condition evaluation form dated 1/27/24, that recorded the resident had shortness of breath while performing tasks. The attending provider was notified and ordered to send the resident to the emergency room for evaluation. Further review of the medical record failed to reveal that the resident and/or the resident representative was notified in writing of the transfer/discharge of the resident along with the reason for the transfer. Continued review of Resident #15's medical record on 2/21/24 at 12:50 PM, revealed an e-interact transfer form dated 1/27/24. The transfer form included a section labeled SNF to ED or Outpatient Clinic Transfer checklist, followed by a list of statements to be checked if completed and sent with the resident to the hospital. The checked statements were: lab results, MOLST and face sheet. The statement Notice of Transfer was not checked, indicating written notification was not sent with the resident upon transfer to the hospital. On 2/22/24 at 1:41 PM, during an interview with staff #21, a Licensed practical nurse (LPN), she was asked about the process for transferring a resident to an acute care facility. Staff # 21 reported that she only notified the Resident's representative of a hospital transfer via phone and not in writing. A subsequent interview with staff #3, an LPN on 2/23/24 at 11:59 AM, showed that she gave a packet that included face sheet, MOLST (medical orders for life-sustaining Treatments), medication list and any recent laboratory results to the Emergency Medical Staff at the time of transfer of a resident to the hospital. On 2/23/24 at 1:36 PM, an interview was conducted with the Director of Nursing. During the interview, she stated that per Resident #15's e-interact Transfer form completed on 1/27/24, a written notification along with the reason for transfer was neither given to the resident nor the Resident's Representative upon transfer to the hospital. She also reported that the staff only notified Residents' Representatives of an acute facility transfer via phone calls. Based on medical record review and staff interviews, it was determined that the facility failed to notify the resident/resident's representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (#27, #15 and #33) of 4 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 2/27/24 at 11:00 AM, a review of Resident #27's electronic health record (EHR) revealed that Resident #27 was transferred to an acute care facility on 2/2/24. In a SBAR Summary for Providers note, on 2/2/24 at 12:24 PM, the nurse documented that Resident #27 had a change in condition, the primary care provider was notified, and recommended Resident #27 be sent to the hospital. Further review of the resident's EHR, and hard paper medical record failed to reveal any documentation that Resident #27 and/or the resident's representative (RR) was notified in writing of the resident's transfer along with the reason for the transfer. On 3/1/24 at 11:52, during an interview, Staff #15, Social Services Director (SSD), stated that s/he notified the Ombudsman of resident transfers and discharges monthly, however, the SSD was not responsible for notifying the resident's representative in writing of the transfer. On 3/5/24 at 12:22 PM, during an interview, when asked if residents were provided with a written transfer notice upon transfer to the hospital, Staff #20 indicated s/he was unsure if a resident would be given a transfer notice when transferred to the hospital. The above concerns were discussed with the Director of Nurses (DON) and Assistant Director of Nurses (ADON) on 3/5/24 at 1:30 PM and the DON and ADON indicated they understood the concerns at that time.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected multiple residents

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3) Resident #33 had been residing in the facility since 2019. On 2/21/24 at 3:09 PM, Resident #33's medical record was reviewed and revealed that s/he was sent out to the emergency room in January of 2024. On 2/28/24 at 1:40 PM, Resident #33's transfer form, with a reference date of 1/21/24 completed by Licensed Practical Nurse (LPN Staff #21), was reviewed and revealed section E, item number 5 as emergency department or outpatient transfer checklist. The items listed in this checklist wereas follows: a) X-Ray b) Medication list c) Lab results d) Care plan goals e) MOLST f) Facesheet g) Other info h) Bed Hold i) Notice of Transfer with an instruction to print these documents in this order and include with the transfer from to send with the patient to the hospital. A check mark in a boxed area before each item indicated which document was printed and sent with the resident. Staff #21 did not put a check mark next to item (h) for bed hold. On 3/01/24 at 12:09 PM, Registered Nurse (RN Staff #10) working on the 2nd floor, was interviewed about her process when a resident needed to be sent out to the hospital. Staff #10 reported that, after having the Physician or Nurse practitioner evaluate the resident and getting an order to send the resident to the hospital, she would print the necessary documentation for transfer and call 911. Staff #10 stated each document that she would print including the bed hold policy and then call the family and/or resident representative (RP) to inform them of the resident's situation and which hospital the resident would be transferred to. If the incident were to happen after hours, then she would call the on-call provider and repeat the same process. On 3/01/24 at 1:46 PM, a nurse working on the 1st floor (RN Staff #22) was also interviewed about her process when a resident had an order to be sent out to the hospital. Staff #22 indicated that the process would be individualized for each resident, but failed to report that she would provide the bed hold policy to the resident and/or RP. When Staff #22 was asked if there was anything else she would provide the resident or RP with, she reported that she would also inform the family of any personal belongings that went with the resident. On 3/01/24 at 5:44 PM, the surveyor discussed the concern with the Director of Nursing (DON) about the bed hold policy notification, where there was no evidence of the bed hold policy being provided to the resident and/or RP in a practicable time. The DON confirmed that this was the responsibility of the nurse and indicated that a transfer form is used by the nurses and that it had a portion where the nurse would mark all the required documents that were printed and sent with the resident. The surveyor reviewed with the DON the transfer form for Resident #33 with a reference date of 1/21/24 and revealed the portion the DON was referring to was section E and confirmed the surveyor finding that the bed hold policy was not marked as printed and was provided to the resident when s/he was transferred to the hospital or provided to the RP in a practicable time. 3) Resident #33 had been residing in the facility since 2019. On 2/21/24 at 3:09 PM, Resident #33's medical record was reviewed and revealed that s/he was sent out to the emergency room in January of 2024. On 2/28/24 at 1:40 PM, Resident #33's transfer form with a reference date of 1/21/24, completed by Licensed Practical Nurse (LPN Staff #21) was reviewed and revealed section E, item number 5 as emergency department or outpatient transfer checklist. The items listed in this checklist were as follows: a) X-Ray b) Medication list c) Lab results d) Care plan goals e) MOLST f) Facesheet g) Other info h) Bed Hold i) Notice of Transfer with an instruction to print these documents in this order and include with the transfer from to send with the patient to the hospital. A check mark in a boxed area before each item indicated which document was printed and sent with the resident. Staff #21 did not put a check mark next to item (i) for Notice of Transfer. On 3/1/24 at 11:52 AM, the Social Service Director (SSD Staff #15) was interviewed about her process when a resident is transferred or discharged to the hospital. Staff #15 reported that she would send the notification to the Ombudsman and indicated that sending the notification to the family member or RP was the nurse's responsibility. On 3/01/24 at 12:09 PM, Registered Nurse (RN Staff #10) working on the 2nd floor was interviewed about her process when a resident needed to be sent out to the hospital. Staff #10 reported that, after having the Physician or Nurse practitioner evaluate the resident and getting an order to send the resident to the hospital, she would print the necessary documentation for transfer and call 911. Staff #10 stated each document that she would print and then call the family and/or resident representative (RP) to inform them of the resident's situation and which hospital the resident would be transferred to. If the incident were to happen after hours, then she would call the on-call provider and repeat the same process. The surveyor asked Staff #10, is there anything else you would do or provide the resident and family or RP with? Staff #10 answered No, and added, if the resident is not coming back immediately, then she would update the family on the treatment and development of the resident in the hospital. On 3/01/24 at 1:46 PM, a nurse working on the 1st floor (RN Staff #22) was also interviewed about her process when a resident had an order to be sent out to the hospital. Staff #22 indicated that the process would be individualized for each resident but also failed to note that she would provide a written notice of transfer to the resident and/or RP. When Staff #22 was asked if there was anything else she would provide the resident or RP with, she reported that she would also inform the family of any personal belongings that went with the resident. On 3/01/24 at 5:44 PM, the surveyor discussed the concern with the Director of Nursing (DON) about the notice requirements before transfers, where there was no evidence of the written notice of transfers being provided to the resident and/or RP in a practicable time. The DON confirmed that this was the responsibility of the nurse and indicated that a transfer form is used by the nurses and that it had a portion where the nurse would mark all the required documents that were printed and sent with the resident. The surveyor reviewed with the DON the transfer form for Resident #33, with a reference date of 1/21/24, and revealed the portion the DON was referring to was section E and confirmed the surveyor finding that the notice of transfer was not marked as printed and sent with the resident when s/he was transferred to the hospital or provided to the RP in a practicable time. 2) A review of Resident #15's medical record on 2/21/24 at 12:15 PM revealed that the resident was transferred to an acute care facility on 1/27/24 for shortness of breath. Further review of the medical record showed that Resident #15's representative was called. However, there was no written documentation that the resident and /or the resident representative were notified in writing of the bed-hold policy. A continued record review for Resident #15 revealed an e-interact transfer form dated and completed on 1/27/24. The transfer form included a section labeled SNF to ED or Outpatient Clinic Transfer checklist, followed by a list of statements to be checked if completed and sent with the resident to the hospital. The checked statements were: lab results, MOLST, and face sheet. The statement Bed-hold was not checked, indicating a written notification of the bed hold policy was not done. On 2/23/24 at 1:36 PM, during an interview with the Director of Nursing (DON), she stated that per Resident #15's e-interact Transfer form completed on 1/27/24, a written notification of the bed hold policy was neither given to the Resident nor the Resident's Representative upon transfer to the hospital. During a subsequent interview with the DON on 2/23/24 at 2:31 PM, she reported that she was working on calling Resident #15's Representative about the bed hold policy for the resident's hospital transfer on 1/27/24. Based on medical record review and interviews, it was determined that the facility failed to notify residents and/or their representatives in writing of the bed-hold policy upon transfer of residents to an acute care facility. This was evident for 3 (#27, #15, #33) of 4 residents reviewed for hospitalizations. The findings include: 1) A review of Resident #27's electronic health record (EHR) on 2/27/24 at 11:00 AM, revealed that the resident was transferred to an acute care facility on 2/2/24. In an SBAR Summary for Providers note, on 2/2/24 at 12:24 PM, the nurse documented that Resident #27 had a change in condition, the primary care provider was notified, and the resident was sent to the hospital. Continued review of the medical record failed to reveal evidence that the resident was given a copy of the facility's bed hold policy when s/he was transferred to the hospital. On 3/1/24 at 11:52 AM, during an interview, the SSD stated that she was not responsible for notifying the resident's representative (RP) of the facility's bed hold policy when the resident was transferred to the hospital and indicated that s/he did not know who was responsible for notifying the RP. On 3/5/24 at 12:22 PM, during an interview, when asked if a resident was provided with a copy of the facility's bed hold policy when transferred to the hospital, Staff #20 stated that s/he was not familiar with the bed hold policy, indicating the bed hold policy was not provided to the resident upon transfer. The above concerns were discussed with the Director of Nurses (DON) and Assistant Director of Nurses (ADON) on 3/5/24 at 1:30 PM and the DON and ADON indicated they understood the concerns at that time.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility staff failed to complete comprehensive Minimum Data Set (MDS) assessments within the regulatory time frames to facilitate appropriate care planning and maintain current and accurate assessment records. This was evident for 3 (#37, #57, #59) of 44 residents reviewed during the survey. The findings include: The MDS is a federally mandated assessment tool nursing home staff use to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. The admission MDS assessment is a comprehensive assessment for new residents and, under some circumstances, returning residents. It must be completed by the end of day 14, counting the date of admission to the facility as day 1. Completion of the Comprehensive Annual MDS assessment, including the Care Area Assessments (CAA), must be completed no later than 14 days after the Assessment Reference Date (ARD). The last day of this observation period is the Assessment Reference Date (ARD). This is the end date of the observation period and provides a common reference point for all team members participating in the assessment. In completing sections of the MDS that require observations of a resident over specified periods such as 7, 14, or 30 days, the ARD is the common endpoint of these look back periods. 1a) On 2/22/24 at 8:47 AM, a medical record review was completed for Resident #37. The review revealed an MDS assessment with ARD 12/15/23 that documented that Resident #37 was admitted from an acute hospital to the facility on [DATE]. Continued review revealed that Resident #37's admission MDS assessment, with ARD 12/15/23 was signed as complete on 12/27/23, 20 days after Resident #37's admission to the facility and 6 days late. 1b) A review completed on 2/22/24 at 9:30 AM of Resident #57's admission MDS assessment with ARD 12/20/23, revealed that Resident #57 was admitted to the facility on [DATE]. Further review of the MDS assessment revealed that the admission MDS assessment was due on 12/26/23; however, it was signed as complete on 1/5/24, 24 days after Resident #57's admission to the facility and 10 days late. 1c) On 2/22/24 at 9:50 AM, A medical record review was completed for Resident #59. The review showed an admission MDS assessment with ARD 12/8/23 which documented that Resident #59 was admitted to the facility on [DATE]. Further review of the MDS assessment revealed that the admission MDS assessment was due on 12/14/23; however, it was not completed until 12/27/23, on day 27 after Resident #59's admission to the facility and 13 days late. On 3/1/24 at 12:33 PM, an interview with staff #16, a corporate mobile MDS Coordinator revealed that an admission MDS assessment was supposed to be completed in 14 days after a resident was admitted to the facility. During a subsequent interview with staff #16 on 3/1/24 at 3:04 PM, she confirmed that the admission MDS assessments for Residents #37, #57, and #59 were completed late.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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Based on record review and interviews, it was determined that the facility, 1) failed to ensure that interdisciplinary team (IDT) care plan meetings were scheduled after each Minimum Data Set (MDS) assessment, and 2) failed to ensure that resident care plans were reviewed and revised by the IDT after each MDS assessment. This was evident for 4 (Resident #6, #9, #21, #16) of 4 residents reviewed for care planning, and 1 (Resident #70) of 2 residents reviewed for activities of daily living. The findings include: Minimum Data Set (MDS)- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. 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 Assessment Reference Date (ARD) is the last day of the observation period that the assessment covers. 1a) On 02/22/24 at 12:35 PM, medical record review revealed that Resident # 6 had been in the facility, receiving long-term care, for more than two years. The most recent MDS has ARD of 02/01/2024 and care plan meeting occurred on 01/31/24, which was the day before the last day of the MDS assessment period. No documentation was found to indicate a meeting was held after the 02/01/24 MDS was completed. 1b) On 02/27/24 at 10: 25 AM, the medical record review revealed Resident #9 had been in the facility for more than two years. The last care conference note was done on 8/22/23. The Resident's ARD dates for MDS were: 09/08/2023 and 12/8/23. No documentation was found to indicate that an interdisciplinary care conference meeting occurred after the completion of the 09/08/23 or 12/08/23 MDS assessment. On 2/28/24 at 02:45 PM, the surveyor reviewed concern with the DON that the only documentation of the care plan meeting found was from August 2023. DON reported that there have been meetings since then. On 02/28/24 at 04:30 PM, an interview was conducted with Staff #15, the Social Service Director, and Staff #1, the Nursing home administrator (NHA). During the interview, the surveyor reviewed the concern that no documentation was found that a care plan meeting had occurred since August 2023. NHA stated that we meet and discuss residents always. Staff #15 stated that attempts were made to contact the family member to schedule a meeting, and a care plan meeting was not held if the resident or family member could not attend the meeting. When asked if the interdisciplinary team (IDT) still held a meeting to review a resident's care plan if the resident or family could not attend, staff #15 stated that they do not. The surveyor team discussed the concern that the care plan is expected to be reviewed by the IDT after the assessments, and if the resident/family is unable/unwilling to attend, there is still an expectation that a care plan meeting occurs to specifically review the residents care. 1c) Resident #21 had been residing in the facility since 2021. On 2/28/24 at 12:38 PM, Resident #21's medical records were reviewed and revealed the last date of a care plan meeting taking place for the resident was 11/28/23. Further review of Resident #21's medical record revealed that the most current MDS assessment was an annual assessment with an assessment reference date (ARD) of 12/27/23. There was no evidence that a care plan meeting was conducted after this comprehensive assessment. On 2/28/24 at 12:42 PM, the Social services Director (SSD) was interviewed, in the presence of the Nursing Home Administrator (NHA), about her process in scheduling IDT care plan meetings. The SSD reported that she schedules the meeting every 3 months and as needed. The SSD indicated that as needed meant when there was a significant change or when family members requested it. The concern was discussed with the NHA and the SSD that a care plan meeting needed to be scheduled within 7 days of a comprehensive assessment. 1d) Resident #16 was admitted in the facility in late 2023. The resident's record indicated that s/he was a smoker when s/he was admitted . On 2/21/24 at 1:39 PM, in an interview with the resident, s/he indicated that s/he had quit smoking since being readmitted after her hip surgery and stated, I wear a patch now. On 2/23/24 at 9:22 AM, a review of Resident #16's medical record indicated that the resident was sent to the hospital in November of 2023 due to a fall that resulted in a fractured hip and was readmitted in December. On 2/23/24 at 10:16 AM, a review of Resident #16's medical record revealed a current care plan regarding the resident's behaviors of smoking in his/her room and non-compliance with the facility's smoking policy. Further review of the medical record revealed the last MDS assessment was a quarterly assessment with an ARD of 12/31/23. A note from the SSD created on 1/25/24 indicated that a care plan meeting was scheduled for 2/1/24 but was held on 2/6/24. On 2/28/24 at 12:42 PM, the Social services Director (SSD) was interviewed, in the presence of the Nursing Home Administrator (NHA), about her process in scheduling IDT care plan meetings. The SSD reported that she schedules the meeting every 3 months and as needed. The SSD indicated that as needed meant when there is a significant change or when family members request it. The SSD was asked, when there is a significant change, do u update the care plan? the SSD stated, if we have to, we will update the care plan. The NHA confirmed in this interview that Resident #16 had not smoked since being readmitted and used a nicotine patch. The concern was discussed with the NHA and the SSD that 1) a care plan meeting needed to be scheduled within 7 days of a comprehensive assessment, and 2) Resident #16's care plan was not reviewed and revised as it indicated behaviors of smoking in the resident's room and non-compliance with the smoking policy. 2) Resident #70 had been residing in the facility since 2019. The residents medical record indicated that the resident was sent out to the hospital in late 2023 and was readmitted in November of 2023 after a G-tube placement. PEG: A percutaneous endoscopic gastrostomy (PEG) is a surgery to place a feeding tube. These feeding tubes are often called PEG tubes or G tubes. Feeding tubes, or PEG tubes, allow you to receive nutrition through your stomach. This type of feeding is also known as enteral feeding or enteral nutrition. You may need a PEG tube if you have difficulty swallowing or can't get all the nutrition you need by mouth. On 2/28/24 at 4:29 PM, Resident #70's medical record was reviewed and revealed care plans related to tube feeding (with interventions like - administer flushes, administer medications via tube, check for placement and residuals, etc.) and Diet (with interventions like - alert dietician if consumption is poor for more than 48 hours, monitor and record food intake at each meal, offer substitute as requested or indicated, regular diet dysphagia advance texture, Large portion with Breakfast and Lunch, etc.) Further review of the medical record indicated that the resident had been on an NPO diet that started on 11/8/23. NPO stands for nil per os, or nothing by mouth. On 2/28/24 at 4:54 PM, the Registered Dietician (RD) was interviewed about her process, and she reported that she conducted a quarterly assessment and updated the care plans for the residents. The RD reported that Resident #70 had an unfortunate decline in health and had a G-tube upon readmission in November of 2023. The RD confirmed that Resident #70 does not take anything by mouth, and that all nutrition and medications are administered through the G-tube. Resident #70's care plan was reviewed with the RD, and she indicated that it should have been revised based on changing goals and needs of the resident.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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Based on observation, interviews, and records review, it was determined that the facility failed to provide the resident with an ongoing program for activities based on individual preference and the comprehensive assessment. This was evident for 3 (Resident #33, #70, #16) of 6 residents reviewed for activities. The findings include: 1) Resident #33 has been residing in the facility since 2019 and his/her medical record indicated that s/he is dependent on staff for bowel and bladder needs, eating, bathing, dressing, and feeding. On 2/20/24 at 10:47 AM, Resident #33 was observed sitting in a wheelchair outside the resident's room with no activity being provided. On 2/28/24 at 8:39 AM, Resident #33's medical record was reviewed and revealed the resident was not assessed for section F (Preferences for customary routine and activities) in the last annual Minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/22/23. Further review of the resident's medical record revealed an Activity Preferences Interview documented by the Activities Director (AD Staff #27) on 1/31/24 that indicated the resident was interviewed, however, all the answers to the interview questions were either resident refused to answer or resident could not answer. On the same day at 2:26 PM, the resident's current care plan was reviewed and revealed interventions for activities such as, but not limited to: Needs assistance/escort to activity functions; Will receive friendly weekly 1:1 visits from activities staff; When not in group programming, activities will make sure TV or Radio is on in room; and Provide 1:1 in room visits if unable to attend out of room events. Minimum Data Set (MDS)- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. The resident was observed on 2/28/24 at 2:58 PM, lying in bed, television was off, no radio in the room, and no activity being provided. The next day on 2/29/24 at 10:20 AM, Resident #33 was again observed in his/her room without any activity and was asked, is there any staff member that comes in your room to do activities with you? The resident answered by shaking his/her head indicating no. On 2/29/24 at 2:48 PM, the AD (Activity Director) was interviewed about Resident #33's activity preferences. The AD reported that the resident liked listening to music, but did not like watching television, confirmed the resident does not have his/her own radio and indicated that the facility has a radio that she brings to resident rooms. The AD was asked specifically about her process for the activity preference interview she had conducted with the resident on 1/31/24, where she documented that the resident refused to answer or could not answer her questions. The AD reported that she would call the family if the resident does not answer and indicated that she did have a conversation with Resident #33's family, but was not sure if she documented it, and would check the resident's records. On 3/5/24 at 12:11 PM, the concern was discussed with the Director of Nursing (DON) that resident preferences for activities were not evaluated to formulate the residents care plan. to this date, no documentation had been provided by the AD to show that resident preferences were assessed to provide an ongoing program for activities. 2) Resident #70 had been residing in the facility since 2019. During the initial tour of the facility on 2/20/24 at 1:18 PM, the resident was observed in bed with no activity being provided. On 2/23/24 at 11:51 AM, the resident's family members voiced concerns regarding the facility not providing activities that meet the resident's needs and preferences. On 2/27/24 at 3:08 PM, Resident #70's medical records were reviewed and revealed care plans for activities with interventions such as, but not limited to: Encouraging attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities; Offer technology of interest i.e. laptop, internet access, tablets, etc.; Provide 1:1 in room visits if unable to attend out of room events. On 2/29/24 At 2:47 PM, the AD was interviewed about Resident #70's participation with activities. The AD reported that the resident used to participate in group activities, but since the resident's decline in health, s/he mostly watched TV and listened to music. The AD explained that watching TV and listening to music was the resident participating in 1 on 1 activities. Resident #70's care plan for activities was reviewed with the AD and was asked, in the resident's current state, do you think the resident could use a laptop or a tablet? The AD replied, No and confirmed that the residents care plan should be updated to reflect the current status of the resident, and interventions to be resident-specific. On 3/5/24 at 12:11 PM, the concern was discussed with the DON that the AD failed to update the residents care plan for activities to meet resident-specific needs and preferences. 3) Resident #16 was admitted in the facility in late 2023. On 2/21/24 at 12:55 PM, the resident reported that after being readmitted in December of 2023, s/he could not attend the scheduled activities due to not being able to walk following hip surgery. The resident also reported that there was no in-room activity being provided and stated, Give me a coloring book and I'd be happy. On 2/23/24 at 10:44 AM, Resident #16's care plan for activities were reviewed and revealed interventions such as: Encouraging attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities; Encourage resident representative to attend activities in order to support participation. Both interventions were initiated on 10/27/23. At 10:50 AM on the same day, the section F0800 (staff assessment of daily and activity preferences) of the MDS for a significant change in status assessment with an ARD of 12/14/23 was reviewed and revealed resident preferences such as but not limited to: L. Reading books, newspapers, or magazines; M. Listening to music; P. Doing things with groups of people; Q. Participating in favorite activities; R. Spending time away from the nursing home; S. Spending time outdoors; T. Participating in religious activities or practices. On 2/29/24 at 2:20 PM, the AD was interviewed about her process in activity preference assessments and care plan revisions. The AD reported that care plans were updated when there is a new assessment or a change in condition. The concern was discussed with the AD that the staff assessment of daily and activity preferences does not match the residents care plan. The AD reported that she tries to encourage the resident to participate in group activities but the resident declines, and when the resident declines participation, there is nothing she can do, indicating she cannot force the resident. The AD was asked if she thought her interventions were effective, the AD replied, No, because we can't force the residents. On 3/5/24 at 12:11 PM, the concern was discussed with the DON that the AD failed to provide residents with an on-going program for activities based on individual preference and comprehensive assessments.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On [DATE] at 12:49 PM, surveyor observed Resident at the dining area, having tracheostomy stoma, without a tracheostomy collar. On [DATE] at 11:40 AM, a medical record review of Resident #9, revealed that the Resident had been in the facility for more than 2 years. The resident received tracheostomy care during his stay at the facility. On [DATE] at 01:00 PM, Provider # 36 encounter notes from [DATE] revealed: tracheostomy stoma noted. On [DATE] at 12:21 PM, a medical record review revealed that Resident # 9, had a current order from [DATE] to change the tracheostomy mask collar every Monday for trach care. Licensed Nurses were signing off the order in the Treatment administration record that the tracheostomy collar was being changed weekly. On [DATE] at 10:33 AM, an interview with Nurse, (Staff # 5) was conducted regarding the trach care-related orders. The nurse confirmed that resident (#9) did not have a tracheostomy collar and tracheostomy care was not provided, that nurses only performed suctioning when needed. Surveyor questioned the Nurse(Staff # 5) regarding the trach mask change order, which was signed off on [DATE] that it was done. RN said Collar change on Mondays? The resident doesn't have a tracheostomy mask, It is just monitoring the stoma and cleaning when needed. 2) On [DATE] at 12:56 PM medical record review revealed that the resident had an order from [DATE] to receive continuous oxygen 3 liters, and may titrate to maintain 02 sats above 93%. Nurses had signed in the treatment administration record (TAR) that the resident was receiving continuous oxygen when this was not occurring. The surveyor observed the resident being at the dining area on [DATE] at 12:49 PM, without using oxygen, and propelling wheelchair without assistance. On [DATE] at 03:30 PM, surveyor reviewed with the Director of Nursing (DON) the failure to ensure that staff documentation was accurate, as evidenced by the documentation of continuous oxygen administration when it was not occurring. DON indicated that the resident would not allow the oxygen to be on continuously. The surveyor reviewed the oxygen order that was written to be given continuously. 3) On [DATE] at 11:23 AM, surveyor requested staff (#33) Medical records, for any MOLSTs that they have for Resident # 9. A review of the MOLST record revealed that there were two different MOLST, in the electronic medical records ( EHR) and the old MOLST was not voided when the new MOLST was initiated. MOLST - Maryland Orders for Life Sustaining Treatment. The MOLST form includes orders for CPR or No CPR but can also include on page two additional orders regarding treatments such as dialysis, diagnostic testing and transfer to the hospital. 3) On [DATE] at 9:42 AM, an observation for medication administration was conducted for Registered Nurse (RN Staff #31) regarding Resident #18's medications. During preparation, Staff #31 verified each medication from the resident's medical record on the computer as she placed them one by one in a medicine cup. Included in the medication that she prepared was Docusate Sodium 100MG. During administration, Staff #31 explained the medications that she had prepared to Resident #18. The resident declined to take the Docusate Sodium and the surveyor observed Staff #31 remove the medication from the medicine cup. Resident #18 then proceeded to take the rest of the medication in the cup. Moving back outside Resident #18's room, Staff #31 was observed discarding medication in the trash bin connected to the medication cart and reported to the surveyor that it was the Docusate Sodium that the resident had declined to take. At 10:23 AM, Staff #31 reported that she was done signing the medication administration record (MAR) for Resident #18. On [DATE] at 10:56 AM, a review of the MAR for Resident #18 revealed the order for Docusate Sodium 100MG was signed as administered by Staff #31. The MAR was again reviewed later that day at 2:34 PM and still revealed the Docusate Sodium as administered for the AM dose. A review of the facility's policy regarding medication administration at 2:36 PM revealed the facility used a liberalized medication administration time, indicating AM doses were administered between 6AM to 11AM. On [DATE] at 12:11 PM, the concern was discussed with the Director of Nursing that an observation was made of Staff #31, where the medication was declined by the resident, but in reviewing the MAR, the medication was marked as administered. The concern was also confirmed by Staff #31, as she reported to the surveyor, the medication that she discarded in the trash bin connected to the medication cart. 2. Review of medical records on [DATE], revealed Resident #49 was admitted to the facility following a stroke with complications that included left side hemiplegia (weakness and decreased mobility). On [DATE] at 8:45 AM, review of Resident's #49 medical records revealed an order, with a start date of [DATE], for a Left elbow extension splint: on for 4 hours in the AM and off in PM, skin checks during and after splint use and on every day shift. Further review revealed an additional order, with a start date of [DATE], for Left hand palm protector: on for 4 hours in the AM and off in the PM at night. Skin checks during and after splint use. On [DATE] the following observations were made for Resident #49. On [DATE] at 8:45 AM, an observation of Resident # 49 revealed he/she was awake lying in bed. Observation failed to reveal the resident had on the left elbow extension splint or palm protector. On [DATE] at 9:40 AM, an observation of Resident # 49 sleeping in bed. Observation failed to reveal the resident had on a left elbow extension splint or palm protector. On [DATE] at 10:40 AM, an observation of Resident # 49 in bed at 10:40 failed to reveal the resident had on the left elbow extension splint or palm protector. On [DATE] at 12:12 PM, an observation of Resident # 49 failed to reveal the resident had a left elbow extension splint or palm protector. Further observation revealed Resident # 49's family member in the room. The family member stated that they did not know why Resident # 49 was not wearing the splint. She stated that sometimes she puts the splint on the resident and another family member can sometimes get him/her to put it on. [DATE] 01:41 PM, observation of resident lying in Bed. Observation failed to reveal left elbow extension splint or palm protector. On [DATE] at 2:58 PM, a review of treatment administration record (TAR) revealed documentation that the elbow extension splint and palm protector were on for 4 hours during the day. On [DATE] at 2:59, during an interview with nurse RN staff #31, they confirmed that they did not apply the splint or palm protector on during the day shift [DATE] for Resident # 49. On [DATE] at 2:58 PM,a review of Resident # 49's treatment administration record (TAR) revealed documentation that the elbow extension splint and palm protector were on for 4 hours during the day. On [DATE], Review of progress notes, dated [DATE], electronically signed by the DON, revealed that Resident #49 was non-compliant with wearing the left elbow extension splint and left-hand protector. On [DATE] at 4:58 PM, an interview was completed with 2 nurses at the nursing station. Nurse RN staff #12 reported that when the TAR was marked for the splint and palm protector, it meant that the splint was applied. Nurse #11 stated when the splint and palm protector were marked with a check, it meant it was put on during the day and removed in the evening. On [DATE], Reviews of TAR revealed documentation that the splint was on: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. Further review of that TAR failed to reveal documentation that Resident # 49 refused to have the splint and palm protector put on. On [DATE] at 4:02 PM, the above concerns were discussed with the Director of Nursing (DON). The DON did not provide any additional information. The DON failed to provide the dates that Resident #49 refused to have the splint and palm protector put on. Based on observation, medical record review, and staff interviews, it was determined that the facility failed to maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. This was evident for 3 (#9, #49, #68) of 43 residents, reviewed during the survey. Maryland MOLST (Maryland Orders for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. If an updated MOLST form is completed, all older forms shall be voided in accordance with the MOLST's instructions: Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician, NP, or PA to void the MOLST order form. Keep the voided order form in the patient's active or archived medical record. 1) On [DATE] at 3:12 PM, a review of Resident #68's electronic health record (EHR) revealed the resident had two active MOLST in his/her paper medical record (chart). One unvoided MOLST form, which was physician signed and dated [DATE], documented Resident #68's surrogate elected No CPR (cardiopulmonary resuscitation), Option A-2, Do Not Intubate (insert breathing tube for mechanical ventilation) (DNI): comprehensive efforts may include limited ventilatory support, and an active MOLST form, which was physician signed and dated on [DATE] at 3:04 PM, that documented Resident #68's surrogate elected No CPR, Option B, Palliative and supportive care. The concerns with a resident having more than one active MOLST in his/her medical record were discussed with the Director of Nurses (DON) on [DATE] at 12:20 PM. The DON offered further comments at that time.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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Based on the interview with facility staff, it was determined that the facility failed to have a full time (Full-time means working 35 or more hours a week) clinically qualified Food Service Director. This was evident for 1 of 1 Food service Director reviewed for required credentialing. The findings include: On 02/28/24 at 01:07 PM, during an interview with Registered Dietician (RD) Staff #13, it was revealed that she/he worked 16 hrs a week and did not get involved with the kitchen, but monitored monthly food tasting and temperatures only. On 02/29/24 at 12:01 PM, the Dietary Director (staff #17) was interviewed and reported that he/she worked for five years in healthcare-related areas, and had a certificate for Baltimore food service manager valid until Sep 2026. They were enrolled in a self-paced Certified Dietary Manager (CDM) program. They had initiated the first module and anticipating to complete it in 8-12 months. Staff #17 reported he has oversight from a corporate CDM. Surveyor Requested copies of any credentials he currently has; as well as credentials from the corporate CDM. 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] On 02/29/24 at 02:08 PM, surveyor reviewed with staff # 17 the Code Of Maryland Regulations (COMAR) and the definition of dietary supervisor(see above). Staff #17 revealed that s/he does not have any of these qualifications. On 03/04/24 at 03:30 PM, surveyor reviewed with the Director of Nursing (DON) the concern regarding the failure to ensure the facility has a qualified dietary manager. As of the time of the survey exit 03/05/2024 at 5:30 PM, no documentation was provided regarding the credentials of the corporate individual who Staff #17 had reported was a CDM providing oversight.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents at the facility. The findings include: On 02/22/24 at 12:52 PM, surveyor observed food serving trays with chipped and cracked edges. On 02/22/24 at 01:20 PM, surveyor reviewed chipped and cracked trays that were observed in use with the Food service Director (staff#17). On 02/29/24 at 12:08 PM, an observation of the trayline revealed several food trays with chips and cracks. At least 6 out of 10 trays observed in a food transportation cart revealed significant chips and cracks. On 02/29/24 at 02:08 PM, surveyor reviewed the concern with staff #17, that many of the serving trays had chips and cracks. Staff #17 confirmed that new trays would be ordered to replace the chipped and cracked trays. On 03/04/24 at 03:30 PM, surveyor reviewed with the Director of Nursing (DON) the concern regarding the failure to maintain food trays in good condition.

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

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Based on observation and interviews, it was determined that the facility failed to ensure that all laundry was processed and handled in a manner that prevents cross contamination and the spread of infections by failing to keep the door closed that separated the clean from the soiled area of the laundry room. This was evident for 1 of 1 laundry rooms and had the potential to affect all residents. The findings include: On 3/5/24 at 3:38 PM, while accompanied by the Nursing Home Administrator (NHA), a tour of the facility's laundry area revealed the laundry area consisted of a soiled laundry room, a clean laundry room and a room holding clean clothing , which the NHA indicated held clothes and linens belonging to residents which had not been labeled with a resident's name. Both the clean laundry room and the clean clothing room were accessed from the soiled laundry room. At that time, 2 surveyors observed that the door between the soiled and clean laundry room remained open while a laundry aid was processing clean laundry and, the entrance to the clothing room was open, with no barrier between the soiled linen room and the clean clothing room. Upon entering the opened door into the clean laundry room, an observation was made of washing machines and dryers that were next to each other, without a physical barrier separating soiled (washer) and clean (dryer) laundry. In front of the washers and dryers, there was a was a large counter height table which had folded stacks of clean linens on the top of the table, and in a corner of the laundry room, there were clean clothes hanging on a garment rack. At that time, during an interview, the laundry aide, Staff #26 confirmed she had been processing clean laundry, and the folded linens on the table were clean. Staff #26 also indicated that the clothes on the garment rack in the corner of the laundry room were overflow of residents' clean clothes. When asked to explain the laundry process, Staff #26 stated that prior to bringing soiled laundry into the laundry room, she would remove the clean linens from the table and remove them from the laundry room, however, the overflow of residents' clean clothes and linens remained in the room when the soiled laundry was brought in and remained in the room when the soiled laundry was sorted. Staff #26 stated that once the soiled laundry was brought out of the soiled laundry room into the clean laundry room, the laundry would be sorted before being placed in the washers. The above concerns were discussed with the NHA on 3/5/24 at 3:45 PM and the NHA acknowledged the surveyor's concerns at that time.

Dec 2023 14 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was on 2 of 3 nursing units of the facility during a complaint survey. The findings include: On 12/12/23 at 8:30 AM observation was made of Resident #24 lying in bed. Resident #24's breakfast tray was sitting on the over the bed tray table. The laminate on the over the bed tray table was peeled off on the right side of the table approximately 8 to 10 inches. The back wall by the resident's bed was observed to have an area of white spackle on the wall. On 12/14/23 at 10:48 AM Resident #41 was lying in bed on top of a fitted sheet which was torn and had holes throughout the sheet. On 12/14/23 at 10:50 AM Resident #27 was observed sitting in a wheelchair in the common area. There was no armrest on the right side of the wheelchair. The vinyl on the left armrest was missing. Observation was then made in Resident #27's room. The laminate on the over the bed tray table was peeling on the top approximately 7 inches and around the perimeter of the tray table. The wall behind the bed where the call bell outlet was located was spackled with scrapes in the spackle. There was no toilet paper in the bathroom and there was a white sock in the toilet. On 12/14/23 at 10:52 AM Resident #52 was observed sitting in a wheelchair in the common area. The vinyl on the left wheelchair armrest was cracked throughout. On 12/14/23 at 10:56 AM Resident #51 was observed sitting in a wheelchair. There was no padding on the right wheelchair armrest and the left armrest had vinyl covering that was cracked and peeling. On 12/14/23 at 10:53 AM GNA #3 was asked what she did when she saw something needed repair. She stated she will report it to the nurse or let maintenance know. On 12/14/23 at 12:15 PM an interview was conducted with the Director of Maintenance. He was asked how he was made aware of repairs needed in the facility. He stated that he would look in the TELS (electronic) system or staff would tell him. At that time, he was made aware of the concerns with the over-the-bed tray tables and the wheelchairs. He stated they were doing a facility wide sweep and ordering new furniture and he had a crew that was coming into spackle and then paint. He stated the crew was currently at a sister facility and not in the building. He was also informed of the sock observed in the toilet.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on review of complaint, medical record review, and interview with staff, it was determined that the facility failed to ensure that a care plan meeting was held at least quarterly and included the resident's representative. This was evident for 1 (#11) of 30 complaints reviewed during a complaint survey. The findings include. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 12/6/23 at 11:47 AM complaint MD00177360 was reviewed and alleged that Resident #11 had not had a care plan meeting in 2 years. On 12/6/23 at 11:47 AM Resident #11's medical record was reviewed and revealed Resident #11 was admitted to the facility in February 2019 and discharged from the facility in June 2023. Resident #11's medical record documented that the complainant was Resident #11's guardian. Review of Resident #11's medical record revealed documentation that care plan meetings were held on 3/25/19, 10/1/20, 1/22/21, 7/11/22, 8/9/22, 12/22/22, and 2/23/23. There were no care plan meetings documented from 1/22/21 to 7/11/22. On 12/13/23 at 12:40 PM the care plan meetings were reviewed with the Assistant Director of Nursing (ADON). The ADON confirmed that there was no documentation of care plans during that time period and no documentation that efforts were made to schedule a care plan meeting during that time frame.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility staff failed to administer medications as ordered by the physician (Resident #32). This was evident for 1 of 52 residents reviewed during a complaint survey. The findings include: Review of Resident #32's medical record on 12/12/23 revealed the Resident was admitted to the facility on [DATE] from the hospital. A. Further review of Resident's medical record revealed on 2/17/23 the physician ordered the Resident to have Prednisone 40 mg one time a day for 5 days with a start date of 2/18/23. Review of Resident #32's February 2023 Medication Administration Record (MAR) revealed the facility staff documented on 2/18/23 the medication was not available. On 2/19/23 and 2/20/23 the facility staff did not administer Prednisone. On 2/20/23 the physician reordered Prednisone 40 mg one time a day for 5 days with a start date of 2/21/23. Review of Resident #32's February 2023 MAR revealed the facility staff documented the facility administered Prednisone 40 mg on 2/21/23, but did not administer Prednisone after that. B. Further review of Resident's medical record revealed on 1/22/23 the physician ordered Furosemide 20 mg every 48 hours for hypertension. Review of the Resident's February 2023 MAR revealed on 2/18/23 the facility staff documented Furosemide was not given and unavailable. Review of the facility's Omnicell report which includes all medications in the facility's in house stock revealed the facility has both Furosemide and Prednisone available. Interview with the Assistant Director of Nursing on 12/12/23 at 2:45 PM confirmed the facility failed to administer Furosemide and Prednisone as ordered to Resident #32.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers per the Wound Specialist recommendations (Resident #4 and #6). This is evident for 2 of 52 residents reviewed during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. 1. Review of Resident #4's medical record on 12/6/23 revealed the Resident was admitted to the facility on [DATE] from the hospital with a diagnosis to include sacral pressure ulcer. Further review of Resident #4's medical record revealed the Resident was seen by the Wound Specialist on 7/15/21 and ordered treatment of Medihoney and Calcium Alginate for the Resident's unstageable sacral pressure ulcer. Review of Resident's July 2021 Treatment Administration Record (TAR) revealed although the facility staff provided a Medihoney dressing, they failed to administer Calcium Alginate to the Resident's sacral pressure ulcer daily from 7/15/21 until the Resident's discharge on [DATE]. Interview with the Director of Nursing on 12/7/23 at 10:50 AM confirmed the facility staff failed to administer Calcium Alginate to Resident #4's sacral pressure ulcer per the Wound Specialist's recommendations. 2. Review of Resident #6's medical record on 12/12/23 revealed the Resident was admitted to the facility on [DATE] from the hospital. Further review of the Resident #6's medical record revealed the Resident was seen by the Wound Specialist on 10/7/21 for the Resident's unstageable sacral pressure ulcer. At that time the Wound Specialist ordered a Medihoney and Calcium Alginate dressing daily. Review of Resident's October 2021 TAR revealed the facility staff failed to add Calcium Alginate to the Resident's sacral wound dressing until 10/15/21. On 12/2/21 the Resident was seen by the Wound Specialist and ordered Medihoney only dressing daily. Review of the Resident's December 2021 TAR revealed the facility staff failed to change the sacral wound dressing to Medihoney only at that time until the Resident's discharge on [DATE]. Interview with the Assistant Director of Nursing on 12/12/23 at 9:15 AM confirmed the facility staff failed to provide sacral wound dressings per the Wound Specialist recommendations for Resident #6.

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

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Based on medical record review, observation, and interview, the facility staff failed to supervise residents to prevent accidents (Resident #28 and #50) . This was evident for 2 of 25 residents on the 2nd floor of the facility. The findings include: Observation of 2nd floor staffing board on 12/13/23 at 8:07 AM revealed a census of 25 residents with 1 nurse and 2 geriatric nursing assistants (GNAs) for 7 AM - 3 PM shift with a floater GNA. Observation of staff on the unit at that time revealed 1 nurse (Staff #23) and 1 GNA (Staff #7). Observation of Resident #28 on 12/13/23 at 8:10 AM was walking down hallway and walked into Resident #50's room. The Surveyor followed Resident #28 into Resident #50's room and observed Resident #28 eating off Resident #50's breakfast tray. Staff #7 entered the room at 8:11 AM and intervened walking Resident #28 out of Resident #50's room. During interview with Staff #7 on 12/13/23 at 8:12 AM, Staff #7 was asked where the other GNA (Staff #3) was and she stated at that time Staff #3 is downstairs getting clothing. During interview of Staff #23 on 12/13/23 at 8:16 AM at the nurse's station, Staff #23 stated the day shift nurse had not yet arrived and she was just covering until she got here. The Surveyor asked Staff #23 where the floater GNA was and she stated on the ground floor working with residents on that floor. Continued observation of 2nd floor revealed Staff #3 returned to the unit on 12/13/23 at 8:18 AM and at that time Staff #7 left the unit to return meal cart to the kitchen and get a replacement tray for Resident #50. Staff #7 returned to the unit on 12/13/23 at 8:24 AM. During interview with the Administrator on 12/13/23 at 9:30, the Surveyor informed the Administrator on 12/13/23 from 8:07 AM until 8:24 AM there were only 2 staff on the unit for 25 residents and Resident #28 ate off Resident #50's breakfast tray.

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, observation and staff interview, the facility staff failed to provide services for a resident receiving oxygen therapy (Resident #46). This was evident for 1 of 3 residents reviewed with oxygen therapy during a complaint survey. The findings include: Review of Resident #46's medical record on 12/12/23 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include tracheostomy. A tracheostomy is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help you breathe. Observation of Resident #46 on 12/12/23 at 12:10 PM revealed the Resident to have a tracheostomy with a suction canister and suction tubing dated 12/4/23. Observation also at that time revealed the Resident's oxygen tubing and humidification bottle was not dated or initialed by staff. At that time the Assistant Director of Nursing (ADON) was called to the Resident room and confirmed the Surveyor's observation. Further review of Resident #46's medical record revealed a physician order on 9/28/23 to change suction tubing and canister once per week and as needed. Review of the facility's Oxygen Extension Tubing policy provided by the ADON stated Procedure #4: Label current date and initial. Review of the facility's Tracheostomy Suctioning policy provided by the ADON stated Post Procedure #20 stated: Replace a disposable suction collection canister, as necessary (at least weekly). Interview with the ADON on 12/12/23 at 12:15 PM confirmed the facility staff failed to provide appropriate respiratory services for Resident #46 by not dating and initialing oxygen tubing and humidification bottle and also not changing the Resident's suction canister and tubing weekly.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 3 nursing units observed during random observations made during a complaint survey. The findings include: On 12/12/23 at 7:00 AM observation was made of an unlocked and unattended medication cart sitting in front of the nursing station on the 100-nursing unit. The surveyor was able to open all the drawers and go through the cart which contained insulin supplies and resident medications in the first drawer, and resident medication cards in the other drawers. On 12/12/23 at 7:02 AM Registered Nurse (RN) #19 came out of a door and asked the surveyor if she was done at the medication cart. The surveyor asked RN #19 if he realized he left the medication cart unlocked and unattended. RN #19 stated, yes, I know. I was only gone for a minute. I had to run upstairs. On 12/14/23 at 8:27 AM observation was made of an unlocked and unattended medication cart sitting on the first-floor nursing unit outside of room [ROOM NUMBER]. Certified Medicine Aide (CMA) #13 was administering medications to the resident in that room. CMA #13 was standing up towards the head of the bed, out of view of the medication cart. While CMA #13 was in the room administering medications, Resident #37 was sitting on the sofa that was positioned in front of the medication cart. Resident #37 had a brain injury with behaviors and wandered on the unit. CMA #13 administered medications and then walked to the trash can with her back to the door. CMA #13 then came out of the room and the surveyor explained that her medication cart was left unlocked while she was in the room. The surveyor then walked back into room [ROOM NUMBER] with CMA #13 in the exact position where she was standing at the head of the bed and asked her if she could see the medication cart. CMA #13 stated, no, I understand what you are talking about. On 12/14/23 at 11:03 AM discussed the observations with the Assistant Director of Nursing (ADON) who confirmed it was concerning.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 #16, #46) This was evident for 2 of 52 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. The facility staff failed to have a consultant report in Resident #16's medical record. Review of Resident #16's medical record on 12/13/23 revealed the Resident was admitted to the facility on [DATE] from the hospital. During interview with the Resident's representative (RP) on 5/13/22 at 11:00 AM, the RP stated the Resident was taken out of the facility for an appointment in December 2022 by the facility staff and no one could tell the family where the Resident went. Further review of the Resident's medical record revealed a nurse's note on 12/30/2022 at 2:11 PM that stated: resident left facility at 9:15 AM, accompanied by care giver to Dr's appointment. stable and baseline within normal limit. Another nurse's note on 12/30/22 at 2:15 PM that stated: resident returned back to facility at 2:16 PM . alert, stable and baseline within normal limit. Further review of the Resident's medical record on 12/13/23 revealed no consultation report from 12/30/22. After Surveyor intervention the facility obtained a consultation report on 12/13/23 from a Urologist visit on 12/30/22. Interview with the Assistant Director of Nursing (ADON) on 12/13/23 at 12:45 PM confirmed the facility failed to obtain a consultant report for Resident #16 and have it in the Resident's medical record. 2. The facility staff inaccurately documented on Resident #46's medical record. Review of Resident #46 medical record on 12/12/23 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include tracheostomy. A tracheostomy is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help you breathe. Observation of Resident #46 on 12/12/23 at 12:10 PM revealed the Resident to have a tracheostomy with a suction canister and suction tubing dated 12/4/23. At that time the ADON was called to the Resident room and confirmed the Surveyor's observation. Review of Resident #46's December 2023 Treatment Administration Record revealed on 12/11/23 the facility staff documented the Resident's suction canister and suction tubing were changed on 12/11/23. Interview with the ADON on 12/12/23 at 12:25 PM confirmed the facility staff inaccurately documented Resident #46's suction canister and tubing were changed on 12/11/23.

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation and interviews it was determined the facility staff failed to follow infection prevention and control practices. This was evident in the kitchen while preparing food for residents. The failure to follow effective infection prevention and control practices increased the risk for the spread of infection to all residents, staff, and visitors in the building during an active COVID-19 outbreak. The findings include: On 12/12/23 at 9:44 AM observation was made in the kitchen of dietary Staff #26 and Staff #27 at the food preparation table. The 2 staff members were preparing food. Both staff members were wearing a face mask that was positioned under their chins and not covering their nose and mouth. As the surveyor stood and observed the staff, their masks remained positioned under their chins. At the time of the observation there was an active COVID-19 outbreak in the facility where all staff were required to wear masks while in the building. On 12/12/23 at 10:30 AM an interview was conducted with the Infection Control Preventionist, Staff #10 and the Assistant Director of Nursing (ADON). Staff #10 was asked about the COVID-19 outbreak. Staff #10 stated they have to wait 14 days after someone tests positive to be off outbreak so that is why all staff in the facility had to wear a mask. On 11/30/23 a staff member tested positive for COVID-19. Staff #10 was informed of the observation of the 2 culinary aides standing over the food preparation table preparing food and not properly wearing a mask. Staff #10 was asked if the culinary aides should have been wearing a mask over their nose and mouth. Staff #10 stated, absolutely. The Nursing Home Administrator was informed on 12/15/23 at 1:30 PM.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the Office of Health Care Quality (OHCQ). This was evident for 4 (#25, #22, #7, #41) of 21 residents reviewed for incidents related to facility reported incidents during a complaint survey. The findings include: 1) On 12/11/23 at 10:02 AM a review of facility reported incident MD00194116 revealed on 7/5/23 Resident #25 alleged that geriatric nursing assistant (GNA) #30 was rough while providing care. Review of the facility's investigation revealed an email confirmation that documented the allegation was first reported to OHCQ on 7/6/23 at 5:50 PM and was not within the 2-hour timeframe for an allegation of abuse. Review of the facility staff interviews and statements documented that GNA #30 reported the allegation to licensed practical nurse (LPN) #14 on 7/5/23. On 12/11/23 at 2:46 PM Staff #12 was interviewed. Staff #12 confirmed that GNA #30 stated she reported the incident to LPN #14. Staff #12 stated that LPN #14 should have reported the allegation to administration and should have gone to check on the resident on 7/5/23. Staff #12 confirmed that it was not reported in a timely manner. On 12/12/23 at 8:35 AM an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated that he reports the incidents as soon as he is aware of them. The NHA acknowledged that the staff was not reporting to him timely, therefore he was not reporting the allegations to OHCQ timely. 2) On 12/11/23 at 10:06 AM a review of facility reported incident MD00186502 revealed on 12/5/22 at around 9:30 PM Resident #25 alleged that an agency GNA was rough while providing care. Review of the facility's investigation revealed RN #31's written statement that documented, during final rounds on 12/5/22 approximately 22:30 (10:30 PM), [name of Resident #25], room [ROOM NUMBER] was in bed and verbalized that [he/she] didn't care for the way [he/she] was handled from the short dark lady. The statement continued that the resident got up afterwards and went to the bathroom by walking. The statement documented that RN #31 asked another nurse to talk with the resident and the resident made the same allegation. The resident was asked if he/she was dreaming and the response was, no. Further review of the facility's investigation revealed an email confirmation that the initial report was sent to OHCQ on 12/6/22 at 6:47 PM, which was not within 2 hours of the alleged abuse. On 12/12/23 at 8:35 AM an interview was conducted with the NHA who stated, I immediately report the incident as soon as I am aware of them. The NHA acknowledged that staff were not reporting to him timely. 3) On 12/11/23 at 1:00 PM a review of facility reported incident MD00183319 revealed on 9/10/22 Resident #22 reported to the Speech Pathologist that he/she had been abused. Review of the facility's investigation revealed they did a phone interview with the Speech Pathologist (SP) who stated she entered the resident's room and introduced herself and told the resident that she was there to do an evaluation. The SP stated the resident said, I am being abused by the GNA. The SP stated she walked out and asked the nurse if she was the one taking care of the resident and the nurse stated yes. She then told the nurse what the resident stated to her. Review of the facility's copy of the Comprehensive and Extended Care Facilities Self-Report Form documented the report was sent in on 9/11/22 at 7:15 PM, which was not within 2 hours of the allegation. Additionally, the NHA could not provide an email confirmation to the surveyor. The same report documented that the final report was sent to OHCQ on 9/11/22 at 7:15 PM. On 12/13/23 at 2:05 PM the NHA was interviewed and stated that it was not reported timely and that is why they did the education. The NHA also confirmed that he could not find the email confirmations for the initial and 5-day report. 4) On 12/12/23 at 9:34 AM a review of facility reported incident MD00182178 revealed on 2/18/22 it was alleged by Resident #7's family member that a housekeeper was cussing at Resident #7. The facility's investigation documented that the family member did not report the incident until 2/21/22, however a statement from the previous social worker documented she was called by the family member on 2/18/22. The previous social worker did not tell the NHA until 2/21/22, therefore the allegation of abuse was not immediately reported to OHCQ. The date the allegation was first reported to OHCQ was 2/21/22 at 10:24 AM. On 12/12/23 at 2:00 PM the NHA was interviewed and stated that he reports things as soon as he is informed. 5) On 12/14/23 at 8:00 AM a review of facility reported incident MD00194029 revealed on 7/1/23 Resident #41 allegedly hit Resident #42 with a footrest. Review of the facility's investigation revealed the NHA was informed on 7/3/23 about the incident. Review of the email confirmation of when the initial self-report was made was on 7/4/23 at 12:01 AM which was not within 2 hours of the alleged abuse. On 12/14/23 at 2:00 PM the NHA confirmed that he was not informed immediately.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) The facility staff inaccurately coded Resident #47's dental status. Review of Resident #47's medical record on 12/13/23 revealed the Resident was admitted to the facility on [DATE] from the hospital. Observation of Resident #47 on 12/13/23 at 9:15 AM revealed the Resident to have 3 broken black lower teeth. Further review of the Resident's medical record revealed on Annual MDS assessment on 6/2/23 revealed the facility staff assessed and coded the Resident in Section L Oral/Dental Status as 1. No natural tooth or tooth fragment(s) (edentulous) and 2. No obvious or likely cavity or broken natural teeth. The Surveyor observed Resident #47 with the Assistant Director of Nursing (ADON) on 12/13/23 at 9:50 AM and confirmed the Resident has 3 broken black lower teeth. Interview with the ADON on 12/13/23 at 10:15 AM confirmed the facility staff failed to accurately assess and code Resident #47's Dental Status on the 6/2/23 MDS Assessment. Based on medical record review and interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#44, #30, #38, #47) of 52 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 12/7/23 at 8:06 AM a review of Resident #44's medical record revealed the resident was admitted to the facility in October 2023 with diagnoses that included alcohol use disorder. A 10/17/23 care plan note documented that Resident #44 began to tell the police that he/she wanted to leave the facility. The note documented that Resident #44 had been to the front desk multiple times with belongings packed, stating that he/she was leaving the facility. The note documented the resident was continuously being redirected and was a risk for elopement and a wanderguard was placed on the resident at that time. A 10/17/23 behavior note documented, resident is high risk for elopement, wandering trying to leave the facility, packed [his/her] personal belongings, pacing with no cause of action, attempted to exit doors, refused to follow redirection. A 10/18/23 nurse's note documented, resident is wandering around with a sheet tied around [his/her] waist going into others room. A 10/19/2023 note documented, repeatedly calling 911 and hanging the phone up. Resident initially admitted with alcohol use disorder with delusions/ delirium. Is not cognitively intact, recent BIMS 11 shows moderate impairment. Conversations are sporadic. At some points resident believes [he/she] is in a police station on RT. 40 and then other points [he/she] states [he/she] is on [NAME] Rd at the liquor store. Residents wants to leave the facility but is unsafe at this time. A 10/20/23 note documented, resident continues to express [his/her] desire to leave the facility. Review of Resident #44's admission MDS with an assessment reference date (ARD) of 10/21/23 revealed the assessment failed to capture delusions in section E100B. Section E0900 wandering, has the resident wandered? was coded as behavior not exhibited. Further review of Resident #44's admission MDS, Section N0300, Medications, failed to capture the PPD done on 10/19/23. Review of Resident #44's October 2023 Medication Administration Record (MAR) documented that Resident #44 received the PPD and the skin test was read on 10/19/23. On 12/7/23 at 10:56 AM the Mobile MDS Coordinator stated the last MDS Coordinator left this past Friday. The Mobile MDS Coordinator stated she reviewed the notes for delirium and wandering. She confirmed that it should have been coded. 2) On 12/11/23 at 11:03 AM Resident #30's medical record was reviewed and revealed an MDS note dated 5/19/23 that documented, Pt. discharged to ER (emergency room) s/p fall with laceration to back of head that revealed left-sided subdural hematoma. A physician's note dated 5/19/23 documented, subdural hematoma. Review of Resident #30's MDS with an ARD of 5/19/23 documented an injury in section J1900, however it was not coded as a major injury. According to the Resident Assessment Instrument (RAI) Manual, a subdural hematoma should be coded as a major injury. There was no evidence in Resident #30's medical record that a corrected MDS was completed and submitted. On 12/15/23 at 10:52 AM the MDS was discussed with the Assistant Director of Nursing as she stated the Mobile MDS Coordinator does not come into the facility on Friday. 3) On 12/12/23 at 11:30 AM Resident #38's medical record was reviewed and revealed Resident #38 was admitted to Hospice services in May 2023. Review of Resident #38's quarterly MDS with an ARD of 9/23/23 and discharge return anticipated MDS with an ARD of 10/13/23 failed to capture Hospice services in section O0100K. On 12/12/23 at 12:37 PM discussed with the Assistant Director of Nursing.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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Based on medical record review and staff interview, it was determined that facility staff failed to ensure residents were free from significant medication errors as evidenced by failing to follow a physician's order related to holding blood pressure medications if outside of physician ordered parameters. This was evident for 1 (#30) of 52 residents reviewed during a complaint survey. The findings include: Blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through the arteries. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps the blood out into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). On 12/11/23 at 11:03 AM Resident #30's medical record was reviewed and revealed Resident #30 was admitted to the facility in July 2021 with diagnoses that included repeated falls, dementia, traumatic hemorrhage of cerebrum, and traumatic subdural hemorrhage. Review of physician's orders for Resident #30 revealed the order, Midodrine HCl 5 mg., Give 1 tablet by mouth three times a day for orthostatic hypotension. Hold for b/p (blood pressure) > (greater than) 120/70. Monitor b/p prior to medicating. Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position). Midodrine works by causing blood vessels to tighten, which increases blood pressure. Review of Resident #30's February 2023 Medication Administration Record (MAR) documented on 8 of 28 days, the Midodrine was given outside of physician ordered parameters. On the MAR nurses documented the blood pressure and then put their initials when the medication was administered. If the medication was not administered, the nurses would either put an x, N/A, or code it with 5 or 9 which would have indicated the medication was held. On 2/2/23 at 6:00 AM the b/p was 140/75. The medication was administered. On 2/8, 2/10, 2/15, 2/16, 2/17, 2/23, 2/26, and 2/27/23 the b/p was outside of parameters and the medication was administered. The blood pressures ranged from 121/61 to 140/75. Continue review of Resident #30's medical record revealed the March 2023 MAR that had 9 out of 31 days where the medication was administered outside of physician ordered parameters. On 3/31/23 the b/p was 190/60 and the medication was administered. The medication was administered on 3/7, 3/8, 3/10, 3/13, 3/16, 3/24, 3/27, 3/30, and 3/31/23 when it was outside of the b/p parameters. The b/p ranged from 121/75 to 190/60. Review of the April 2023 MAR had 9 out of 30 days the medication was administered outside of physician ordered parameters. Blood pressure readings when administered out of parameters ranged from 121/67 to 149/78. The medication was administered on 4/3, 4/8, 4/11, 4/12, 4/14, 4/17, 4/19, 4/24, and 4/28/23 when outside of the b/p parameters. On 12/11/23 at 1:12 PM an interview was conducted with Nurse Practitioner (NP) #16 who stated he has been at the facility for about 2 months and came from critical care. NP #16 was asked about the Midodrine and if the systolic (top number of b/p) was greater than 120, should the medication be held. NP #16 stated, for older patients you go with systolic. Hold systolic greater than 120. At that time the surveyor showed NP #16 the blood pressures that were administered when the systolic b/p was greater than 120. NP #16 stated, if the systolic was borderline to 120 then the nurses should have called and asked the provider if they should hold or give because it is individualized for the resident. With a history of falls the nurses should have held the medicine, even if it was only 122 systolic. They need more education. On 12/14/23 at 12:52 PM an interview was conducted with the Assistant Director of Nursing (ADON). When given the exampled blood pressures that were greater than 120 systolic, the ADON stated the medication should have been held when they were outside of parameters. The ADON was informed that it was a pattern of not following physician ordered parameters for the Midodrine. The Nursing Home Administrator was informed on 12/15/23 at 2:30 PM.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation and interview, it was determined the facility failed to develop, implement and maintain an effective training program for all new and existing staff for the care of residents with a tracheostomy (Resident #46). This was evident for 1 of 1 residents with tracheostomies in the facility reviewed during a complaint survey. The findings include: Review of Resident #46's medical record on 12/12/23 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include tracheostomy. A tracheostomy is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help you breathe. Observation of Resident #46 on 12/12/23 at 12:10 PM revealed the Resident to have a tracheostomy with a suction canister and suction tubing dated 12/4/23. Observation also at that time revealed the Resident's oxygen tubing and humidification bottle was not dated or initialed by staff. At that time the Assistant Director of Nursing (ADON) was called to the Resident room and confirmed the Surveyor's observation. During interview with the Staff Educator on 12/12/23 at 12:25 PM the Staff Educator stated she began working in the facility in August 2023. The Staff Educator was asked if she had done any tracheostomy education and training with the nursing staff. The Staff Educator at that time said no. The Surveyor asked the Staff Educator to check for education for 5 nurses who had documented care of Resident #46 (Staff #14, Staff #18, Staff #23, Staff #24 and Staff #25) The Staff Educator said the staff in person education is kept in the employee's Human Resources files and she would check to see if the staff had any documented education. Follow up interview with the Staff Educator on 12/12/23 at 2:00 PM confirmed the facility had no documentation of 5 nursing staff receiving in person education on tracheostomies. Interview with the Assistant Director of Nursing on 12/13/23 at 11:40 AM confirmed the facility had no documentation of in person or online education on tracheostomies for the 5 nursing staff.

MINOR (C) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected most or all residents

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Based on observation and staff interview, it was determined the facility failed to post a notice of where the results of the most recent surveys, certifications, and complaint investigations were located. This was evident during the first day of the complaint survey. The findings include: On 12/6/23 at 1:08 PM, observation was made of the facility lobby and entrance hallway. There was no sign posted of where the most recent results from the annual and complaint surveys were located. The surveyor looked around the lobby for a survey binder and was unable to locate. The receptionist, Staff #4 was asked where the survey binder could be located, and she got up from her chair and walked over to the hallway where a grievance binder was located on the wall. She then walked back to the receptionist desk and behind her were several binders. The survey results binder was located behind the receptionist's desk. The surveyor asked Staff #4 if she was aware that a sign should be posted letting residents, staff, and the public know where the survey results could be located. She stated she was not aware. She also said she was not aware that the survey results had to be available without asking to see the results. On 12/6/23 at 1:30 PM the Nursing Home Administrator (NHA) was made aware and he stated, the survey binder usually is sitting on the little table by the chair as you walk in. The NHA was informed it was behind the receptionist desk and there was no sign posted along with the binder not being accessible without asking to see it.

Apr 2019 20 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

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Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#53) with the most dignified existence. This was evident for 1 of 37 residents selected for dignity during the annual survey process. The findings include: Medical record review for Resident #53 revealed on 11/23/18, the physician ordered: supervise at all meals and assist when he/she stops eating. Surveyor observation of Resident #53 on 4/12/19 at 12:30 PM revealed Resident #53 was served lunch, in the dining room with approximately 11 other residents. Further observation revealed the resident was served: breaded fish, noodles, peas, fruit cocktail and a carton of health shake. Further observation revealed the facility staff opened the health shake, of which the resident drank. Further observation revealed, Resident ate the fruit cocktail by putting the bowl to his/her mouth and consuming the food from the bowl. Further observation revealed the facility staff walking past Resident #53 and asking if Resident #53 was going to eat; however, there was no evidence the facility staff attempted to feed the resident. At 1:05 PM the facility staff removed Resident #53's lunch tray and Resident #53 had had none of the solid food (other than the fruit cocktail). (Of note, observation revealed the facility staff feeding Resident #53 breakfast on 4/11/19 and lunch on 4/15/19). Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to provide Resident #53 with the most dignified existence.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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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 an advance directive was in place for Residents (#52 and #53). This was evident for 2 of 3 residents selected for review of advance directives and 2 of 37 residents selected for review during the annual survey process. The findings include: 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. The (Medical Orders for Life-Sustaining Treatment) MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments or do-not-resuscitate order (DNR). DNR order, is a medical order written by a doctor in collaboration with the resident or Health Care Agent and it instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. The orders on a MOLST form are based on a patient's wishes about medical treatments. 1. The facility staff failed to ensure advance directives were in place for Resident #52. Medical record review for Resident #52 revealed the physician completed a MOLST for Resident #52. At that time, it was indicated the completion of the MOLST, and end of life orders are based on: other legal authority in accordance with all provisions of the Health Care Decisions Act. All supporting documentation must be contained in the patients' medical record. Further record review revealed the medical record contained a Power of Attorney (POA); however, the POA was for financial decisions: real estate transactions, baking transactions, making investments, tax matters, insurance transactions and government benefits to name a few. There is no evidence the facility obtained a copy of the advance directive directing the health care agent or any specific wishes of the resident. Interview with the Director of Nursing on [DATE] at 1:30 PM confirmed the facility staff failed to ensure the evidence of an advance directive for Resident #52. 2. The facility staff failed to ensure advance directives were in place for Resident #53. Medical record review for Resident #53 revealed on [DATE] revealed the physician completed a MOLST for Resident #53. At that time, it was indicated the completion of the MOLST, and end of life orders are based on: other legal authority in accordance with all provisions of the Health Care Decisions Act. All supporting documentation must be contained in the patients' medical record. There is no evidence the facility obtained a copy of the advance directive directing the health care agent or any specific wishes of the resident. Interview with the Director of Nursing on [DATE] at 1:30 PM confirmed the facility staff failed to ensure the evidence of an advance directive for Resident #53.

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

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Based on medical record review and interview, it was determined the facility staff failed to notify the guardian of person of a change of condition for Resident (#11) and failed to complete a change of condition form for Resident (#11). This was evident for 1 of 1 resident reviewed for change of condition and 1 of 37 residents selected for review during the survey process. The findings include: 1 A. The facility staff failed to notify the guardian of person of a change in condition for Resident #11. Medical record review for Resident #11 revealed the facility staff nurse #1 documented the resident's temperature of 102 approximately 4/15/19 at 8:30 AM. The resident was medicated with standing order of Tylenol and the physician notified. The physician assessed the resident at 12:30 PM and ordered laboratory blood tests and x-rays. Further record review revealed no evidence the facility staff notified the resident's guardian of person of the temperature and the ordered test. 1 B. The facility staff failed to complete a change in condition form for Resident #11. Medical record review for Resident #11 revealed the facility staff nurse #1 documented the resident's temperature of 102 approximately 4/15/19 at 8:30 AM. The resident was medicated with standing order of Tylenol and the physician notified. The physician assessed the resident at 12:30 PM and ordered laboratory blood tests and x-rays. The change in condition technique provides a framework for communication between members of the health care team about a patient's condition. The change in condition is an easy-to remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician's immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of resident safety. Interview with the Director of Nursing on 4/15/19 at 1:00 PM revealed the expectation of the facility staff is to complete change of condition forms. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to notify the guardian of person and failed to complete a change of condition form for Resident #11 when a temperature of 102 was noted and medical test ordered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The findings include: On 4/10/2019 at 9:59 AM during an initial tour of the facility the following observations were made: 1. room [ROOM NUMBER] had loose door handles on the hallway door and bathroom door 2. The bathroom in room [ROOM NUMBER] had a leaky faucet and brown stains on the ceiling tiles around the sprinkler. On 4/11/2019 during resident observation and interview the following observations were made: 1. The first-floor hand sink opposite the elevator had chipped surfaces that are not easily cleanable and may harbor bacteria. 2. A bariatric wheelchair was observed on the first floor to be in disrepair. The stitching was busted on the top of the chair exposing the foam cushioning underneath. This surface is no longer easily cleanable. The Director of Maintenance was informed of these findings during an environmental walkthrough on 4/16/2019 at 8:48 AM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview it was determined that the facility failed to thoroughly investigate the allegation of abuse-misappropriation of property for a resident (#67). This was evident for 1 of 2 residents selected for review of misappropriation of property and 1 of 37 residents selected for review during the annual survey process. The findings include: The purpose of a thorough investigation is first to determine if abuse or misappropriation of property of the resident has occurred. It is the expectation that any allegation of abuse or injury of unknown occurrence being investigated by the facility. This investigation includes interviews with all direct care giver staff for a least 1-2 days prior to the reported allegation. Surveyor investigation of MD00130006 revealed Resident #67 was missing $100.00 from a locked drawer in his/her room. Further investigation revealed Resident #67 indicated $276.00 was in the inner drawer of the dresser. It was stated by the resident the inner drawer was locked and the key was kept around the resident's neck. It was stated the resident reported the money missing 8/2/18 at 11:15 PM and the $276.00 was present in the drawer in the morning. The resident stated he/she left the room during the day to attend a resident council meeting with activities at 3:00 PM. The resident indicated he/she did not look for the money until 11:15 PM when he/she reported the money missing. The resident also stated the lock to the drawer was noted to be bent. Surveyor attempt to interview the resident on 4/15/19 at 10:00 AM revealed Resident #67 refused to talk about the incident. Upon notification of the missing money, the facility staff obtained statements from 5 staff members; however, the staff all appear to be from the 3-11 shift. There is no evidence the administrative staff obtained statements from the 7-3 shift or ancillary department staff who may have had access to the resident's room. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to thoroughly investigate the allegation of misappropriation of property for Resident #67.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview with staff it was determined that the facility staff failed to have a system in place to ensure that the transfer of the resident's medical record and appropriate information is communicated to the receiving health care provider. This was found to be evident for 2 out of 3 (#55 and # 222) residents reviewed for hospitalization during the investigative portion of the survey. The findings include: The facility staff failed to meet the requirement for transfer information. If the resident is being transferred, and return is expected, the following information must be conveyed to the receiving provider: 1. Resident representative information, including contact information. 2. Advance directive information. 3. The resident's comprehensive care plan goals. 4. Medications (including when last received) 5. Most recent relevant labs, other diagnostic tests. The facility must ensure that the transfer or discharge is documented in the resident's medical record and, who is responsible for making the documentation. 1. A medical record review for Resident # 55 was conducted on 4/15/19. Review of the physician order on 3/11/2019 revealed that Resident # 55 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal if medical information was conveyed to the receiving provider. 2. A medical record review for Resident # 222 was conducted on 4/15/19. Review of the physician order written on 9/20/2018 revealed that Resident # 222 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal if medical information was conveyed to the receiving provider. On 04/15/19 12:30 PM, interview with the Director of Nursing revealed that a copy of the Advance directive, Laboratory results, Medication list, History and Physical and a copy of the face sheet is sent with the resident to the receiving facility at the time of discharge/transfer but was unable to confirmed if any information was conveyed to the receiving Facility. There was no documentation found in the medical record that the information was sent with the residents at the time of transfer.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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Based on complaint, reviews of a closed record, and staff interview, it was determined that the facility staff failed to notify residents and/or representative and the Ombudsman of transfer and reason for transfer to the hospital in writing. This was evident for 2 (Resident #55 and #222) of 3 residents reviewed for hospitalization during an annual recertification survey. The findings include: 1. Review of the medical record for Resident #55 revealed the resident was transferred to an acute care facility on 3/11/2019. There was no documentation found in the medical record that the resident, the resident's responsible party, or the Ombudsman was given written notice of Resident #55 being transferred to the hospital and the reason for the transfer to the hospital. 2. Review of the medical record for Resident #222 revealed the resident was transferred to an acute care facility on 9/20/2018. There was no documentation found in the medical record that the resident or the resident's responsible party was given written notice of Resident #222 being transferred to the hospital and the reason for the transfer to the hospital. On 4/11/19 at 11:06 AM, the Director of Nursing stated that the Resident and or Resident's responsible party did not receive written notice as to why the Residents was being transferred to the hospital and the reason for the transfer to the hospital.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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Based on review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization. This was evident for 2 (Resident # 55 and #222) of 3 residents reviewed for Hospitalization during an annual recertification survey. The findings include: 1. Review of the medical record for Resident #55 revealed the resident was transferred to an acute care facility on 3/11/2019 and returned to the facility on 3/15/2019. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. 2. Review of the medical record for Resident #222 revealed the resident was transferred to an acute care facility on 9/20/2018. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. On 4/15/19 at 11:00 AM, the Director of Nurses confirmed that the Residents and or the Resident's responsible party did not receive the facility bed hold policy when transferred to the hospital.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined the facility staff failed to assess Resident (#67) for PASARR. This was evident for 1 out of 2 residents reviewed for PASARR's during the annual survey process. The findings include: The Level I Pre-admission Screening and Resident Review (PASARR) must be completed by either the nursing facility or the referring doctor for every individual who will be admitted to a nursing facility to identify individuals who may have Mental Illness (MI), Intellectual Disability (ID), and/or Related Condition (RC). The nursing facility is responsible for ensuring a Level I screen is completed for everyone prior to admission. The PASRR determines whether an individual who has an active diagnosis of Mental Illness (MI) or Intellectual/Developmental Disability (ID/DD) meets the criteria for admission to a nursing facility and may require specialized services. PASARR is required for all persons seeking admission to Medicaid certified nursing facilities, regardless of whether their stay at the nursing facility will be paid for by Medicaid, Medicare or with other resources. Medical record review for Resident #67 revealed the facility staff had not completed a PASARR. This was brought to the Director of Nursing's (DON) attention on 4/11/2019 at 9:45 AM who stated the Social Worker sometimes maintained a separate record of residents' PASARRs. On 4/11/2019 at 9:53 AM the facility's SW confirmed the facility did not have a completed PASARR for Resident #67. The Administrator and DON were made aware of these findings on 4/16/2019 during the exit conference. Refer to F 745

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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3. The facility staff failed to fail to apply ace bandage wraps for Resident #49. Medical record review for Resident #49 revealed on 3/8/19 the physician ordered: ace bandage wrap apply in the morning and off at bedtime for edema and remove per schedule. Surveyor observation of the resident on 4/11/19 at 11:30 AM and on 4/12/19 at 1:30 PM, revealed the resident sitting in his/her wheelchair in the room however, the facility staff failed to apply the ace bandage as ordered by the physician. The Director of Nursing was informed that the facility staff failed to apply ace bandage wraps as ordered by the physician. Based on medical record review, observation and interview, it was determined the facility staff failed to provide an environment which produced the highest level for practicable well-being for Residents (#1, #26 and #49). This was evident for 3 of 37 residents selected for review of during the annual survey for well-being. The findings are 1. The facility staff failed to clarify and correct a physician's order for Resident #1. Medical record review for Resident #1 revealed on 3/1/18 the physician ordered: Weigh patient monthly every day shift every 1 month(s) starting on the 1st for 28 day(s). Review of the Treatment Administration Record (TAR) revealed the facility staff transcribed the resident's weight to be obtained every day during the month; however, further record review revealed the last documented weight for Resident #1 was 11/11/18. Record review no evidence of Resident #1 refusing weights except on 4/15/19. Interview with the Director of Nursing on 4/15/19 at 12:00 PM revealed the facility staff failed to transcribe the physician's order correctly to reveal a weight to be obtained on the day shift, 1 time a month on the first; however, the facility staff documented indication that Resident #1 was weighed daily. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to thoroughly clarify or correct the transcription of a physicians' order for weights for Resident #1. 2. The facility staff failed to apply bilateral palm guards on Resident #26. Medical record review for Resident #26 revealed on 4/6/18 the physician ordered: Cleanse bilateral hands. [NAME] bilateral palm guards in morning, doff bilateral palm guards after 4 hours of wear and check skin for sign of irritation and 4/10/18 ordered: Occupational therapy clarification: resident to wear bilateral palm guards 4-6 hrs during the day. A finger flexion contracture is a bent finger, usually at the middle joint of the finger, that one cannot straighten using one's own muscle power or with the help of the opposite hand. The finger has become bent or stuck in that position. The person can make a fist but is not able to straighten the finger. A finger flexion contracture can cause digging finger nails into the palm of the hand. Palm guards are used as a barrier between fingers and palmar skin to prevent injury to the palm from finger flexion contracture. Further review of the physician's order revealed: restorative nursing to don on and off and cleanse hands and observe for any irritation. Restorative nursing refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Surveyor observation of Resident #26 on 4/15/19 at 12:05 PM revealed the resident out of bed, in the second-floor dining room; however, the facility staff failed to apply the palm guards as ordered. Interview with the Director of Nursing on 4/15/19 at 12:30 M revealed there were no restorative nursing staff available, therefore the palm guards were not applied. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to apply palm guards to Resident #26 as ordered by the physician. See F 842

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation and interview, it was determined the facility staff failed to apply leg rest to the wheel chair of Resident (#53) as ordered and failed to apply fall mats to both sides of the bed as ordered for Resident (#53). This was evident for 1 of resident selected for review of accidents and 1 of 37 residents selected for review during the survey process. The findings include: 1. The facility staff failed to provide Resident #53 with leg rest for the wheelchair as ordered. Medical record review for Resident #53 revealed on 8/6/18 the physician ordered: high back wheelchair, pommel cushion, leg rest with foot board to prevent falls. A pommel cushion is a gel filled cushion designed to prevent the resident from sliding forward, promotes proper hip and knee alignment and the pommel helps keep residents in position. Surveyor observation of resident #53 on 4/ 12/19 at 12:26 PM and 4/15/19 at 12:00 PM revealed the resident out of bed, in a high back wheelchair with a pommel cushion; however, the facility staff failed to apply leg rest with foot board for the resident. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to apply leg rest to the wheelchair of Resident #53 as ordered by the physician. 1 B. The facility staff failed to apply fall mats to both side of the bed for Resident #53 Medical record revealed on 8/3/18 the physician ordered: fall matt bilateral sides of bed. Bedside fall mats are safety features that are placed on the floor along the sides of the bed. Fall protection mats for the residents are made from high-impact foam and are designed to help prevent injury from potential falls. Each mat is specifically made with shock-absorbing material that resists compression under impact. Surveyor observation of the resident on 4/15/19 at 10:35 AM revealed the resident in bed; however, the fall mats were only on 1 side of the bed. Further observation revealed both fall mats were placed on the window side of the bed. Interview with the Director of Nursing on 4/15/19 at 12:00 PM revealed the facility staff Geriatric Nursing Assistant moved the fall mat to 1 side of the bed to provide care to Resident #53; however, failed to replace the fall mat to each side of the residents' bed as ordered. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to provide Resident #53 with fall mats on each side of the bed as ordered by the physician.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication and medicate Resident (#44). This was evident for 1 of 1 resident selected for review of pain assessment and 1 of 37 residents selected for review during the annual survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. Medical record review for Resident #44 revealed on 3/9/18 the physician ordered: Tylenol Arthritis Pain Tablet Extended Release 500 milligrams by mouth every 8 hours as needed for pain. On 10/4/18 the physician ordered: Tramadol 50 mgs by mouth every 6 hours as needed by mouth for pain. Tylenol Arthritis is a bi-layer design having two layers of pain relief, the first dissolves fast and the second lasts all day, up to 8 hours, to ease minor arthritis pain. Tramadol is used to relieve moderate to moderately severe pain. Tramadol extended-release tablets and capsules are only used by people who are expected to need medication to relieve pain around-the-clock. Tramadol is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. Review of the Medication Administration Record (MAR) revealed the facility staff assessed the resident's pain on 1/1/19 on the 3-11 and 11-7 shift and documented the resident's pain as a 5 out of 10. Further review reviewed no evidence the facility staff medicated or offered to medicate Resident #44 for the pain level of 5. There is also no evidence the resident refused any pain medication at that time. Further review of the MAR revealed the facility staff documented administration of the Tramadol on: 1/2/19 at 10:15 PM, 1/3/19 at 9:57 PM, 1/4/19 at 4:47 PM, 1/5/19 at 2:53 PM, 1/6/19 at 12:22 PM and 1/7/19 at 12:56 PM and documented Resident #44's pain level as 5. On 2/21/19-124/19 the facility staff documented the resident's pain as a 2 and documented the administration of the Tramadol. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to medicate Resident #44 for pain when documenting the resident's pain level 5 out of 10.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined the facility staff Social Worker (SW) failed to complete Preadmission Screening and Resident Review (PASARR) for Resident #67. This was evident for 1 of 2 residents reviewed for PASARR's during the annual survey process. The findings include: The Level I Pre-admission Screening and Resident Review (PASARR) must be completed by either the nursing facility or the referring doctor for every individual who will be admitted to a nursing facility to identify individuals who may have Mental Illness (MI), Intellectual Disability (ID), and/or Related Condition (RC). The nursing facility is responsible for ensuring a Level I screen is completed for everyone prior to admission. The PASRR determines whether an individual who has an active diagnosis of Mental Illness (MI) or Intellectual/Developmental Disability (ID/DD) meets the criteria for admission to a nursing facility and may require specialized services. PASARR is required for all persons seeking admission to Medicaid certified nursing facilities, regardless of whether their stay at the nursing facility will be paid for by Medicaid, Medicare or with other resources. Medical record review for Resident #67 revealed the facility staff had not completed a PASARR. This was brought to the Director of Nursing's (DON) attention on 4/11/2019 at 9:45 AM who stated the Social Worker sometimes maintained a separate record of residents' PASARRs. On 4/11/2019 at 9:53 AM the facility's SW confirmed the facility did not have a completed PASARR for Resident #67. The Administrator and DON were made aware of these findings on 4/16/2019 during the exit conference. Refer to F 645

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview, it was determined the facility staff failed to ensure medications were thoroughly labeled with residents' name and dated the medication was open. This was evident for 1 of 37 medication carts observed during the annual survey process. The findings include: Observation of the medication cart on 4/16/19 at 10:00 AM revealed the following observations: 1. The medication cart on the ground floor had a bottle of eye drops Timolol Maleate with no name on the bottle to determine which resident it was to be administered to. 2. The medication cart on the ground floor had a bottle of eye drops Dorzolamide with no open date. 3. The medication cart on the ground floor had a bottle of Nasacort nasal spray with no open date. 4. The medication cart on the 1st floor had the following insulin medications with no open dates, Lantus, Victoza, Humalog, Novolog and two Basaglar pens. 5. The medication cart on the 1st floor had the following bottles of eye drops with no open dates, Simbrinza, Bepreve, and Dorzolamide. Interview with the Director of Nursing on 4/16/19 at 11:30 AM confirmed the facility staff failed to ensure medications were thoroughly labeled with residents' name and dated when open.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood test as ordered for Residents (#44 and #52). This was evident for 2 of 37 residents selected for review of laboratory results in the survey sample. The findings include: 1. The facility staff failed to obtain laboratory blood specimen for Resident #44 as ordered. Medical record review for Resident #44 revealed on 2/11/19 the physician ordered: CBC, BMP, CRP and ESR every Thursday for 3 weeks. A complete blood count (CBC) is a test that measures the cells that make up the blood: red blood cells, white blood cells, and platelets. A complete blood count (CBC) is a blood test used to evaluate overall health and detect a wide range of disorders, including anemia, infection and leukemia. A basic metabolic panel is a blood test that measures the sugar (glucose) level, electrolyte and fluid balance, and kidney function, this panel measures the blood levels of blood urea nitrogen (BUN), calcium, carbon dioxide, chloride, creatinine, glucose, potassium, and sodium. The C-reactive protein (CRP) is a blood test marker for inflammation in the body. CRP is produced in the liver and its level is measured by testing the blood. An erythrocyte sedimentation rate (ESR) is a type of blood test that measures how quickly erythrocytes (red blood cells) settle at the bottom of a test tube that contains a blood sample. Normally, red blood cells settle relatively slowly. A faster-than-normal rate may indicate inflammation in the body. Further record review revealed the facility staff failed to obtain the laboratory blood specimens on 2/21/19 and 2/28/19. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to obtain laboratory blood specimens as ordered for Resident #44. 2. The facility staff failed to obtain laboratory blood specimen for Resident #52 as ordered. Medical record review for Resident #52 revealed the facility staff obtained laboratory blood specimen on 3/6/19. At that time, the facility staff notified the physician with the instruction at the bottom of the laboratory slip to repeat the BMP in 1 week. Further record review revealed the facility staff failed to obtain the BMP on 3/13/19 as ordered. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to obtain laboratory blood specimens as ordered for Resident #52.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0807 (Tag F0807)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#52) with nectar thick water as ordered by the physician. This was evident for 1 of 1 resident selected for review of nutrition and 1 of 37 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #52 revealed on 2/28/19 the physician ordered: nectar thick liquids including bedside water. Nectar-thick liquids - are easily pourable and comparable to apricot nectar or thicker cream soups. Surveyor observation of Resident #52's room on 4/15/19 at 12:05 PM revealed the facility staff failed to provide nectar thick water at the bedside for Resident #52. Further observation revealed the resident had a thin water pitcher dated 4/15/19. The Director of Nursing was notified, and it was revealed that the water pitcher had come from the night shift. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to provide Resident #52 with nectar thick water at the bedside as ordered by the physician.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Residents (#49). This was evident for 2 of 37 residents selected for review during the survey process. 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. The facility staff failed to maintain the medical record in the most complete form for resident #49 Medical record review for Resident #49 revealed: 1. Medical record review for Resident #49 revealed on 3/8/19 the physician ordered: ace bandage wrap apply in the morning and off at bedtime for edema and remove per schedule. On 4/11/19 and 4/12/19 a nurse's note revealed that the nurse signed the Treatment Assessment Record indicating that Resident # 49 had the ace wraps applied. Surveyor observation of the resident on 4/11/19 at 11:30 AM and on 4/12/19 at 1:30 PM, revealed the resident sitting in his/her wheelchair in the room however, the facility staff failed to apply the ace bandage as ordered by the physician. 2. Medical record review for Resident #49 revealed on 3/17/2019 the physician ordered: Measure abdominal girth and document every month on the 17th. On 3/17/19 the medical record revealed that the nurse signed the Treatment Assessment Record indicating that Resident #49 had the abdominal girth measure but failed to record the abdominal girth measurement. On 4/11/19 at 1:00 PM, the Director of Nursing was informed that the facility staff failed to apply ace bandage wraps and measure and record abdominal girth as ordered by the physician. 3. The facility staff failed to maintain the medical record in the most complete and accurate form. Medical record review for Resident #26 revealed on 4/6/18 the physician ordered: Cleanse bilateral hands. [NAME] bilateral palm guards in morning, doff bilateral palm guards after 4 hours of wear and check skin for sign of irritation and 4/10/18 ordered: Occupational therapy clarification: resident to wear bilateral palm guards 4-6 hrs. during the day. A finger flexion contracture is a bent finger, usually at the middle joint of the finger, that one cannot straighten using one's own muscle power or with the help of the opposite hand. The finger has become bent or stuck in that position. The person can make a fist but is not able to straighten the finger. A finger flexion contracture can cause digging finger nails into the palm of the hand. Palm guards are used as a barrier between fingers and palmar skin to prevent injury to the palm from finger flexion contracture. Further review of the physician's order revealed: restorative nursing to don on and off and cleanse hands and observe for any irritation. Restorative nursing refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Surveyor observation of Resident #26 on 4/15/19 at 12:05 PM revealed the resident out of bed, in the second-floor dining room; however, the facility staff failed to apply the palm guards as ordered. Interview with the Director of Nursing on 4/15/19 at 12:30 PM revealed there were no restorative nursing staff available, therefore the palm guards were not applied. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed the facility staff failed to apply palm guards to Resident #26 as ordered by the physician. Review of the Treatment Administration Record revealed the facility staff nurse #1 documented the palm guards were on; however, surveyor observation on 4/15/19 at 12:00 PM revealed the palm guards were not on. See F 684 ++

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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3. The facility staff failed to provide a safe, sanitary environment to prevent the development and transmission of disease and infection. The facility failed to maintain infection control during transfer and handling of food items. On 4/12/19 1:13 PM, an observation of lunch being served on the ground floor revealed GNA #4, assisting Resident #65 with her/his salad by opening the salad dressing packages with his/her teeth. On 4/12/19 at 1:13 PM, the Administrator wittiness the opening of the salad dressing with his/her teeth by GNA #4. Based on medical record review, observations and interview, it was determined the facility staff failed to promote an environment that decreased the potential of transmission of communicable diseases or infections for Residents (#10, #52 and #65). This was evident for observations of dining in 2 of the 3 dining rooms and 3 out of 37 residents selected for infection control during the survey process. The findings include: 1. The facility staff failed to promote an environment free from the potential of transmission of communicable diseases or infections. Based on observation of lunch in the second-floor dining room on 4/15/19 at 12:34 PM revealed facility staff Geriatric Nursing Assistant #1 was noted to have bare hand food contact with Residents # 10's food. Further observations at that time revealed the resident was served a slice of ham. It was also noted a piece of white bread on the food tray. Facility staff GNA #1, using bare hands, placed the piece of ham on the bread and folded the bread to make a sandwich and provided to the resident. 2. The facility staff failed to promote an environment free from the potential of transmission of communicable diseases or infections. Based on observation of lunch in the second-floor dining room on 4/15/19 at 12:34 PM revealed facility staff Geriatric Nursing Assistant #1 was noted to have bare hand food contact with Residents # 52's food. Further observations at that time revealed the resident was served a slice of ham. It was also noted a piece of white bread on the food tray. Facility staff GNA #1, using bare hands, placed the piece of ham on the bread and folded the bread to make a sandwich and provided to the resident. It is the expectation the facility staff refrain from the use of bare hand food contact when preparing foods for residents. Interview with the Director of Nursing on 4/16/19 at 1:30 PM confirmed GNA #1 failed to assist Residents #10 and #52 without the use of bare hand food contact.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observations and interviews with staff it was determined that the facility failed to ensure residents had a means of directly contacting staff. This was evident in 1 public bathroom accessible to residents and 1 resident bathroom. The findings include: 1. On 4/11/2019 at 09:21 AM and 4/15/2019 at 10:21 AM surveyors observed the call light system in the public/staff bathroom on the first floor. This door is not locked and can be accessed by residents. The chord for the call light system was wrapped around the toilet grab bar multiple times preventing the call light system from being activated by pulling the chord. Interview of the Maintenance Director revealed that residents may sometimes wrap the chord around the grab bar themselves. If this bathroom is accessible to residents the facility must ensure they have a means of directly contacting staff in the event of an emergency. 2. On 4/16/2019 at 10:00 AM during a Resident Council meeting, Resident #19 stated that the call light in their bathroom was not operable and had not been for months. At 11:01 AM the bathroom call light was tested with the Director of Maintenance (DOM). It was observed that the emergency call light was a push button system commonly used on resident beds and not an emergency pull chord system appropriate for bathrooms and showers. The system was confirmed to be inoperable. The DOM was made aware at this time.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0923 (Tag F0923)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility failed to have adequate ventilation in resident bathrooms. This was evident for 2 resident bathrooms observed on the 1st floor of the facility. The findings include: Observation of resident rooms/bathrooms on 4/10/2019 at 10:35 AM revealed that exhaust fans were not operational in rooms [ROOM NUMBERS]. The bathrooms had a lingering smell of feces due to the lack of airflow. Interview with Staff #5 confirmed that the wall switches should trigger the bathroom fans when the lights come on. Staff #5 stated they would inform maintenance of the issue. At 1:09 PM the Director of Maintenance confirmed that the lack of airflow was caused by a broken exhaust motor on the roof and had been repaired. The Administrator was made aware of these findings on 4/16/2019 during the exit conference.

Dec 2017 17 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

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Based on observation and interview, it was determined the facility staff failed to provide the most dignified existence for Residents (# 28 and # 63). This was evident for 2 of 30 residents selected for investigation during the survey process. The findings include: Surveyor observation of Resident # 28 and Resident # 63 on 12/11/17 at 8:15 AM revealed the resident's breakfast tray was in the room. The tray was on the bedside table of both residents, to the side of the bed. The residents were not eating (the facility staff indicated both residents were to be fed). There was no facility staff in the room. It was noted the facility staff started collecting dirty trays from residents that had eaten their meal. It was noted that approximately 20 trays had been picked up and placed on the dietary cart. Further surveyor observation revealed no facility staff addressed the resident's breakfast until 8:30 AM; however, the facility staff was collecting dirty trays prior to addressing the breakfast tray for Residents # 28 and Resident # 63. Interview with the Director of Nursing on 12/11/17 at 1:00 PM revealed it is expected residents that need assistance or to be fed, to be provided with that assistance prior to the collection of dirty trays. Interview with the Director of Nursing on 12/13/17 at 2:30 PM confirmed the facility staff failed to provide Residents # 28 and # 63 with the most dignified existence by collecting dirty dietary trays before feeding the residents breakfast.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the December 12, 2017 observation of resident bedrooms and bathrooms, it was revealed that there was evidence of unattended maintenance needs in evidence. In addition, observation of the laundry area revealed multiple issues with disrepair. The findings included: 1. A tour of the environment of care was conducted on December 12, 2017 in response to team discussions of prior findings building during a tour on for this survey. Based on this tour, there was evidence of unattended maintenance needs. The following is a summation of those findings. a. room [ROOM NUMBER] was found with marred walls, a hole in the wall along the exterior wall of the room, the bedside table for the window side bed was missing a drawer handle, and the attached bathroom was found where the connected to mechanical ventilation at the ceiling was missing a grille or cover. b. Wall damage near entry to room where some effort of repair using wall compound was noted but application was rough and incomplete, plus the area of repair was never filled in, sanded, and painted as necessary to restore the damaged wall. A bedside table for one bed was lacking a door handle, a small dresser was found with a drawer handle partially detached, a large dresser was found with no handle for the lower drawer. c. room [ROOM NUMBER] found with damaged or scraped walls, and a hole in the wall near the head of the bed. Also the dresser and wardrobe were scraped and marred such that the finish of the furniture was damaged. 2. Observation of the laundry on December 11, 2017 revealed that there were multiple issues in evidence of unattended maintenance. The ceiling was found to be crumbling apart or paint was peeling off, for a large portion of the room. Walls along the exterior were found in evidence of crumbling or cracking, and in some areas the interior wall was gone and the exterior stone wall was exposed. In addition, the floor tiles were cracked or broken for up to half of the floor area of the room. Observation of a cabinet used to store personal protective equipment was found such that the door did not latch and was being tied closed by means of twine. Note that the laundry is a one room area such that there was no physical separation between the clean and soiled areas. 3. All nursing homes must assure that adequate housekeeping and maintenance services were provided as necessary to maintain a sanitary, orderly, and comfortable environment of care.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and review of the medical record it was determined the facility failed to initiate a care plan to manage a resident's incontinence (Resident #33). A comprehensive care plan outlines a resident's needs and drives the provision of care as required to meet those needs. Findings include: Review of the medical record on 12/12/17 at 9:10 AM revealed that resident #33 was admitted to the facility on [DATE]. The admission MDS (Minimum Data Set) completed on 9/30/17 revealed that Resident #33 was frequently incontinent of bowel and bladder. A MDS is a complete resident assessment tool used to develop the resident plan of care on admission and then completed quarterly or with a significant change in condition. A second MDS was completed on 10/24/17 following a hospital admission and a change in condition. This MDS also revealed that Resident #33 was always incontinent of bowel and bladder. Further review of the medical record revealed that facility staff failed to initiate and implement a comprehensive care plan to manage Resident #33's incontinence which required specific care to effectively manage the incontinence and protect his/her skin from breakdown. In an interview with the the DON (Director of Nursing) on 12/12/2017 3:25PM the DON was made aware of this concern and was asked if there was any additional care plan information available. On 12/13/17 at 7:50 AM the DON confirmed that there was no additional care plan information available.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record on [DATE] at 9:10 AM revealed that resident #33 was admitted to the facility on [DATE] and a care plan indicating resident is a full code was established on [DATE]. Review of nursing and social work notes from a care plan meeting held on [DATE] with Resident #33 , his/her son, spouse, the physician, the nurse and the social worker revealed that Resident #33 at that time decided to discontinue dialysis and and was being placed on palliative care. It was further determined that that Resident #33's code status would be changed to Do Not Resuscitate (DNR) and a physicians order No CPR, Option B, Palliative and Supportive Care was written on [DATE]. Further review of the medical record revealed that facility staff failed to revise and update the care plan to manage a Resident #33's code status care plan changing it from a full code to DNR. (Code status refers to the level of medical interventions a patient wishes to have started if their heart or breathing stops.). In an interview with the the DON (Director of Nursing) on [DATE] 3:25PM the DON was made aware of this concern and was asked if there was any additional care plan information available. On [DATE] at 7:50 AM the DON confirmed that there was no additional care plan information. Based on medical record review, observation and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for residents (# 30 and # 33). This was evident for 2 of 30 residents selected for investigation during the survey process. Findings include: Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. 1. Surveyor observation of Resident # 30 at lunch on [DATE] at 12:45 PM revealed the resident's meal ticket indicated Resident # 30 was to have paper plates. Surveyor observation of the resident at that time, revealed the resident eating lunch; however, the resident was supplied with a glass plate. Further record review revealed the facility staff initiated a care plan for Resident # 30- Resident has a behavior problem of throwing his/her plates and utensils at staff after eating or when annoyed related to anxiety, agitation. The facility staff failed to provide Resident # 30 with paper plates as indicated on the care plan. Interview with the Director of Nursing on [DATE] at 2:30 PM confirmed the facility staff failed to review and revise care plans for Resident # 30 to reflect current and appropriate interventions or failed to provide Resident # 30 with paper plates as indicted on the care plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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Based on medical record review and interview, the facility failed to provide treatment/services to maintain vision (Resident #46). This is evident for 1 out of 30 residents selected for review during the investigation stage of the survey process. The findings include: During interview with Resident #46 on 12/7/17 at 11:55 AM, the Resident stated he/she is waiting for a follow up appointment with the eye doctor. Review of the Resident's medical record revealed the Resident did see the eye doctor on 7/31/17. The new orders for the Resident at that time were Refresh Tears oph. Solution apply 1 drop, Both eyes, twice daily for 60 days. Referral Ophthalmology Consult. Further review of the medical record revealed the Resident never received the eye drops as ordered and an Ophthalmology Consult was never scheduled. Interview with the Director of Nursing and Administrator on 12/12/17 at 11:00 AM confirmed the surveyor's findings.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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2. Medical record review for Resident # 61 revealed on 11/02/17 the Dietitian ordered Ensure Plus three times a day and ice cream two times a day to prevent further weight loss. Ensure Plus helps patients with malnutrition or involuntary weight loss by providing calories and protein needed to gain and maintain a healthy weight. Surveyor observation of the Resident # 61 for breakfast and lunch on 12/07/17 and 12/08/17, revealed no Ensure Plus nutritional supplement. Further investigation of the resident meal ticket for the month of December did not include the special request for Ensure Plus. Interview with the Director of Nursing on 12/11/17 at 1:30 PM confirmed the facility staff failed to provide Resident # 61 with Ensure Plus. Based on medical record review, observation and interview, it was determined the facility staff failed to provide a resident the food as indicated on the meal ticket (#30) or ordered by the dietitian (#61). This was evident for 2 of 30 residents selected for investigation during the survey process. The findings include: 1. Medical record review for Resident # 30 revealed the resident was ordered: CCD/NAS- Carbohydrate Controlled Diet/No Added Salt. A carbohydrate controlled diet is a diet in which carbohydrate intake is either limited or set at a value. Setting carbohydrate intake at set values or limits can be used by people with diabetes help stabilize blood glucose levels. A NAS diet is still a balanced diet. It includes grains, fruits, dairy products, meat and vegetables, but the choices made must be lower-sodium choices. The NAS diet allows all milk, all yogurt, all fruits and all breads without salted tops. Vegetables must be fresh or frozen and not canned or pickled. Surveyor observation of Resident # 30's meal ticket on 12/11/17 at 12:45 PM revealed the meal ticket indicated the resident was to receive Skim milk; however, the facility staff served 2% milk to the resident. Interview with the Director of Nursing on 12/13/17 at 2:30 PM confirmed the facility staff failed to provide Resident # 30 with the skim milk as indicted on meal ticket.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0742 (Tag F0742)

Could have caused harm · This affected 1 resident

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2. Medical record review for Resident # 61 revealed on 10/26/17 the physician ordered: psychiatry consultation for competency. Further record review revealed the facility staff failed to obtain that psychiatric consultation. Interview with the Director of Nursing and Administrator on 12/11/17 at 10:30 AM confirmed the facility staff failed to obtain the psychiatric consultation as ordered by the physician. Based on medical record review and interview it was determined the facility staff failed to obtain psychiatric consultations as ordered by the physician for residents (#45, #61, and #65). This is evident for 3 out of 30 residents selected for review during the investigation stage of the survey process. The findings include: 1. Medical record review for Resident # 65 revealed on 11/1/17 the physician ordered: psychiatry consultation and treatment for diagnosis of cancer. Further record review revealed the facility staff failed to obtain that psychiatric consultation. Interview with the Director of Nursing and Administrator on 12/12/17 at 12:10 PM confirmed the facility staff failed to obtain the psychiatric consultation as ordered by the physician. 3. A review of Resident # 45's clinical record revealed that the primary physician wrote an order on 4/29/17 for a follow up consultation with the psychiatrist. A review of the MedOptions Psychiatry Progress Note for a service date of 4/27/17 revealed the recommendation and plan for the resident was for a follow up in two weeks. This consultation was not done. The Director of Nursing (DON) was interviewed on 12/13/17 at 12:51 PM. She said the resident was discussed at the Pharmacy and Treatment roundtable meeting. She explained that the resident's medications as well as other residents' medications were discussed at this meeting and the psychiatric nurse practitioner was present. It was discussed with the DON that this roundtable meeting does not constitute a consult.

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

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2. Review of Resident # 47's medical record revealed the resident had a daily order of aspirin. Low dose of aspirin reduces the risk of stroke and heart attack. On November 7, 2017 the Physician wrote an order to discontinue the aspirin. A reviewed of the medical record revealed that the Resident received aspirin in the month of November and up to December 12, 2017. On 11/07/17 the aspirin should have been discontinued at that time to prevent the Resident from receiving the medication. Further record review revealed that the Consultant Pharmacist was in the facility and reviewed the resident's medical record on 11/28/17 however, no evidence that the consultant pharmacist reviewed, identified and reported to the facility staff the Resident has an order to discontinue the aspirin. Interview with the Director of Nursing on 12/12/17 at 2:00 PM confirmed that the Consultant Pharmacist failed to identify and notify the facility staff of an unnecessary medication order. See F757 Based on medical record review and staff interview the facility failed to ensure Consultant Pharmacist recommendations were acted upon accurately and as recommended for Resident (# 23), failed to ensure residents were free from unnecessary medications (# 47), and Consultant Pharmacist failed to identify labs were not done (Resident #9). This is evident for 3 of 30 residents selected for investigation during the survey process. The findings include: 1. Medical record review for Resident # 23 revealed on 10/17/13 the physician ordered: Calcium 600 milligrams/Vitamin D 400 milligrams (Mgs) by mouth 2 times day. Calcium is a mineral that is necessary for life. In addition to building bones and keeping them healthy, calcium helps our blood clot, nerves send messages and muscles contract. Vitamin D plays an important role in protecting your bones and your body requires it to absorb calcium. Review of the Medication Administration Record (MAR) revealed the facility staff documented the Calcium/Vitamin was administered at 8:00 AM and 4:00 PM. On 5/4/15 the physician ordered Iron Sulfate 325 mgs every day. Review of the MAR revealed the facility staff documented the Iron was to be administered at 8:00 AM. Further record review revealed the Consultant Pharmacist was in the facility on 8/10/17. At that time, the Consultant Pharmacist reviewed the medical record with the recommendation of at least 2 hours between the administration of the Calcium/Vitamin D and Iron due to absorption concerns of the Iron. Review of the MAR revealed the facility staff changed the time of the Iron from 8:00 AM to 3:00 PM; however, maintained the administration time of the Calcium/Vitamin D at 4:00 PM., therefore the facility staff failed to provide at least 2 hours of time between the administration of the Iron and Calcium/Vitamin D. Interview with the Director of Nursing on 12/13/17 at 2:30 PM confirmed the facility staff failed to act upon the recommendation of the Consultant Pharmacist for Resident # 23 accurately by failing to provide at least 2 hours between the administration of Iron and Calcium/Vitamin D. 3. The Consultant Pharmacist failed to identify labs were not done. A review of Resident # 9's clinical record revealed that the resident's primary physician ordered on 9/21/16 for a Liver Function Test (LFT) to be done every three months. Further review revealed that a LFT was done in April 2017 (one month late) but not in June or September 2017. Pharmacy review notes indicate that the pharmacist reviewed the clinical record monthly but there was no evidence that the pharmacist was aware that the LFT's were not done.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on medical record review, observation and interview, it was determined the facility staff failed to ensure a resident was free from unnecessary medications (# 47). This was evident for 1 of 30 residents selected for review during the investigation stage of the survey process. The findings include: Review of Resident # 47's medical record revealed the resident had a daily order of aspirin. Low dose of aspirin reduces the risk of stroke and heart attack. On November 7, 2017 the Physician wrote an order to discontinue the aspirin. A reviewed of the medical record revealed that the Resident received aspirin in the month of November and up to December 12, 2017 until surveyor intervention. On 11/07/17 the aspirin should have been discontinued at that time to prevent the Resident from receiving the unnecessary medication. Interview with the Director of Nursing on 12/12/17 at 2:00 PM confirmed that the facility staff failed to ensure a resident's medication regimen was free from unnecessary medications. See F756

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on record review, observation and interview it was determined that the facility staff failed to obtain a medication error rate less than 5 %. This was evident for 2 errors out of 25 opportunities for Residents (# 28) resulting in an error rate of 8%. The findings include: Error # 1: The facility staff failed to administer the correct dose of a medication to a resident. Medical record review of Resident # 28's record revealed on 8/17/16 the physician ordered: Aspirin 325 milligrams (mgs) by mouth every day for prevention of stroke. Aspirin is a pain reliever. It is used to treat mild pain and fever. This medicine is also used as directed by a doctor to prevent and to treat heart attacks, to prevent strokes, and to treat arthritis or inflammation. Review of Medication Administration pass on 12/11/17 at 8:23 AM revealed Certified Medication Aide # 1 attempted to administer Aspirin 81 mg instead of 325 mg. The CMA obtained Aspirin 81 mg from the bulk medication and placed in the medicine cup to administer to the resident. Prior to entering the room and after surveyor intervention, the CMA obtained the correct dose of Aspirin for Resident # 28. Error # 2: The facility staff failed to administer the correct dose of medication to a resident. * Medical record review of Resident # 28's record revealed on 8/17/16 the physician ordered: Miralax 17 grams by mouth every day for bowel control. Miralax is a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements. Miralax is used as a laxative to treat occasional constipation or irregular bowel movements. To measure the amount of medication to be administered: the bottle top is a measuring cap marked to contain 17 grams of powder when filled to the indicated line (white section in cap) or a heaping tablespoon can be used; however, the CMA # 1 failed to use the bottle top to measure the correct dose of Miralax and failed to use a heaping tablespoon. The CMA # 1 used a small plastic teaspoon and obtained some Miralax for administration. Interview with the Director of Nursing on 12/13/17 at 2:30 PM confirmed the facility staff failed to administer medications to Resident # 28 as ordered by the physician.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident received ordered laboratory services (# 9). This was true for 1 out of 30 residents selected for review during the investigation stage of the survey process. The evidence is as follows: A review of Resident # 9's clinical record revealed that the resident's primary physician ordered on 9/21/16 for a Liver Function Test (LFT) to be done every three months. Further review revealed that a LFT was done in April 2017 (one month late) but not in June or September 2017. The Director of Nursing was interviewed on 12/13/17 at 12:46 PM. She confirmed that the LFT's were not done as ordered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, it was determined that the facility staff failed to obtain a physician's order prior to obtain laboratory blood specimen for a resident (# 63). This was evident for 1 of 30 residents selected for investigation during the survey process. The findings include: Medical record review of Resident # 63's record revealed on 5/31/17 the physician ordered: Liver Function Test (LFT) every 3 months. Liver function tests are blood tests used to help diagnose and monitor liver disease or damage. The tests measure the levels of certain enzymes and proteins in your blood. Some of these tests measure how well the liver is performing its normal functions of producing protein and clearing bilirubin, a blood waste product. Other liver function tests measure enzymes that liver cells release in response to damage or disease. Record review revealed the facility staff obtained the LFT 6/2/17, 8/24/17 and 11/6/17; however, the facility staff also obtained LFT on 7/3/17 and 10/2/17 without evidence of a physicians' order for those laboratory blood test. Interview with the Director of Nursing on 12/13/17 at 2:30 PM confirmed the facility staff obtained LFT on Resident # 63; however, failed to obtain a physician's order for those laboratory blood test.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0807 (Tag F0807)

Could have caused harm · This affected 1 resident

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Based on record review, observation and interview, it was determined the facility staff failed to provide a resident with the nectar thick water as ordered by Speech therapy (#70). This was evident for 1 of 30 residents selected for investigation during the survey process. The findings include: Medical record review for Resident # 70 revealed on 12/8/17 the Speech/Language Therapist ordered: discontinue thin liquids, begin nectar thick liquids by cup sips. Speech-language pathologists (SLPs) work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults. People who have trouble swallowing thin liquids often thicken liquids to help prevent choking and stop fluids from entering the lungs. Nectar-thick liquids are easily pourable and comparable to apricot nectar or thicker cream soup. Surveyor observation of Medication Administration pass on 12/11/17 at 8:30 AM revealed Certified Medication Aide (CMA) administered medications (Aspirin, Claritin for allergies, Cardizem for blood pressure, Vitamin D for supplement, Tylenol, Senna for bowel regimen, and Dilantin for seizures); however, the CMA provided Resident # 70 with thin water instead of the nectar thick water as ordered by Speech therapy. Interview with the Director of Nursing on 12/13/17 at 2:30 PM confirmed the facility staff failed to provide Resident # 70 with the consistency of water as ordered by Speech Therapy.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected 1 resident

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Based on record review, observation and interview, it was determined the facility staff failed to provide residents with assistive devices as ordered (# 28, # 30 and # 70). This was evident for 3 of 30 residents selected for investigation during the survey process. The findings include: 1. The facility staff failed to provide Resident # 28 a 3 compartment plate as ordered. Meal ticket review for Resident # 28 revealed: 3 compartment plate. The three compartments help keep foods divided so different foods can be prevented from mixing and is designed to increase the dining independence of those who can only use one hand, or those with limited flexibility or motor coordination. Surveyor observation of Resident # 28 on 12/7/17 at 12:45 PM, 12/8/17 at 1:00 PM and 12/11/17 at 12:45 PM revealed the facility staff failed to provide the resident with the 3 compartment plate as noted on the meal ticket. Interview with the Director of Nursing on 12/13/17 at 2:30 PM confirmed the facility staff failed to provide Resident # 28 with a 3 compartment plate. 2. The facility staff failed to provide Resident # 30 a sectional plate as ordered. Medical record review for Resident # 30 revealed on 4/29/17 the physician ordered: sectional plate to promote independence. Divided plates help solve eating problems for those who are handicapped or disabled. These devices allow people to perform eating tasks more independently and improve quality of life. Meal ticket review for Resident # 30 revealed: sectional plate. Surveyor observation of Resident # 30 on 12/7/17 at 12:50 PM, 12/8/17 at 12:55 PM and 12/11/17 at 8:30 AM and 12/11/17 at 12:45 PM revealed the facility staff failed to provide the resident with the sectional plate as ordered. Interview with the Director of Nursing on 12/13/17 at 2:30 PM confirmed the facility staff failed to provide Resident # 30 with a sectional plate. 3. The facility staff failed to provide Resident # 70 with a Provale cup. Medical record for Resident # 70 revealed on 11/28/17 the Speech/Language Therapist ordered: thin liquids via 10 cc Provale cup. Speech-language pathologists (SLPs) work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults. People who have trouble swallowing thin liquids often thicken liquids to help prevent choking and stop fluids from entering the lungs. The Provale cup is an adapted drinking cup which encourages normal drinking habits and small swallows. This cup may be used by therapists to help eliminate the need for pre-thickened liquids with some patients with dysphagia (impaired swallowing). The Provale cup delivers a fixed delivery amount of 5 cc (1 teaspoon) or 10 cc with every normal drinking motion; can be used with water, nutritional supplements, and thin liquids and can have one or two easy-grip-handle or no-handle design. Surveyor observation of Resident # 70 on 12/7/17 at 12: 45 PM revealed the resident in the dining room eating lunch; however, the facility staff failed to provide Resident # 70 with the Provale cup as ordered. (The resident was noted with juice in a regular container, no Provale cup). Interview with the Director of Nursing on 12/12/17 at 2:30 PM confirmed the facility staff failed to provide Resident # 70 with a Provale cup as ordered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based upon record review and staff interview it was determined that facility staff failed to ensure that the resident's medical record was accurate and complete (Resident # 61). This is evident for 1 of 30 residents selected for review during the investigation stage of the survey process. 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. Medical record review for Resident # 61 revealed a physician ordered dated 10/24/17 for cervical collar to be worn every shift. A cervical collar is an intervention to immobilize the cervical spine, the neck. It is also used for the treatment of neck pain. Surveyor observation of the resident on 12/07/17 at 10:45 AM and at 1:30PM, 12/08/17 at 8:00 AM and at 2:00 PM, revealed the resident in his room and in the hallway sitting in his wheelchair, however, facility staff failed to apply cervical collar as ordered by the physician. Review of the Resident's TAR (Treatment Administration Record) the facility staff documented that the Resident had the cervical collar applied in the AM on 12/07/17 and 12/8/17. Interview with the Director of Nursing on 12/11/17 at 1:30 PM confirmed the facility staff failed to maintain the medical record in the most complete and accurate form for Resident # 61.

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

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4. Interview with Resident # 60 on 12/08/17 at 8:45 AM revealed that a hand surgeon consultation was to be made and leg wraps were to be ordered. Medical record review for Resident # 60 revealed the following physician orders: a. On 09/11/17 the physician ordered hand surgeon consultation for right third trigger finger. However, the facility staff failed to obtain the consultation as ordered by the physician. (Trigger finger is a painful condition that causes the fingers or thumb to catch or lock when bent). b. On 10/13/17 the physician ordered Velcro compression wraps for lower legs lymphedema and return to physician office in 2-3 weeks after obtaining garments for re-evaluation. However, the facility staff failed to obtain the Velcro compression wraps. (lymphedema is a condition of localized fluid retention and tissue swelling). c. On 10/27/17 the physician ordered routine breast mammogram to rule out abnormalities. However, the facility staff failed to obtain the ordered by the physician. Interview with the Director of Nursing on 12/12/17 at 1:00 PM confirmed the facility staff failed to provide as ordered for Resident's # 60. Based on interview, observation and medical record review the facility staff failed to provide all treatments and services as ordered by the physician (Resident #3, #45, #60, #65 and #70). This is evident for 5 out of 30 residents selected for review during the investigation stage of the survey process. The findings include: 1. Review of Resident #3's medical record revealed an order on 7/9/16 for Mighty Shakes two times a day at lunch and dinner, document % consumed. Further review of the Resident's Administration Records revealed the facility staff failed to follow the physician order and document the % consumed. Interview with the Director of Nursing and Administrator on 12/12/17 at 9:30 AM confirmed the surveyor's findings. 2. Review of Resident #65's medical record revealed an order on 11/22/17 for fluid aspiration daily via pleurx catheter daily for recurrent pleural effusion. If CT drains less than 50ml/day for 3 consecutive days notify physician, every evening shift Document amount of drainage. Review of the Resident's Treatment Administration Record revealed the facility staff failed to follow the physician order and document the pleurx catheter output daily. For December 1st-12th, 2017 the output was not documented on 12/1, 12/2, 12/4, 12/5, 12/6, 12/7, 12/8 and 12/11. Interview with the Director of Nursing and Administrator on 12/12/17 at 11:00 AM confirmed the surveyor's findings. 3. The facility staff failed to follow physician's order for no right shoe. Medical record review for Resident # 70 revealed on 7/18/17 the physician ordered: Do not wear shoe on right foot- right foot pain. Surveyor observations of Resident # 70 on 12/7/17 at 12:00 PM and 12/11/17 at 1:00 PM revealed the resident out of bed, with shoes on both feet. The facility staff failed to follow the physicians' order and failed not to apply a shoe to the right foot. Interview with the Director of Nursing on 12/13/17 at 2:30 PM confirmed the facility staff failed to follow physicians' order for no shoe on right foot by applying a shoe to the right foot of Resident # 70. 5. A review of Resident # 45's clinical record revealed that the resident's primary physician wrote an order for the resident to receive Med Pass 2.0 (a nutritional supplement) 120 cc's (cubic centimeters) four times a day with 120 cc of water and document the percentage of the supplement consumed each time. A review of the Medication Administration Record for October, November, and December of 2017 revealed that nursing staff has not documented the amount consumed as ordered. The Director of Nursing was interviewed on 12/13/17 at 12:48 PM. She confirmed that the nursing staff did not document the amount of Med Pass 2.0 consumed.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0804 (Tag F0804)

Minor procedural issue · This affected multiple residents

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Based on observations made, interview of staff and measurement of food temperatures measured from two test trays observations by this surveyor, it was found that food was not prepared and served in a manner that the food was attractive, palatable at the proper temperature. In addition, discussions with other surveyors as to dining observation revealed concerns of observed tray delivery delay and food being served to only one resident seated at a table while others at the same table were not served at the same time. The findings included: In response to resident reports as related to concerns of poor food quality, this surveyor was assigned the task to evaluate food as served. As part of the inspection of the kitchen, this surveyor was able to determine that the kitchen was not equipped with the standard equipment per standard of practice that would be employed to maintain hot food temperatures when food was disseminated by tray distribution. The equipment lacking was a base for a heated pellet and the heated pellet. The only approach used by dietary staff at this nursing home was to pre-heat the plates and to send plates on trays with a plastic dome cover. Observation the plates of food on trays, as trays of food were passed out by staff, was that the dome cover did not fit tightly on the plate and in fact allowed for one side of the plate edge to be uncovered as the dome would rest on the tray on the opposite side of the plate. As such, heat from the food would readily escape. While watching the lunch meal being prepared, this surveyor noted a large saucepan full of mixed vegetables being cooked on a stovetop. Although there was a food steamer in place for use (preferred for cooking of vegetables per standard of practice as it does not cause the vegetables to be easily over-cooked and to then become soft or mushy. Upon observing this, the lead cook was asked as to why a large sauce pan on a stove top was being employed as opposed by a steamer. The cook indicated that those vegetables were for residents on a pureed diet. As there were only 9 residents on a pureed diet per interview of the same lead cook, the amount of vegetables being cooked were determined to be far in excess of the amount required for 9 servings of pureed food. On December 8, 2017, during a lunch test tray observation at 12:15 PM, it was revealed that staff were removing plates from an oven. Interview of the acting manager revealed that the plate heating equipment was not functional so staff were using an oven to heat the plates. A test tray was then assembled by staff, left the kitchen at 12:24 PM, and the last tray served to a resident (first tray cart full of trays, sent to first floor nursing unit) was served at 12:48 PM -- 24 minutes later. Upon checking the temperatures of the food with a food thermometer calibrated that day, it was revealed that milk and a fruit cup were at a temperature of 46 degrees Fahrenheit and both were tepid to taste. Hot food items, were as follows: chicken breast, 116 degrees Fahrenheit; oven-baked potato wedges, 108 degrees Fahrenheit; mixed vegetables, 106 degrees Fahrenheit. The potato was found to be cold to taste, the mixed vegetables were very soft and mushy and cold to taste, and the chicken breast was dry and tepid to taste. As noted prior, the reason for the soft and mushy vegetables being the method used to cook those vegetables. Based on this surveyors' review, the food for this test tray was determined to be unpalatable. On December 11, 2017, during a lunch test tray observation at 12:10 PM, a test tray was assembled and placed onto a tray caddy by 12:23 PM. Interview of the acting manager revealed that the plate heating equipment had been repaired by the end of the day on December 8, 2017. The test tray was sent to the second floor nursing care unit, and the last tray was served at 12:40 PM -- 15 minutes after the food tray caddy arrived on the unit. Upon checking the temperatures of the food with a food thermometer calibrated that day, the milk was found to be at 40 degrees Fahrenheit and was cool to taste. Unfortunately, the hot food items were found to be at the following: roast turkey, 118 degrees Fahrenheit; bread stuffing, 118 degrees Fahrenheit; broccoli, 116 degrees Fahrenheit. The taste of the turkey was good, but the food was determined to be tepid to taste. The taste of the stuffing was good, but the food was determined to the tepid to taste. The broccoli was determined to be very soft and was tepid to taste. Based on this surveyors' review, the food for this test tray was determined to be unpalatable. All nursing homes must assure that food would be prepared by methods that conserve nutritive value, flavor, and appearance. An example of a method that does not conserve nutritive value would be cooking of vegetables on a stove top with lots of water. In addition, nursing homes must assure that food and drinks will be served such that all is palatable, attractive, and at a safe and appetizing temperature. Failure to obtain and employ equipment recommended for use per standard of practice will result in foods not being served at a safe and appetizing temperature. In addition, failure to organize how trays of food would be disseminated will result in a delay of prompt food tray delivery and the potential for food to not be served at a safe and appetizing temperature.

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 safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Maryland facilities.

Concerns

• Multiple safety concerns identified: Federal abuse finding. Review inspection reports carefully.
• 83 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade F (35/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Holly Hill Healthcare Center's CMS Rating?

CMS assigns HOLLY HILL HEALTHCARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Holly Hill Healthcare Center Staffed?

CMS rates HOLLY HILL HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 55%, compared to the Maryland average of 46%. RN turnover specifically is 59%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Holly Hill Healthcare Center?

State health inspectors documented 83 deficiencies at HOLLY HILL HEALTHCARE CENTER during 2017 to 2024. These included: 81 with potential for harm and 2 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates Holly Hill Healthcare Center?

HOLLY HILL HEALTHCARE 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 COMMUNICARE HEALTH, a chain that manages multiple nursing homes. With 75 certified beds and approximately 72 residents (about 96% occupancy), it is a smaller facility located in TOWSON, Maryland.

How Does Holly Hill Healthcare Center Compare to Other Maryland Nursing Homes?

Compared to the 100 nursing homes in Maryland, HOLLY HILL HEALTHCARE CENTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (55%) 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 Holly Hill Healthcare Center?

Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the substantiated abuse finding on record and the below-average staffing rating.

Is Holly Hill Healthcare Center Safe?

Based on CMS inspection data, HOLLY HILL HEALTHCARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-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 Holly Hill Healthcare Center Stick Around?

HOLLY HILL HEALTHCARE CENTER has a staff turnover rate of 55%, which is 9 percentage points above the Maryland average of 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 Holly Hill Healthcare Center Ever Fined?

HOLLY HILL HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Holly Hill Healthcare Center on Any Federal Watch List?

HOLLY HILL HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 75
Avg. Residents: 72
Occupancy: 96.1%
Ownership: For profit - Corporation
Chain: COMMUNICARE HEALTH
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
83 Deficiencies: -10
Abuse Finding: -15
Final Score: 35/100

Nearby Alternatives

TOWSON REHABILITATION AND HEA... 5-star COMPLETE CARE AT MULTI MEDICAL... 5-star FUTURE CARE OLD COURT 5-star

View all in TOWSON →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 215204