How many inspection deficiencies does MONTCARE AT WHEATON have?

MONTCARE AT WHEATON has 58 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at MONTCARE AT WHEATON?

MONTCARE AT WHEATON has a three-star staffing rating from CMS with 0.79 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 MONTCARE AT WHEATON located?

MONTCARE AT WHEATON is located in WHEATON, MD. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MONTCARE AT WHEATON have?

MONTCARE AT WHEATON has 94 certified beds.

Who owns MONTCARE AT WHEATON?

MONTCARE AT WHEATON is a for profit - limited liability company facility and operates independently (not part of a chain).

What questions should families ask when visiting MONTCARE AT WHEATON?

Families visiting MONTCARE AT WHEATON should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does MONTCARE AT WHEATON compare to other nursing homes?

MONTCARE AT WHEATON has a 3-star overall rating, which is average compared to other nursing homes in MD. Consider visiting multiple facilities before making a decision.

MONTCARE AT WHEATON

Name: MONTCARE AT WHEATON
Address: 11901 GEORGIA AVENUE, WHEATON, MD, 20902, US
Telephone: (301) 942-2500
Rating: 3.0

11901 GEORGIA AVENUE, WHEATON, MD 20902 · (301) 942-2500

For profit - Limited Liability company 94 Beds Independent Data: November 2025

Trust Grade

65/100

#118 of 219 in MD

Share this report:

MONTCARE AT WHEATON nursing home in WHEATON, MD - Photo 1 of 5

MONTCARE AT WHEATON nursing home in WHEATON, MD - Photo 2 of 5

Photo by Montcare Wheaton

MONTCARE AT WHEATON nursing home in WHEATON, MD - Photo 3 of 5

Photo by S. Anne

MONTCARE AT WHEATON nursing home in WHEATON, MD - Photo 4 of 5

Photo by Gruen Agency HCR - ManorCare

MONTCARE AT WHEATON nursing home in WHEATON, MD - Photo 5 of 5

1 / 5 photos

Last Inspection: July 2024

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

Overview

Montcare at Wheaton has a Trust Grade of C+, indicating it is decent and slightly above average, but not particularly noteworthy. It ranks #118 out of 219 nursing homes in Maryland, placing it in the bottom half of facilities in the state, and #24 out of 34 in Montgomery County, meaning only a few local options are better. Unfortunately, the facility is experiencing a worsening trend, with reported issues increasing from 7 in 2019 to 35 in 2024. Staffing is a positive aspect, with a turnover rate of 24%, significantly lower than the Maryland average of 40%, which suggests staff members tend to stay longer and are familiar with the residents. However, there are some concerns, such as a failure to properly store food, which could affect all residents, and a past incident of alleged abuse that, while not substantiated, raises questions about resident safety. Overall, while there are strengths in staffing and no fines reported, the increasing number of health and safety issues is troubling for families considering this facility.

Trust Score: C+
In Maryland: #118/219
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 24% annual turnover. Excellent stability, 24 points below Maryland's 48% average. Staff who stay learn residents' needs.
Penalties: No fines on record. Clean compliance history, better than most Maryland facilities.
Skilled Nurses: Each resident gets 47 minutes of Registered Nurse (RN) attention daily — more than average for Maryland. RNs are trained to catch health problems early.
Violations: 58 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★★

5.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2019: 7 issues

2024: 35 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Low Staff Turnover (24%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (24%)
24 points below Maryland average of 48%

Facility shows strength in quality measures, staff retention, fire safety.

The Bad

3-Star Overall Rating

Near Maryland average (3.0)

Meets federal standards, typical of most facilities

The Ugly 58 deficiencies on record

Jul 2024 35 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

Read full inspector narrative →

3) On 6/18/24 at 10:08 AM, Resident #28's urine drainage bag was observed hanging on the right side of the bed frame without a privacy bag. A healthcare provider typically inserts a Foley catheter before surgery or to treat conditions like urinary incontinence or urinary retention. It can also be used for patients who have had gynecological or urological surgery. Most catheters are only needed until the person can urinate on their own again, but older adults or people with permanent injuries or illnesses may need to use them long-term or permanently. A Foley bag, also known as a urine drainage bag, is a collection bag that connects to a Foley catheter to drain urine from the bladder when a person is unable to urinate on their own. On 6/25/24 at 12:54 PM, Resident #28's medical records were reviewed and revealed an order to ensure their Foley bag was housed in a privacy bag every shift. Further review of the resident's medical records at 1:23 PM revealed that this order was marked as done for day shift by the Registered Nurse (RN Staff #46) On the same day at 2:21 PM, an observation of Resident #28's urine drainage bag without a privacy bag was again made by the surveyor. Shortly after at 2:27 PM, the Unit Manager (Staff #13) accompanied the surveyor to Resident #28's room and confirmed the observation that the urine drainage bag was exposed and was not in a privacy bag. Staff #13 looked around the resident's room but could not locate a privacy bag. The resident's orders were also reviewed with Staff #13 and confirmed that Staff #46 had already marked the order as done to ensure that the Foley bag was housed in a privacy bag. The concern was discussed with Staff #13 that the nursing staff had marked an order as done without ensuring it and that it was a dignity concern. Staff #13 acknowledged the concern. On 7/10/24 at 2:56 PM, the findings were discussed with the Director of Nursing (DON) that 2 of 2 observations of Resident #28's urine drainage bag failed to utilize the privacy bag to ensure the resident received services with dignity. The DON acknowledged the concern. 2) A meal observation on the long-term care unit on 6/17/24 at 12:39 PM showed staff #31, a geriatric nurse aid (GNA), standing over Resident #4, who was lying in bed while assisting him/her in eating lunch. In a continued observation, staff #31 took Resident #4's meal tray out to the meal cart and then was observed going back to Resident #4's room with a dessert. Staff #31 continued to feed the Resident dessert while standing over the Resident. A medical record review on 6/17/24 at 1:01 PM showed that Resident #4 had been living in the facility since June 2013 and required maximal assistance from staff with eating. In an interview with staff #31 on 6/17/24 at 1:16 PM, she stated that she usually stood up while assisting residents with eating. During a subsequent interview on 6/26/24 at 9:32 AM, the DON stated that she expected staff to be seated while assisting residents with eating and not to stand over them. Based on observations, record review, and interviews, it was determined that the facility failed to maintain a resident's dignity by 1) by standing over a resident while assisting him/her during a meal, and 2) by failing to cover the urine drainage bag with a privacy bag. This was evident for 3 (#61, #35, #4) of 3 residents reviewed for dignity, and 1 (#28) of 3 residents reviewed for urinary catheter or UTI. The findings include: 1) On 6/18/24 at 8:09 AM, an observation revealed LPN staff # 7 assisting Resident #61 with a meal. Resident #61 was lying in bed with the head of the bed elevated. Staff #7 was standing over the resident while assisting the resident with eating. Further observation revealed that a vacant chair was available in the room. On 6/18/24 at 8:09 AM, an observation revealed Resident #35 was lying in bed with the head of the bed elevated. GNA #6 was standing up over the resident and assisting the resident with eating. Further observation revealed that there was a chair available in the room. On 6/18/24 at 8:11 AM, the surveyor and the Director of Nursing (DON) made observations of Resident #61 and Resident #35 being assisted with eating. The DON reported that the facility's best practice is that staff sit next to the resident while assisting the residents with meals. On 6/18/24 at 8: 13 AM, an observation was noted of the DON entering Resident #35 and Resident #61's rooms and following that intervention by the DON, it was noted that Staff #7 and Staff #6 were seated while assisting the residents with eating.

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, pertinent document review, and interview, it was determined that the facility failed to have a process in place to communicate with a resident in their preferred language. This was evident for 1 ( # 61) of 2 residents reviewed for communication-sensory during a survey. The findings include: On 6/20/24 at 9:49 AM, the hospital discharge summary of Resident #61, a long-term resident, was reviewed. The review revealed that Resident #61 had a history of dementia and deafness. Also, that she communicated using American sign language (ASL). On 6/18/20 at 7:43 AM, during an interview with GNA staff #6, she reported that she routinely provides care to Resident # 61. She reported that she communicated with the resident through writing on a white board. Staff #6 reported that the resident would also use gestures or pointing to communicate. In addition, she reported she has never used an ASL interpreter to communicate with the resident. On 6/18/24 at 11:49 AM, an observation was made of the Maryland State Service Coordinator for DDA services (an outside provider, staff #18), signing with the Resident #61. On 6/18/24 at 12:14 PM, the DDA service provider reported that she had worked with Resident #61 in the community as an outreach sign language service coordinator for Maryland DDS. She reported that Resident #61's language was ASL. She reported that she has worked with the resident for several years and that the resident has a decrease in anxiety and delusions when provided with increased oppurtunities for communication when others are using ASL. On 6/20/24 at 12:05 PM, an interview was conducted with Nurse (RN) unit manager Staff # 13. He reported that he is the supervisor of the unit where Resident # 61 resides. He reported that he has never used an interpreter in ASL, either personally or virtually to communicate with Resident #61. He reported that a whiteboard is used to communicate with the resident. On 6/20/24 at 1:04 PM, review of care plan revealed that the resident uses sign language and a communication board to communicate with staff. On 6/24/24 at 2:51 PM, the Long-Term Care Social Worker Coordinator Staff #16 was interviewed. She reported that the preferred way to communicate with a deaf resident is to use a ASL interpreter. She reported that the facility has not used an ASL interpreter (in person or virtually) for the resident during her/his stay at the facility. On 7/5/2024 at 7:45 AM, Resident #61 was interviewed with the assistance of a qualified ASL Interpreter. The surveyor and [NAME] President of Clinical Operations were present during the interview. The resident reported (via the ASL interpreter) that the best way for her to communicate is with sign language. Resident # 61 said the white board has been okay, but signing is best. On 7/5/2024 at 8:00 AM, the Surveyor discussed with the [NAME] President of Clinical Operations the concerns of Resident #61. Primarily, that she had not had any opportunity to communicate in her preferred language, over the year of her stay at the facility. The [NAME] President of Clinical Operations reported that education has already begun with the facility staff on how to use the virtual interpreter. Additionally, she would discuss with the facility when to use the virtual interpreter and when it is appropriate to use the white board along with gestures for communication.

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 F0572 (Tag F0572)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to notify a resident and the resident's representative of his/her rights upon admission by not executing an admission contract. This was evident for 1 (#90) of 2 residents reviewed for personal property during a complaint and recertification survey. The findings include: Review of complaint MD00187269 on [DATE] revealed an allegation the facility staff failed to return Resident #90's belongings to the family after the resident suddenly died. A review of the facility admission contract/financial agreement on [DATE] at 11:14 AM revealed Section H, Limitations of Liability, paragraph one that stated: The facility is obligated to take reasonable precautions to provide the Resident and the Resident's personal belongings with security, including providing a reasonable amount of secured space for Resident's belongings. The facility, however, cannot be responsible for loss or damage to the Resident's valuables unless that loss or damage is caused by the negligence or willful action of the facility staff. Review of Resident #90's closed medical records on [DATE] revealed that Resident #90 was admitted to the facility on [DATE]. The nursing staff completed a personal inventory of Resident #90's belongings which included a phone, blouses, shirts, comb, brush, glasses, and a pair of slacks. The nursing staff updated Resident #90's personal effects list on [DATE] and [DATE] by adding 3 pairs of eyeglasses and an IPAD as being received into the facility. In an interview with the complainant on [DATE] at 12:35 PM, the complainant stated that after Resident #90 died on [DATE], the facility failed to return Resident #90's phone, blouses, shirts, comb, brush, glasses, and a pair of slacks. The complainant stated that s/he nor Resident #90 were approached by staff to sign an admission contract. The complainant stated that s/he was not aware of any rules, how to place a grievance nor a complaint, how to obtain or review a copy of the medical record, or any limitations about receiving reimbursement for lost or misplaced items. Prior to exit conference on [DATE], in an interview with the facility administrator at 11:25 AM, the facility administrator stated that s/he was not aware that Resident #90 was admitted with a phone. The facility administrator stated that s/he did speak with the complainant about the IPAD and that administration reimbursed the complainant with a check for the IPAD. The administrator confirmed that a request had been created for the offsite medical record storage facility to send a copy of Resident #90's signed admission contract. In a phone conversation with the facility administrator on [DATE] at 12:45 PM, the administrator stated that the offsite storage company was unable to locate a signed admission contract by Resident #90.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility staff failed to reveal evidence that the resident or resident representative was informed of their right to formulate an advanced directive. This was evident for 2 (#44, #59) of 6 residents reviewed for advanced directives. The findings include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual is not able to make their own decisions. A Medical Orders for Life Sustaining Treatment or MOLST form contains medical orders regarding life-sustaining treatments, the use of medical tests, whether to transfer a patient to a hospital and any other matter considered appropriate by the Department to implement the treatment preferences of patients. A MOLST form is not an advance directive. A MOLST form contains written medical orders related to a patient's medical condition. 1) Resident #44 has been residing at the facility since 2022. On [DATE] at 11:46 AM, the resident's medical record was reviewed and revealed a MOLST form labeled as advanced directive. No other documentation was found to reveal an advanced directive was in place. On [DATE] at 11:26 AM, Resident #44's medical record was reviewed and revealed a care conference progress note with a reference date of [DATE] that indicated the resident was his/her own decision maker. Later at 10:29 AM, further review of the resident's medical record revealed a psychosocial evaluation with a reference date of [DATE] that indicated the resident's memory was intact, cognition was functionally intact, and judgement was adequate. On [DATE] at 10:10 AM, the Social Services Director (SSD) was interviewed about her process with advanced directives. The SSD also reported her knowledge of the difference between a MOLST form and an advanced directive. The SSD was asked if the resident had an advanced directive in place and she indicated that she would check the resident's medical records. On [DATE] at 10:06 AM, the SSD indicated that she did not find an advanced directive in place for Resident #44 or that it was discussed and/or offered to the resident during admission. The concern was discussed with the SSD about the resident's right to receive information and to formulate an advanced directive. The SSD acknowledged the concern and reported that the resident was admitted before she was hired. On [DATE] at 11:09 AM, further review of Resident #44's medical records revealed a progress note done by the SSD on [DATE] at 11:47 AM, after discussing with the surveyor, that indicated an advanced directive was discussed with the resident, and that s/he did not have one in place and refused to formulate one at that time. 2) On [DATE] at 10:58 AM, a review of Resident #59's EHR (electronic health record) and paper medical record failed to reveal evidence that Resident #59 had an advanced directive in place and no documentation was found in the medical record to indicate Resident #59 had been informed of his/her right to formulate an advanced directive. On [DATE] at 10:13 AM, a review of Resident #59's medical record revealed the resident was admitted to the facility in the middle of [DATE], following an acute hospitalization and the resident was his/her own representative. Resident #59's admission assessment with an assessment reference date (ARD) of [DATE] documented Resident #59 BIMS (brief interview for mental status) summary score was 12, indicating the resident had moderate cognitive impairment. Further review of the medical record revealed a [DATE] at 3:41 PM, Social Services Note that documented Resident #59 was alert and oriented x 3 (oriented to time, person and place). The social services note documented the resident's MOLST was addressed and is full code, indicating Resident #59 had elected to attempt CPR, if cardiac and/or pulmonary arrest occurred. The documentation contradicted the resident's [DATE] MOLST which documented Resident #59 elected No CPR. There was no further documentation in the social services note to indicate that advanced directives had been discussed with Resident #59. Continued review of Resident #59's EHR revealed a [DATE] care conference note, signed by the SSD, that included a check off list labeled Topics Discussed followed by a list of multiple topics that could potentially be discussed with a resident. The topics, Advanced Directive, and POLST (Physician Orders for Life Sustaining Treatment)/MOLST were not checked off, indicating advanced directive and the MOLST were topics that were not discussed with Resident #59 during the care conference. Review of Resident #59's care plans revealed a care plan with the focus, [Resident #59's] advanced directive is Full Code, which was initiated on [DATE] and had a revision date [DATE]. The care plan focus was inaccurate, as Resident #59's active MOLST documented the resident elected No CPR. Continued review of Resident #59's medical record failed to reveal documentation to indicate whether Resident #59 had formulated an advanced directive or that the resident had been informed of his/her right to formulate an advanced directive. The above concerns were discussed with the Social Service Director on [DATE] at 10:16 AM. The SSD acknowledged the concerns and offered no further comments at that time.

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review and staff interviews, it was determined that the facility, 1) failed to notify the provider that the resident was not receiving a medication due to an allergy, 2) failed to notify a resident's family representative after a resident had a change in condition, and 3) failed to notify the provider when a resident's blood pressure was below prescribed parameters, and blood pressure medication was not administered. This was evident for 1 (#5) of 1 residents reviewed for notification of change, 1 (#91) of 11 residents reviewed for neglect and 1 (#95) of 4 residents reviewed for discharge The findings include: 1) Review of Resident #5's medical record on 6/28/24 revealed that the resident had been residing at the facility since March 2024, needed partial to maximal assistance with Activities of Daily Living (ADLs), was alert and oriented, and able to verbally communicate. On 06/17/24 at 02:32 PM, during an interview with Resident #5, he/she reported having blisters on the back of her/his legs. Record review revealed that, on 5/31/2024 at 10:41, there was a progress note completed that on assessment they found a, penny size blister on Left posterior thigh, and that an order was received to apply skin prep twice a day to the blisters. Record review revealed that on 6/14/24 there was an order for Silver Sulfadiazine Cream 1% to be applied to the area of blisters every day shift and as needed. An interview with Divisional Director of Quality Assurance (Staff #5), on 06/27/24 at 03:05 PM, revealed that that Resident #5 had an allergy to sulfa so the order for Silver Sulfadiazine Cream 1% was discontinued on 6/21/24 and that pharmacy never sent the medication. Staff #5 presented the surveyor with a printed email receipt from the pharmacy, dated 6/17/24 which revealed, .Please note patient has a sulfa allergy. Please clarify has patient used this cream before? An interview, on 06/26/24 at 12:54 PM, with Registered Nurse (Staff #22) who attended the wound rounds, revealed that to her knowledge, the wound physician had ordered the sulfadiazine in relation to the wound. When the surveyor asked if the physician was notified of the medication not being delivered, she reported, I believe but did not report having informed the physician herself. On 06/27/24 at 10:29 AM, an interview with Licensed Practical Nurse (LPN, Staff #12) revealed there was a silvadene order active for a week. When the surveyor asked what the process was if a medication was not delivered, she indicated that the nurses would have to call the doctor and let them know. Further review of the medical record revealed an order to discontinue the Silver Sulfadiazine Cream on 6/21/24. Further record review on 06/28/24 at 9:58 AM failed to reveal documentation that the provider was notified of Resident #5's allergy to sulfa, or that the Silver Sulfadiazine Cream was not delivered or administered prior to the discontinuation order on 6/21/24. On 06/28/24 at 11:00 AM, the surveyor reviewed the concern with Nursing Home Administrator (Staff #1) that the medication was ordered on 6/14/24, and the pharmacy alerted the facility on 6/17/24, but there was no documentation found to indicate the physician was notified prior to the discontinuation of the order on 6/21/24. 2) On 7/5/24 at 9:41 AM, intake # MD00174028 was reviewed. On 7/5/24 a review of progress notes, dated 11/5/22, revealed that Resident #91 was observed by nursing staff on the floor lying next to her bed. Further review revealed that the resident's daughter was notified, of the fall, on 11/5/22, On 7/5/24 continued review of progress notes from 11/5/22 through 11/10/22 failed to reveal that there was an attempt to contact the resident's PR regarding the fall. On 7/5/24 at 9:41 AM, intake # MD00174028 was reviewed. Further review revealed a concern that the facility failed to notify Resident #91's husband who was the documented personal representative (PR) for Resident # 91. On 7/05/24 at 2:24 PM, the RN Unit Manager Staff # 13 confirmed that the husband was the official PR. He reported that another family member would be contacted if the PR is unavailable. Staff #13 failed to provide documentation that an attempt was made to contact Resident # 91's PR. 3) On 7/11/24 at 9:00 AM, a review of Resident #95's August 2022 Medication Administration Record (MAR) revealed an 8/3/22 order for Diltiazem (Cardizem) (antihypertensive drug) tablet by mouth to be given every 6 hours for hypertension (HTN) (high blood pressure). The order stated to hold for systolic blood pressure (SBP) (top number of a blood pressure reading) less than 110 or heart rate (HR) (pulse) (P) less than 60. The MAR documented the Resident #95's blood pressure and pulse were outside of the physician ordered parameters and the diltiazem was not given. This was evident on 5 (8/3 at 12 AM, 8/6 at 12 AM, 8/9 at 6 AM, 8/11 at 6 AM and 8/12 at 12 PM. In addition, the MAR indicated the resident's Diltiazem medication was held with no BP or pulse documented in the medical record. This was evident for 21 Diltiazem administration times (8/3 at 12 PM, 8/4/22 at 12 PM, 8/6/22 at 12 PM, 8/7 at 12 PM, 8/9 at 12 AM, 8/9 at 12 PM, 8/10 at 12 AM, 8/11at 12 AM, 8/14 at 12 AM, 8/15 at 12 AM, 8/15 at 12 PM, 8/17 at 12 AM, 8/18 at 12 AM, 8/19 at 12 AM, 8/19 at 12 PM, 8/23 at 12 AM, 8/25 at 12 AM, 8/26 at 12 AM, 8/28 at 12 AM, 8/28 at 12:00 PM, and 8/29 at 12 AM) in August 2022. Continued review of the Resident #95's medical record failed to reveal documentation to indicate the attending physician was notified the resident's blood pressure or pulse was not within parameters and the multiple times Resident #95's blood pressure medication was not given. The Nursing Home Administer (NHA) was made aware of the above concerns related to physician notification on 7/11/24 at 11:29 AM and the NHA acknowledged the concerns at that time.

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and interview, it was determined that the facility failed to ensure that items in need of repair were reported to the maintenance department. This was found to be evident for 2 out of 23 resident rooms observed in the initial stage of the survey. The findings include: 1) On 6/17/24 at 2:18 PM, surveyor observed in Resident #5's room several areas of the wallpaper with staples in sections where the sheets of wallpaper were separating. Also observed at this time, the material covering the right arm rest padding of the resident's wheel chair was not intact, with a small section missing. On 7/1/24 at 1:44 PM, interview with geriatric nursing assistant (GNA Staff #27) revealed that, if environmental concerns were identified, the staff were able to initiate a computer report for repairs. When asked if a resident's arm rest was peeling or torn, the GNA responded that they would definitely report it. On 7/8/24, Resident #5 was observed in the dining room. Observation of the armrest on the resident's wheelchair again revealed that the material covering the right arm rest padding was not intact with a section missing. On 7/9/24 at 11:35 AM, the maintenance director (Staff #28) confirmed they use a computerized system, known as TELS, for reporting maintenance issues. He reported there were no current TELS for Resident #5 and denied any recent work on the resident's wheelchair. Surveyor reviewed the concern that damage had been noted to the resident's armrest at the beginning of the survey and recent observation revealed the same observation. The maintenance director reported staff usually would tell him about issues like that. Also during the 7/9/24 interview, the maintenance director reported there were no plans at present for wallpaper removal. On 7/9/24 at 11:45 AM, surveyor and maintenance director observed the wallpaper in Resident #5's room. There were at least four areas where the wallpaper had started to separate and had been stapled together. The stapled areas were approximately 12 inches in length each. Upon observation of the stapled wallpaper, the maintenance director reported that was before his time. 2) On 6/18/24 at 9:59 AM, surveyor observed in Resident #67's room cracks in four floor tiles. The tiles were located between the bathroom and the left wall of the room upon entrance. The cracks ran the length of each tile. During the 7/9/24 11:35 AM interview with the maintenance director, he reported that he had replaced tiles in a couple of rooms. On 7/9/24 at approximately 11:40 AM, surveyor and maintenance director observed the cracked tiles in Resident #67's room, additional cracks were observed in a similar area in the room next door. The maintenance director reported this was a structural problem.

CONCERN (D) 📢 Someone Reported This

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

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, pertinent documentation and staff interviews, it was determined that the facility failed to provide the resident and/or the resident representative, in writing, of a notice of transfer, along with the reason for the transfer. This was evident for 2 (#2, #100) of 4 residents reviewed for hospitalization. The findings include: 1) Resident #22 was admitted to the facility in mid-2022. A quick look in the resident's medical record revealed that s/he was cognitively intact and was his/her own resident representative (RP). On 6/17/24 at 2:53 PM, Resident #22 was interviewed regarding hospitalizations. The resident reported that s/he was hospitalized early this year and did not get any written notification regarding the transfer. A review of Resident #22's medical record on 6/20/24 at 10:40 AM, revealed that s/he was hospitalized on [DATE]. A transfer form was documented by a Registered Nurse (RN Staff #43) that indicated the resident was observed with slurred speech and was unable to hold things with his/her hand, and the attending physician decided to transfer the resident to the hospital. On 6/21/24 at 11:02 AM, the Director of Nursing (DON) was interviewed and reported her expectations from the nursing staff when a resident was ordered to be transferred out. The DON also reported that the nursing department does not do anything regarding the bed hold policy and was not aware of the transfer notifications, she indicated that the Unit Managers (UM) would know more about these requirements. On the same day at 12:10 PM, the UM (Staff #13) for the long-term care unit was interviewed and enumerated the documents that the nursing staff prepares for a resident transfer. Staff #13 reported that they do a verbal notification to the resident and/or RP, and the Nursing Home Administrator (NHA) sends the written notification and bed hold afterwards. The NHA was interviewed on 6/21/24 at 2:19 PM. The NHA reported that he keeps a copy of the envelopes that he sends out a day after a resident was transferred but that the envelopes only contained the bed hold policy. The NHA indicated that he would look for written notice of transfers for the resident and RP. Later at 3:24 PM, The NHA reported and confirmed that the facility was not sending notifications of transfers to residents and/or RP's. The NHA acknowledged that it was a concern that the facility would be addressing. 2) Review of complaint MD00168858 on 07/01/24 at 1 PM revealed an allegation that Resident #100 did not receive quality of care. Resident #100 was sent to the emergency room on [DATE] around 1 PM due to a change in condition. Further review of Resident #100's closed medical record failed to reveal that Resident #100 nor Resident #100's representative was notified in writing of the reasons for the transfer to the hospital. In an interview with the facility assistant director of nurses (ADON) on 07/02/24 at 11:30 AM, the ADON stated that the staff were unable to determine what documents were sent with Resident #100 or to the family after being sent to the hospital on [DATE].

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 F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

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 to an acute care facility. This was evident for 1 (#107) of 11 residents reviewed for neglect. The findings include: A medical record review completed on 7/3/24 at 12:10 PM showed that Resident #107 was admitted to the facility in July 2023. A continued review found a nurse's note, dated 8/21/23, indicating that Resident #107 had a change in condition. The attending provider was notified and gave an order for Resident #107 to be transferred to the emergency room for evaluation. Further review showed that Resident #107's representative was in the facility at the time of the transfer. However, the review failed to show that a copy of the facility's bed hold policy was given to the Resident's representative. In an interview on 7/3/24 at 2:21 PM, the nursing home administrator said he started mailing out the facility's bed hold policy to residents' representatives in March 2024. This means Resident #107's representative was not notified in writing of the facility's bed hold policy when he was transferred to an acute hospital in August 2023.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days following a significant decline in residents' conditions. This was evident for 2 (#37, #4) of 3 residents reviewed for hospice. 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. The nursing home should complete a Significant Change in Status MDS assessment within 14 days when there's a major decline or improvement in a resident's status. 1) A medical record review on 6/17/24 at 1:46 PM showed that Resident #37 was admitted to the facility in June 2020 with diagnoses including stroke with one-sided weakness. Further record review contained an attending provider's order, dated 2/13/24, that stated that Resident #37 was admitted to hospice care with an effective date of 2/13/24. The review also found a Significant Change in Status MDS assessment, dated 2/23/24. The MDS assessment was completed and signed in sections Z0500B & V0200B2 on 3/5/24, 22 days after admission to hospice care and eight days late. In an interview on 6/18/24 at 2:52 PM, staff #9 reported that a Significant Change in Status MDS assessment should be completed within 14 days of noticing a decline in a resident's condition. However, Resident #37's Significant Change in Status MDS assessment, dated 2/23/24, was completed 22 days after he/she was admitted to hospice care. In a subsequent interview on 6/26/24 at approximately 8:55 AM, staff #9 confirmed that Resident #37's Significant Change in Status MDS assessment, dated 2/23/24, was completed late. 2) A medical record review on 6/17/24 at 3:47 PM, showed that Resident #4 had been residing in the facility since June 2013. Continued review found an attending provider's order that stated that Resident #4 was admitted to hospice care effective 5/1/24. Further review contained a Significant Change in Status MDS assessment for Resident #4 dated 5/15/24, completed and signed in sections Z0500B & V0200B2 on 5/24/24, 24 days after admission to hospice care and ten days late. In an interview on 6/18/24 at 2:55 PM, staff #9, an MDS coordinator stated that she completed a Significant Change in Status MDS assessment 14 days after learning about a resident's admission to hospice and not within 14 days of the start of hospice care. In a subsequent interview on 6/26/24 at 8:47 AM, staff #9 confirmed that Resident #4's Significant Change in Status MDS assessment dated [DATE] was completed late.

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

Read full inspector narrative →

Based on record review and interviews, it was determined that the facility failed to ensure that a resident who required assistance with Activities of Daily Living (ADL) was provided with showers. This was evident for 1 (#102) of 4 residents reviewed for ADL. The findings include: The MDS (Minimum Data Set) is a complete assessment of the Resident, which provides the facility with the information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. Medical record review on 7/1/24 at 2:09 PM showed that Resident #102 was admitted to the facility in June 2021 with diagnoses that included a right hip fracture post-surgery. A continued review found an MDS assessment, dated 6/24/21, which documented that Resident #102 had intact cognitive status and required extensive assistance from staff with transfers and bathing. A review of complaint record #MD00169826, on 7/1/24 at 2:09 PM for Resident #102, noted that the Resident had only one shower on 7/6/21 for his/her entire stay in the facility from 6/17/21 to 7/9/21. A subsequent review of the Geriatric Nursing Assistant ADL documentation for Resident #102 from June 17 to July 9, 2021, was done on 7/2/24 at 1:27 PM. The review found a record of bed baths on 6/24, 6/28, 7/1, 7/5, 7/8, and one shower on 7/6/21. Staff had documented N/A (not applicable) on 6/21; the remaining days were left blank. During an interview on 7/2/24 at approximately 1:35 PM with staff #8, the assistant director of nursing (ADON) confirmed that Resident #102 received bed baths from staff on 6/24/21, 6/28/21, 7/1/21, 7/5/21, 7/8/21 and one shower on 7/7/21. In a subsequent interview on 7/2/24 at 4:12 PM, the ADON revealed that Resident #102 was scheduled to have showers twice weekly on Mondays and Thursdays, and that he/she should have received six showers during his/her stay and bed baths on the non-shower days. However, the documentation revealed that the Resident only received one shower and five bed-baths for his/her entire stay in the facility.

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

Read full inspector narrative →

Based on medical record review and interview, it was determined that the facility failed to ensure that an order for a hospice consult was acted upon. This was found to be evident for one (#83) of 2 residents reviewed for death. The findings include: On 6/20/24, review of Resident #83's medical record revealed the resident had resided at the facility for several years. On 5/22/24 at 4:31 PM, an order for a Hospice Consult and evaluation was placed in the medical record. The resident passed away on 5/26/24. Hospice care includes a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members. Further review of the medical record failed to reveal documentation to indicate the hospice referral was addressed with the resident or the resident's family after the initial order was put in place. No documentation was found to indicate that a hospice provider was contacted regarding this consult order. On 7/9/24 at 4:31 PM, the Assistant Director of Nursing (Staff #8) reported that a Hospice consult is reviewed by the interdisciplinary team and then social service will spearhead by calling the hospice, based on what the family chooses. Surveyor then reviewed the concern that there was an order for hospice on 5/22/24 and their was no documentation in the medical record to indicate that social services addressed the issue with the resident or the family prior to the resident's expiration on 5/26/24. As of time of survey exit on 7/11/24 at 3:30 PM, no additional documentation, or other information, was provided regarding the failure to address the hospice consult order.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, closed medical record, complaint and pertinent documentation review and staff interviews, it was determined that the facility staff 1) failed to store oxygen cylinder tanks securely. This was evident for 1 of 2 nursing units observed 1) Compressed Oxygen Cylinders, also known as oxygen tanks, store pressurized oxygen and need to be secured to prevent them from tipping over and becoming damaged. If the valve on the oxygen tank broke off, causing a leak, the oxygen tank could become a flying projectile. On 6/24/24 at 10:00 AM, during an observation of Unit 2's nursing station, 2 surveyors observed an unsecured oxygen cylinder leaning against a counter in the left, back corner of the nurse's station. The Assistant Director of Nurses (ADON), Staff #8, was on the unit and was immediately shown the unsecured oxygen cylinder. At that time, the ADON confirmed the findings and indicated she would make sure the oxygen tank was secured.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

2) Resident #72 was a newly admitted resident of the facility. During an interview on 6/18/24 at 11:47 AM, the resident indicated that s/he had lost a lot of weight and stated, I don't want to lose anymore because I feel like I will get sicker if that happens. On 6/20/24 at 9:52 AM, Resident #72's medical records were reviewed and revealed his weight was 138.8 lbs. taken on 5/13/24 and 131 lbs. taken on 6/4/24 which was a 5.62% weight loss in 22 days. Further review of the resident's medical record revealed a note from a dietician (Staff #48) with an effective date of 6/4/24 at 11:10 AM that indicated a weight warning and requested a reweight for the resident to confirm the weight loss. However, there was no evidence that the resident was reweighed, nor any change in the resident's dietary orders. On 6/21/24 at 1:15 PM, the Registered Dietician (Staff #49) was interviewed and reported that Staff #48 no longer worked for the facility. Staff #49 explained her process on monitoring the residents' weights and indicated that she runs a report to generate a list of residents with significant weight loss. Staff #49 was asked to review the note of Staff #48 on 6/4/24 for Resident #72 and was asked if there was any follow up done for the resident. Staff #49 reviewed the note and Resident #72's medical records and confirmed that the resident had a significant weight loss, reweight was not done, and that she was not aware that the resident needed to be followed up on and stated, His/Her name is not on our list. Staff #49 reported that she did the resident's admission evaluation and put the resident in a dietary program to increase weight but was not aware of Staff #48's note. On 6/21/24 at 2:44 PM, the concern was discussed with the Nursing Home Administrator (NHA) that Resident #72 had a significant weight loss since admission and was noted by Staff #48. However, the facility staff failed to act upon the request for reweight and Staff #49 failed to follow up on Resident #72's significant weight loss. The NHA acknowledged the concern. On 6/24/24 at 9:24 AM, Resident #72's medical records were again reviewed and revealed a progress note from Staff #49 with an effective date of 6/21/24 at 11:07 PM, indicating nutrition order changes that included further increase in the resident's dietary intake and weekly weights to monitor nutritional status with diet change. Based on records review and interviews, it was determined that the facility failed to have an effective system in place to monitor and address a resident's significant weight loss. This was evident for 1 (#1, #72) of 4 residents reviewed for nutrition. The findings include: 1) On 6/17/24 at 2:15 PM, Resident #1, a long-term resident at the facility was interviewed. During the interview s/he reported that s/he had recently lost wight. On 6/20/24, review of Residents #1's medical record, under the category weights, revealed the following: 6/8/2024 11:41 103.8 Lbs. 6/7/2024 15:05 97.4 Lbs. 6/4/2024 10:15 99.8 Lbs. 5/24/2024 13:41 104.2 Lbs. 4/7/2024 21:55 124.4 Lbs. 3/1/2024 16:10 124.0 Lbs. On 6/20/24 at 8:48 AM, a dietician's note, dated 5/24/24, written by Dietician staff #15, was reviewed. The review revealed that dietitian Staff #15 recognized and documented a significant weight loss warning for Resident #1.The weight documented on 5/24/24 indicated a 16 percent weight loss in 47 days. Staff # 15 requested a re-weigh to verify the weight change. On 6/20/24, review of Resident #1 documented weights revealed that the resident was not re-weighed until 6/4/2024. Review of the re-weight revealed the resident had lost an additional 4% in body weight. On 6/20/24 at 11:04 AM, Registered Dietician staff # 15 was interviewed. During the interview, he reported that he does not receive notification of a resident's weight loss or when a re-weight is completed. To obtain weight loss and re-weight information he needs to go into the Electronic Health Record and review a weight loss report. Dietician#15 failed to explain why the re-weight for Resident #1 was done 13 days after the re-weight was requested.

CONCERN (D) 📢 Someone Reported This

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

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

2) A gastrostomy (g-tube) feeding tube is placed into the stomach through an opening in the stomach wall. If one cannot eat or drink all the nutrients they need, liquids such as formula, fluids, and medicines are put through the g-tube tube. A review of complaint Intake #MD00196871 on 7/3/24 at 12:10 PM indicated that Resident #107's g-tube site was leaking all over the place. Continued record review showed that Resident #107 was admitted to the facility in July 2023 with diagnoses including Dementia and a history of stroke with one-sided weakness. The review also found an attending provider's order for Resident #107 for g-tube feedings with Jevity 1.5 formula; however, the review failed to show a plan of care to address the care of the gastrostomy tube site, including measures to prevent complications. In an interview on 7/3/24 at 12:15 PM, the assistant director of nursing (ADON) stated that, for every resident with a g-tube feeding tube, the nurses were expected to obtain orders from the attending provider for the management and care of the g-tube site. The ADON added that the nurses would usually document the g-tube site care in the medication administration record or treatment administration record and the progress notes. However, earlier record reviews failed to show that Resident #107's g-tube insertion site was being examined and cleaned daily to prevent, identify, and treat possible skin irritation. During an interview on 7/3/24 at 1:09 PM, staff #5, a Divisional Director of Quality assurance, stated that there was no documentation to show that the nurses provided treatment and care to Resident #107's g-tube site. Based on record review and interviews, it was determined that the facility 1) failed to provide appropriate treatment and services to a resident receiving gastrostomy tube (g-tube) feedings and 2) failed to develop and implement a care plan that addressed the care and maintenance of a resident with a feeding tube. This was evident for 1 (#73) of 1 residents reviewed for tube feeding, and 1 (#107) of 11 residents reviewed for neglect. The findings include: Enteral feeding (tube feeding) is the delivery of nutrients through a feeding tube directly into the stomach or the small intestine. A gastrostomy tube (g-tube) is a feeding tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube. Bolus feeding is the administration of a limited volume of enteral formula over brief periods of time. There are risks associated with residents using feeding tubes for nutrition which include aspiration (accidentally inhaling your stomach contents), accidental dislodgement (tube moving out of place or coming out), bleeding and perforation (hole in the wall of your bowel or intestine), infection near the site, pain, and stomach leakage to name some. Appropriate treatment and services are required to prevent complications of enteral feeding. 1) On 6/26/24 at 10:00 AM, a review of Resident #73's medical record revealed documentation that the resident was admitted to the facility in early May 2024 with diagnoses which included dysphagia (difficulty swallowing) following cerebral infarction (stroke) and the resident received enteral feedings through a g-tube for nutritional support. Review of Resident #73's physician orders revealed a 5/8/24 order for strict aspiration precautions every shift, a 5/8/24 order, Is the head of bed elevated to prevent SOB (shortness of breath) while lying flat?, a 5/20/24 enteral feed order 4 times a day, bolus feed on Glucerna 1.5, 1 can (237 ml) via PEG/g-tube, 4 times in 24 hours for a total of 948 ml formula, and a 6/1/24 enteral feed order to flush tube with 125 ml (milliliters) water before and after each bolus feeding to provide additional 100 ml (total of 1729ml including tube feeding). Continuous review of Resident #73's medical record failed to physician orders related to the care and maintenance of the resident's g-tube. No documentation was found to indicate that the g-tube insertion site was examined and cleaned daily, or that the feeding tube placement was routinely monitored. No documentation was found to indicate that before beginning a feeding or administering medication, staff routinely assessed the resident for g-tube functioning or gastrointestinal intolerance such as for checking for residual and no order was found to indicate when to hold the feeding based on amount of residual. No physician order was found to indicate the volume of fluid to flush the feeding tube before and after each medication administration, and no documentation found to indicate the feeding tube was being flushed, along with the the fluid volume, before and after each medication administration. In addition, though there was an order for strict aspiration precautions, and an order indicating the head of the bed was to be elevated to prevent SOB, there was no documentation to indicate positioning of the resident before and after administration of the tube feeding. 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. Review of Resident #73's care plans revealed a care plan initiated by the dietician, [Resident #73] is at high nutr (nutritional) risk related to overweight w/ comorbidity (having 2 or more diseases at the same time), TF (tube feeding) at risk for aspiration, skin breakdown risk r/t impaired mobility & therapeutic diet needs. Will follow SLP's (speech therapy) recommendations & monitor nutr status for changes in interventions, with the goals, no s/s (signs/symptoms) TF intolerances, and able to maintain wt (weight) with no sig (significant) wt changes that had the interventions, 1) aspiration precautions, 2) follow recommendations from SLP, 3) monitor labs and wt, 4) monitor s/s TF intolerances, 5) provide diet as ordered, and 6) Provide TF and flushes as ordered The care plan addressed Resident #73's enteral nutritional needs; however, the care plan interventions did not address the care and maintenance of a resident with a feeding tube. Continuous review of the resident's care plans failed to reveal evidence that a comprehensive care plan had been developed and implemented that addressed the care and maintenance of a resident with a feeding tube with resident centered interventions such as g-tube site care and resident positioning, interventions to prevent complications from the tube feeding and resident centered interventions to minimize the negative psychosocial impact that may occur as a result of the tube feeding, A review of the facility's policy Care and Treatment of Feeding Tubes, with a reviewed/revised date of 1/1/24 revealed the policy: It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible, Following the policy statement was the statement, Policy Explanation and Compliance Guidelines, which listed 13 steps or guidelines which included but were not limited to: #3. The resident's plan of care will address the use of feeding tube, including strategies to prevent complications. #6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding is in the right location, a) tube placement will be verified before beginning a feeding and before administering medications, b) the enteral retention device will be check daily to assure it is properly approximated to the abdominal wall and that the surround skin is intact. #7. Direction for staff on how to provide the following care will be provided: a. how to secure a feeding tube externally, b. the importance of, and frequency of providing personal, skin, oral and nasal care to the resident, c. examination and cleaning of the insertion site in order to identify, lessen or resolve possible skin irritation and local infection, e. frequency of and volume used for flushing, including flushing for medication administration and what to do when a prescriber's order does not specify #8. Direction for staff regarding the conditions and circumstances under which a tube is to be changed will be provided . #11. Psychosocial factors will be considered and addressed in the resident's plan of care to minimize the negative psychosocial impact that may occur as a result of the tube feeding. On 6/24/24 at 12:30 PM, the Director of Nurses (DON) was made aware of the above concerns related to the monitoring, care and maintenance of Resident #73's feeding tube. The DON was made that that there was a care plan that addressed the resident's nutritional needs, however, a care plan with interventions that addressed the care and maintenance Resident #73's feeding tube had not been found in the medical record. The DON acknowledged the concerns at that time, and then on 6/27/24 at 12:50 PM, the DON provided the surveyor with a copy of the nutrition care plan for Resident #73 and stated that the care plan interventions were also nursing interventions.

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 F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and staff interviews, it was determined that the facility staff failed to effectively manage a resident's pain. This was evident for 1 (#102) of 2 residents reviewed for pain management. The findings include: A review of Resident #102's medical record on 7/1/24 at 2:09 PM showed that the Resident was admitted to the facility in June 2021 with diagnoses including a right hip fracture post-surgery and was able to communicate needs verbally. A continued review found a discharge medication list from the hospital for Resident #102, which included an opioid medication to be taken every six hours as needed for severe pain. A review of complaint record #MD00169826 on 7/1/24 at approximately 2:15 PM showed that Resident #102 arrived at the facility after midnight on the day of admission, had critical pain but had to wait for more than 4 hours to have his/her pain managed by the staff. Further record review, on 7/1/24 at 2:29 PM, found an attending provider's progress note, dated 6/17/21, that stated that Resident #102 complained of severe pain to the right lower extremity and was given Tylenol, which did not provide pain relief. The progress notes continued to state that Resident #102's doctors sent in RX-[RX-prescription] to the facility upon discharge, but [he/she] has not received any Oxycodone since admission and has complained to the staff. Per nursing staff, overnight team did not find Rx for Oxycodone from the hospital team. Upon reviewing the discharge records myself, Rx found Oxycodone. Nursing informed and issues escalated to the IDT (IDT-interdisciplinary team). A subsequent record review on 7/2/24 at 10:31 AM found a care plan for pain initiated on 6/17/2021 for Resident #102. The interventions on the care plan included but were not limited to Encourage/Assist to reposition frequently to position for comfort. Continued review showed an attending provider's order initiated on 6/17/21 for opioid medication, one tablet every 4 hours as needed for moderate pain and two tablets every 4 hours as needed for severe pain. Further review of Resident #102's medication administration record for June 2021 showed that he/she had received one tablet of opioid medication on 6/7/21 at 09.30 AM for a pain level of 5 and post-medication assessment that stated effective. The Resident also received another tablet of the opioid medication on the same day at 01:34 PM for a pain level of 5, and the post-medication assessment stated: effective. A pain scale/level ranges from 0 to 10; 0 means no pain, and 10 means the worst pain. It is used to assess a patient's level of pain so that better treatment can be provided. The review failed to show that Resident #102 received pain management for complaints of severe pain and whether a follow-up pain level was assessed to help manage the pain effectively or that a non-pharmacological intervention was implemented (non-pharmacological pain management is an intervention without medications). In an interview on 7/2/24 at 11:40 AM, staff #13, a unit manager, reported that the process for obtaining an opioid medication to manage a new resident's pain was to fax the prescription to the facility's pharmacy and then get the pain medication from the facility's back up medication box. However, an earlier record review failed to show that Resident #102 received pain management for his/her severe pain until 9.30 AM on 6/7/21. An interview with staff #8, the assistant director of nursing, on 7/2/24 at 1:36 PM showed that the nurses were supposed to assess and document the Resident's pain level before and after administering pain medication to ensure effective pain management.

CONCERN (D)

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

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and pertinent documents, it was determined that the facility failed to provide Physician/Nurse Practitioner services to the resident at least once every 60 days. This was evident for 1 (#53) of 4 Resident reviewed for dental during a survey. The findings include: On 6/18/24 at 11:40 AM, Resident #53, a long-term care (LTC) resident, was interviewed. During the interview resident #53 reported a concern regarding how frequently s/he sees a physician. On 6/21/24 at 6:57 AM, a review of progress notes from 11/22/23 to 3/8/23, failed to reveal documentation that a Physician or Nurse Practitioner (NP), visited Resident #53. On 6/21/24 at 7:46 AM, the Director of Nursing (DON) was interviewed regarding the required visit frequency of a NP or physician for a long-term resident. The DON reported that, once a resident has been at the facility for 90 days there is normally an order for a physician visit every 60 days for a LTC resident. On 6/21/24 at 8:07 AM, during a second interview with the DON, she failed to provide any handwritten physician visit notes for Resident # 53 from 11/22/23 to 3/8/23. She confirmed there were no progress notes documented of a provider visit from 11/22/23 to 3/8/23.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, medical record review and interview, it was determined that the facility failed to ensure the accurate documentation and accounting of a controlled medication. This was found to be evident for 1 of 2 medication carts reviewed during the survey. The findings include: Review of Resident #138's medical record, on 7/3/24 at approximately 2:00 PM, revealed an order that was in effect since 6/28/24 for Lacosamide Oral Solution 100 mg/10 ml Give 20 ml via g-tube two times a day for seizure for 30 days. Lacosamide, also known as Vimpat, is an anticonvulsant medication. It is classified as a schedule 5 controlled substance. Review of the Controlled Substance Administration & Accountability policy, with a revision date of 12/1/23, included: 3. Ordering and Receiving Controlled Substances: e. The medications delivered are immediately recorded on the appropriate drug disposition record and stored in the controlled drug storage area by the nurse accepting delivery. On 7/3/24, review of the Medication Administration Record (MAR) revealed documentation that Lacosamide was administered to the resident on nine occasions since 6/28/24. The medication was not administered when due on 7/1/24 with a documentation of 9, indicating see nurse's note. Review of the corresponding nursing note revealed: Med on transit from pharmacy. On 7/3/24 at 1:08 PM, review of one of the two medication carts on the skilled unit, with nurse (Staff #12), revealed a bottle of lacosamide oral solution with a label indicating it was for Resident #138. Review of the Controlled Mediation Utilization Record (Control Sheet) that Nurse (#12) indicated corresponded to the lacosamide, failed to include the name of the medication or the name of a resident. This Contol Sheet included documentation of a total of two doses, the removal of one dose on 7/2/24 and the second dose on 7/3/24. Both of these doses were documented as removed by nurse (Staff #12). On 7/3/24 at approximately 1:10 PM, the nurse (Staff #12) reported that the Lacosamide medication was brought in by the family and confirmed it was not delivered or provided by the facility's pharmacy. Nurse (Staff #12) also stated that she had called the pharmacy and it still was not delivered. Further review of the medical record revealed that the original Lacosamide order was discontinued on 7/3/24 at 12:53 AM, with a new order put in place to start on 7/3/24 at 9:00 AM, that included May administer medication from [name of pharmacy (#42)] pharmacy until [name of facility's pharmacy (#41)]Pharmacy delivers. On 7/3/24 at 2:04 PM the unit nurse manager (Staff #14) provided surveyor a copy the Control Sheet which had been updated. This updated sheet revealed the following was hand written in: [Name of Resident #138] Lacosamide Oral Solution Give 20 ml by g-tube 2 times a day. This form failed to include the strength of the medication or the total amount that was originally distributed. On 7/3/24 review of the Unavailable Medications policy, with a revision date of 1/1/24, revealed: 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication.; b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold.; c. Determine whether resident has home supply. Only obtain and use medications that are packaged without evidence of tampering and are labeled with the resident's name, medication name and strength, route, and directions for use. The label should match the physician order. Further review of the medical record failed to reveal documentation to indicate the primary care provider was made aware that the facility's pharmacy had not provided the ordered medication prior to the updated order on 7/3/24. On 7/3/24 at 2:29 PM the [NAME] President of Clinical Operations (Staff #20) reported she was aware of the issue regarding a bottle of Vimpat with no information on the narcotic sheet [Controlled Medication Utilization Record]. Staff #20 went on to report that the the Director of Nursing (DON) was currently investigation the issue and that the nurse was reporting the family brought it in on Friday (6/28/24). On 7/8/24 at 11:16 AM the DON reported that the employees were unaware that the Vimpat was a narcotic (i.e. a controlled substance) and were not aware that it came from home. She went on to report that they have educated the staff to check the electronic health record system to determine what type of medication it is, stating that when entered, or signed, a C will come up to indicate the medication is a controlled substance. The DON also reported that the facility pharmacy has since supplied the medication. And confirmed that the family had brought the previous supply in to the facility directly from the [name of pharmacy (#42)]. Review of the Narcotic and Controlled Substance Shift-To-Shift Count Sheets revealed the following statement: All resident supply AND emergency supply controlled substances must be counted at every shift change. Review of the Shift-To-Shift Count Sheets revealed documentation that two nurses completed the count of the controlled substances at each of the shift changes from 6/28/24 through 7/3/24. During the 7/8/24 interview with the DON, the surveyor reviewed the concern that multiple staff had conducted the Shift-To-Shift Count, but had not identified or addressed the issue with the Vimpat. The DON acknowledged the concern. The DON provided documentation of education that had been provided since this issue was identified on 7/3/24 as well as an updated policy regarding Unavailable Medications. Review of the Unavailable Medications policy, with a revision date of 7/5/24, revealed it was updated and now included: 4.c. Determine whether resident has home supply. Obtain orders to use home supply. Administer first dose after the medication is determined to be in the original dispensed packaging that is not tampered with, labeling includes the resident's name, name of medication, and instructions for administration. If a controlled substance, a countdown sheet will be added to the facility's method of controlled substance documentation records.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review and staff interview, it was determined that the facility 1) failed to ensure that psychotropic medication was prescribed as needed (PRN), had an end date, and 2) failed to ensure that a resident who received psychotropic medication was monitored for behaviors and side effects. This was evident for 1 (#35, #64) of 5 residents reviewed for unnecessary medications. The findings include: 1) As needed (PRN) orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the extended PRN order. On 6/20/24, the records of Resident #35, a long-term resident of the facility, were reviewed. Review of Residents # 35's physicians orders revealed an order for Lorazepam, oral concentration 2mg/ml. Give 0.2ml by mouth, every 6 hours, as needed for anxiety. The order for Lorazepam had a start date of 8/17/23. Continued review revealed that the order was not limited to 14 days and did not have a discontinuation date. Review of the medical record failed to reveal that the physician documented a rational for continuing the order beyond 14 days. On 6/20/24 at 10:18 AM, the monthly pharmacy medications reviews from June 2023 through 6/17/24 were reviewed. The review revealed the following: on 9/7/23, 1/5/24 and 3/7/24, the pharmacist noticed the same irregularities and reported the irregularities along with his recommendations to the physician via a document titled, Note to Attending Physician/Prescriber. On 6/20/24, the facility provided the above-mentioned document: Note to Attending Physician/Prescriber for 9/7/23, 1/5/23 and 3/7/24. Further review of these documents revealed that the pharmacist determined that Resident #35 had an order for PRN Lorazepam without a stop date and there was a 14-day limitation on all PRN orders. After this period, a PRN psychotropic order may be extended beyond 14 days, if the provider documented the appropriateness of the extension and provided a specific duration of use. On 6/21/2004, a review of the Note to Attending Physician/Prescriber revealed a space for the physician to document his response to the pharmacist recommendations. Further review of the physician's response revealed that he maintained the Lorazepam order. It was prescribed as needed without a stop date, not limited to 14 days. Additional review failed to reveal that the physician documented a rational for continuing the order beyond 14 days in his written response to the pharmacist's recommendations dated 9/7/23, 1/5/24 and 3/7/24. On 6/25/24 at 8:38 AM, the pharmacy recommendations and the Physicians response provided in the Note to Attending Physician/Prescriber were discussed with the administrator. He reported he understood the concern and did not have any additional comments. 2) On 6/20/24 at 12:30 PM, a review of Resident #64's medical record revealed that Resident #64 was admitted to the facility towards the end of April 2024, transferred to an acute care facility on 5/1/24, then readmitted in late May 2024 with diagnoses which included depression. Review of Resident #64's June 2024 MAR revealed a 5/22/24 order for Mirtazapine (Remeron) (antidepressant) tablet by mouth at bedtime for depression that was documented as given every day as ordered from 6/1/24 - 6/19/24. Continued review of the resident's medical record failed to reveal evidence that the facility staff monitored Resident #64 for changes in behaviors that necessitated the use of the psychotropic medications or for side effects related to the use of psychotropic medication. The record also failed to reveal that the facility conducted ongoing monitoring of the resident for resident specific behaviors for which the antidepressant had been prescribed and failed to monitor for side effects. In addition, continued review of Resident #64's care plans failed to reveal a care plan that addressed the resident's use of Remeron or the behaviors for which the antidepressant had been prescribed. The above concerns were discussed with the Director of Nurses (DON) on 6/21/24 at 11:02 AM. The DON acknowledged the concerns at that time, and stated the concerns with failing to monitor residents receiving psychotropic medications for behavior, was recently identified, brought to the company's attention, and she wasn't sure they had gotten to Resident #64 yet.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

2) On 6/24/24 at 9:21 AM, during an observation of medication administration, the surveyor observed Staff #12, LPN (licensed practical nurse) dispense 2 pills into a medication cup and administer the pills to Resident #34. One of the pills dispensed and administered was multi-vitamin (MVI) with minerals. Following the medication observation, a review of Resident #34's June 2024 Medication Administration Record (MAR) revealed a 2/12/23 physician's order for Multivitamin Oral Tablet (multiple vitamin), give 1 tablet by mouth one time a day for supplement which was documented as given at 9:00 AM on 6/24/24. Resident #34's physician order was for a multi-vitamin that did not include minerals. The medication administered to the resident contained minerals and was not the same formula as ordered by the physician. The Director of Nurses was made aware of the above findings on 6/24/24 at 2:25 PM and offered no comments at that time. On 6/24/24 at 2:29 PM, Staff #12 was made aware that a medication error occurred when the nurse failed to follow the physician's order to administer one multi-vitamin tablet by mouth and instead administered a multi-vitamin with minerals tablet to Resident #34. Staff #12 acknowledged the concerns at that time, and indicated the multi-vitamins were a stocked item and the stock medication provider would be notified and asked to provide multi-vitamins without minerals. Based on observation, medical record review and interview, it was determined the facility failed to maintain a medication error rate of less than 5%. This was found to be evident based on 2 errors identified out of 26 opportunities for error. The findings include: 1) On 6/20/24 at 8:55 AM, surveyor observed nurse (Staff #35) prepare and administer Resident #36's medications. The nurse prepared a total of 10 medications, two of which were lidocaine patches. The nurse was observed applying one lidocaine patch to the resident's right knee and one lidocaine patch to the left knee. No other lidocaine patches were observed being administered at this time. After the administration, the nurse confirmed she signed off a total of 10 medications, stating there were two separate orders for the two lidocaine patches. On 6/20/24 at 10:09 AM review of the medical record revealed there was one order, with a start date of 1/30/24, for Lidoderm Patch 5% apply to both knees, R.[right] thigh/groin topically one time a day for pain management and remove per schedule. There was another order for a Lidoderm Patch, but this order, dated 1/11/24, was for Lidoderm Patch 5% apply to left lower back topically one time a day for pain management. Review of the Medication Administration Record (MAR) revealed one area for staff to document the administration of the patches to the knees and the right groin area (one sign off for all three ordered patches) and one area to document the patch to the left lower back. Nurse (Staff #35) had documented in both these areas, indicating she had administered the patches to the knees as well as one to the left lower back, when due at 9:00 AM on 6/20/24. On 6/20/24 at 10:35 AM, when asked about any other lidoderm patches for Resident #36, Nurse (Staff #35) indicated the resident had an as needed order for one on his/her back. The nurse confirmed she did not apply the patch to the resident's back today, stating: [s/he] did not ask. The surveyor then reviewed the concern with the nurse that the order does not indicate it was a prn [as needed] order and that the nurse had documented that she applied the patch to the back as ordered. On 6/21/24 at 11:33 AM, the surveyor reviewed with the Director of Nursing the medication error of failure to administer the lidocaine patch to the resident's back as ordered.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, it was determined the facility failed to ensure a resident was free from a significant medication error. This was found to be evident for 1 (#36) of 26 residents observed for medication administration. The findings include: Review of Resident #36's medical record revealed that the resident was admitted in 2023 and whose diagnosis included, but was not limited to, rheumatoid arthritis. Review of the 1/10/24 physician progress note revealed an assessment of left back pain and a plan to order lidocaine 5% to left lower back. A corresponding order, dated 1/11/24 for Lidoderm Patch 5% apply to left lower back topically one time a day for pain management was also found. On 6/20/24 at 8:55 AM, surveyor observed nurse (Staff #35) prepare and administer Resident #36's medications. The nurse prepared a total of 10 medications, two of which were lidocaine patches. The nurse was observed applying one lidocaine patch to the resident's right knee and one lidocaine patch to the left knee. No other lidocaine patches were observed being administered at [NAME] time. After the administration, the nurse confirmed she signed off a total of 10 medications, stating there were two separate orders for the two lidocaine patches. On 6/20/24 at 10:09 AM, review of the medical record revealed two current orders for lidoderm patches. There was one order, with a start date of 1/30/24, for Lidoderm Patch 5% apply to both knees, R.[right] thigh/groin topically one time a day for pain management and remove per schedule. The other order, for Lidoderm Patch 5% apply to left lower back topically one time a day for pain management was still in effect since originally ordered in January 2024. Review of the Medication Administration Record (MAR) revealed one area for staff to document the administration of the patches to the knees and the right groin area (one sign off for all three ordered patches) and one area to document the patch to the left lower back. Nurse (Staff #35) had documented in both these areas, indicating she had administered the patches to the knees as well as one to the left lower back, when due at 9:00 AM on 6/20/24. On 6/20/24 at 10:35 AM when asked about any other lidoderm patches for Resident #36, Nurse (Staff #35) indicated the resident had an as needed order for one on his/her back. The nurse confirmed she did not apply the patch to the resident's back today, stating: [s/he] did not ask. The surveyor then reviewed the concern with the nurse that the order does not indicate it is a prn [as needed] order and that the nurse had documented that she applied the patch to the back as ordered. On 6/21/24 at 11:33 AM surveyor reviewed the concern with the Director of Nursing (DON) regarding staff documenting the administration of a lidoderm patch to a resident that was not actually administered and the staff's report that the order was for it to be given as needed. The DON reported she has been told the staff was nervous when she reported that. Further review of the MAR revealed that staff had documented the administration of the lidoderm patch to the resident's back every morning from 6/1/24 thru 6/20/24. Nurse (Staff #35) documented the administration of the patch to the resident's back on 15 out of these 20 days.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to ensure medications were stored in accordance with acceptable professional standards. This was found to be evident on two out of two nursing units. The findings include: 1) On 6/20/24 beginning at 6:12 AM, an observation of the night shift medication pass was made. On 6/20/24 at 6:15 AM, an observation was made of med cart #1 on the first-floor nursing unit. Observation revealed a vile of insulin resting on top of the cart. On 6/20/24 at 6: 20 AM, an observation of medication cart #2 revealed 2 clear plastic bins laying on top of the medication cart. One of the plastic bins was labeled team 2 and the other one was labeled team1. Further observation revealed the bins contained Insulin medications, including vials and insulin pens. On 6/20/24 at 6:21 AM, LPN nurse Staff #10 was interviewed. During the interview Staff # 10 reported that the bins contained insulin, and they were separated by teams. After showing the surveyor the 2 bins (containing the insulin), she placed them back on top of the med cart. On 6/20/24 at 6:28 AM, an observation of Staff #10 was made. The observation revealed Staff #10 placing the 2 bins containing insulin on the top of medication cart 1 and then Staff #10 walked around the corner to medication cart #2 unlocked that cart, retrieved an item, and then locked the cart. Medication cart #1 was around the corner and out of sight of Staff #10 when she was located at medication cart #2. On 6/20/24 at 6:30 AM, an observation was made of staff #10 walking into room [ROOM NUMBER] and closing the door. Further observation revealed that the 2 bins of insulin remained on top of the medication cart unlocked, in the hallway. On 6/20/24 at 6:31 AM, a second observation was made of staff nurse #10 entering a resident's room while the 2 bins containing insulin remained of top of the medication cart #1 On 6/20/24 at 6:33 AM, an observation was made of Staff #10 leaving the medication cart #1 and walking down the hall with the Director of Nursing (DON) with her back towards the medication cart. On 6/20/24 at 6:34 AM, the surveyor and DON observed the medication cart #1and the 2 bins, containing insulins, on top of the cart. On 6/20/24 at 6:35 AM, during a brief interview, DON reported that it was not facility policy to leave medications of top of the medication cart, unlocked and unmonitored. On 6/20/24 at 6:36 AM, an observation was made of the DON instructing the nurse to maintain medications in a secure location for the safety of the residents. On 6/20/24 at 8:21AM, the DON provided the facility's Policy titled Medication Storage. Review of the policy revealed that all drugs and biologicals will be stored in locked compartments (i.e., medication carts cabinets, drawers, refrigerators, medications room) under proper temperature controls. 2) On 7/3/24 at 1:16 PM review of the long term care unit Team 1 medication cart with nurse (Staff #37) revealed a vial of ceftriaxone for Resident #68 with a date of 5/17/24. The nurse reported that it needed to be sent back to the pharmacy. Ceftriaxone is an antibiotic. After the observation review of the medical record confirmed that the resident had a one time only order for an injection of ceftiaxone on 5/17/24. 3) On 7/3/24 at 12:38 PM, observation of the medication storage room refrigerator, on the skilled unit with the unit nurse manager (Staff #14), revealed one levemir (insulin) pen with no resident name on it that the unit manager reported was brand new; one insulin lispro injection kwick pen, with a date of 5/31/24, but no resident name; and one Trulicity injectable with no resident name. 4) On 7/3/24 at 1:08 PM review of one of the two medication carts on the skilled unit, with nurse (Staff #12), revealed a Controlled Mediation Utilization Record (Control Sheet) that failed to include the name of the medication or the name of a resident. This sheet did include documentation of the removal of one dose on 7/2/24 and one dose on 7/3/24. Both of these doses were removed by nurse (Staff #12). When asked about this Control Sheet, Staff #12 showed surveyor a bottle of lacosamide oral solution with a label indicating it was for Resident #138. The nurse (Staff #12) reported this medication had been brought to the facility by the family. Lacosamide, also known as Vimpat, is an anticonvulsant medication. It is also classified as a schedule 5 controlled substance. Cross reference to F 755.

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interviews and pertinent document reviews, it was determined that the facility failed to provide a resident with dental services while he/she was a long-term resident at the facility. This was evident for 1 (#53) of 4 reviewed for dental during a survey. The findings include: On 6/17/24 at 12:05 PM, Resident # 53, a long-term resident of the facility, was interviewed. During the interview, S/he reported she had not been provided dental services during her stay at the facility. On 6/18/24 at 11:33 AM, a second interview was conducted with Resident # 53. S/he reported that s/he had purchased dental insurance offered to residents, while she was a resident at the facility. In addition, s/he reported s/he had requested dental appointments in the past, but had not seen a dentist since her admission to long-term care. On 6/20/24 at 3:57 PM, a review of the electronic medical records failed to reveal that Resident # 53 had a dental appointment while in the facility. On 6/21/24 at 7:50 AM, a review of orders for Resident #53 revealed an order with a start date of 6/17/24 Consults: Dental care as needed as needed. Continued review of Resident #53 previous or discontinued orders failed to reveal any order for dental consult prior to 6/17/24. On 7/09/24 at11:50 AM, during an interview with the Business Office Manager Staff #50, she reported that Resident $53 enrolled in the dental insurance coverage,on 2/10/23. Staff #50 confirmed that the dental provider provides dental services at the facility. 07/09/24 at 11:39 AM, the Administrator was interviewed regarding the dental services provided to the facility by an outside provider. During an interview, the administrator reported that the dental provider comes to the facility every 2 months to provide dental services to the resident. Once a resident enrolls in the dental coverage, they are placed on a schedule for visits. He reported this does include routine preventive examinations. In addition, he reported additional appointments would be made as needed. The administrator reported he would provide documentation of any dental appointments prior to June 2024. He did provide documentation that the resident was scheduled to receive dental services the next time the dentist visited the facility. On 7/11/24, the administrator failed to provide any documentation that the resident received any dental services while at the facility prior to the end of survey.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, record review, and interviews, it was determined that the facility 1) failed to ensure that a resident was served a meal according to a predetermined menu that incorporated the resident's preferences, and 2) failed to evaluate a resident prior developing a resident's therapeutic diet, resulting in the residents food preference not being considered. This was evident for 2 (#24, #57) of 4 residents reviewed for food during the survey. The findings include: 1) An observation made on 6/17/24 at 12:10 PM of Resident #24's untouched breakfast tray on his/her bedside table. It contained a bowl of oatmeal, three slices of toasted bread, three sausages, and scrambled eggs. The observation also noted a meal ticket on the tray that stated, standing orders-8oz [ounces] coffee, milk low fat. The resident said, I'm supposed to get milk and coffee with all my meals, but as you can see, I don't get it. A medical record review on 6/17/24 at 12:12 PM showed that Resident #24 was admitted to the facility in July 2022, alert, oriented, and able to communicate needs verbally. During an interview on 6/17/24 at 12:15 PM, staff #31, a geriatric nurse aid, reported that there was no milk when she brought Resident #24's breakfast tray to him/her. Staff #31 stated that the kitchen had said they were out of milk and did not have a cup for the resident's coffee. In an interview on 6/26/24 at 12:00 PM, staff #32, a corporate food service manager stated that standing order on the menu ticket meant that the resident should receive those food items for every meal. However, an earlier observation failed to show that Resident #24 received coffee and milk on his breakfast tray on 6/17/24. In a subsequent interview on 6/26/24 at 12:59 PM, staff #32 stated that he could not answer why Resident #24 had no coffee or milk on his/her breakfast tray on 6/17/24. 2) On 6/17/24 at 3:01 PM, Resident #57, a long-term resident of the facility was interviewed. S/he reported that S/he is served puree food and is not sure why. He was told he had a swallowing issue but reported he had never had swallowing issues in the past. On 6/21/24 at 10:12 AM, a review of Resident #57 physician orders dated 2/20/24, revealed that the resident was on a regular diet with Puree texture. On 6/26/24 at 10:58 AM, The supervisor Speech Therapist (SLP) Staff #21 was interviewed regarding procedure to downgrade a diet. She reported that a nurse or physician can downgrade a diet for safety reasons. For example, a nurse can put a resident on a puree diet that had previously been on a regular diet. After a Residents diet is downgraded to puree, a referral is made to the SPT indicating that a diet is downgraded. The SPT would then complete an evaluation to determine the proper diet consistency. The SPT recommendations then would have been forwarded to the physician. On 6/26/24 at 11:05 AM, continued interview with Staff #12 regarding the resident's discharge summary, from a hospital stay Feburary 2024, documentation revealed that the Resident # 57 was Dysphagia for solid. Staff # 21 reported that if a resident is discharged with that documentation SLP would still need to complete an evaluation to determine the texture diet the resident would continue with at the facility. On 7/10/24 at 11:07 AM, Phone interview with remote Dietician Staff #15. He reported that he had worked remotely and his contact with the Resident #57 was via phone. He reported that he did evaluate Resident #57 prior to his diet recommendation. He reported his evaluation included a chart review, speaking with the nursing staff and speaking with the resident for about 2-3 minutes. He reported he did not speak to the SLP but reviewed documentation in the resident's chart. He reported he did not review any swallow evaluation for Resident #57. On 6/20/24 the facility provided Resident#57 most recent speech therapy swallowing evaluation. Review of the evaluation revealed that the resident's clinical bedside assessment of swallowing dated 8/31/23 documented that resident was assessed for a regular texture, mechanical soft. Chopped textures. The facility failed to provide a speech therapy swallowing evaluation after Resident #57 diet was downgraded on On 7/10/24 at 12:30 PM, The above concerns were shared with the administrator. He reported that Resident #57 received speech therapy services which included a swallow study on 6/19/24.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review and staff interview, it was determined that the facility failed to provide a resident snacks as recommended by the dietician and consistent with the resident plan of care. This was evident for 1 (#96) of 6 residents reviewed for general concerns. The findings include: Type 2 diabetes is a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels. Bedtime snacks can help people with type 2 diabetes stabilize their blood sugar levels overnight and prevent high blood sugar in the morning. On 6/28/2024 at 2:00 PM, a review of complaint #MD00180188 revealed the complainant reported that the dietician had stated Resident #96 could have an evening snack, however, the resident, who was a diabetic, was never offered an evening snack and had lost 9 pounds since admission. On 7/9/24 at 4:30 PM, a review of Resident #96's medical record revealed documentation that indicated the resident was admitted to the facility for rehabilitative services in mid-May 2022 following an acute hospital stay, then transferred to an assisted living facility in June 2022. Resident #96 was admitted to the facility with multiple diagnoses which included generalized weakness, COVID-19, non-Hodgkin's lymphoma (blood cancer), hypertension (HTN) (high blood pressure), hyperlipidemia (HLD) (high cholesterol), and Type 2 Diabetes Mellitus (DM). Review of Resident #96's progress notes revealed that, on 5/19/2022 at 10:04 AM, in a nutrition progress note, the dietician documented that Resident #96 was at nutritional risk related to their recent hospitalization with Covid-19, decreased appetite, history of lymphoma on chemotherapy, HTN, HLD and DM. The dietician documented recommendations which included an HS (hour of sleep) snack, alternating sandwich, peanut butter crackers, and yogurt for additional calories. On 5/23/22 at 12:21 PM, in a nutrition/weight note, the dietician documented that Resident #96 remained on a carbohydrate-controlled diet with routine HS snacks for additional calories/protein. Review of Resident #96's care plans, revealed a care plan, [Resident #96] is at nutrition risk r/t recent hospitalization with COVID-19, decreased appetite, history of lymphoma on chemotherapy, HTN, HLD with the goals, will experience no significant weight change, and will tolerate diet and texture/consistency, that had an intervention, snacks per patient preference Review of Resident #96's geriatric nursing assistant (GNA) task documentation for May 2022 revealed the intervention/task HS Snack, which documented Resident #96 received a snack on 2 (5/21 and 5/25/22) of 14 days. On 11 (5/18, 19, 20, 22, 23, 26, 27, 28, 29, 30, 31/22) of 14 days in May, the GNA documented NA (not applicable) indicating Resident #96 had not been offered or had not received an HS snack on 11 of 14 days in May. Review of Resident #96's June 2022 GNA task documentation revealed on 5 (6/1, 2, 3, 5, 6/22) of 7 days in June, the GNA documented N/A ) indicating Resident #96 had not been offered or received an HS snack on 5 of 7 days in June. The facility failed to follow the recommendations of the dietician and the resident's care plan by failing to provide routinely provide Resident #96 with an HS snack. On 7/9/24 at 5:20 PM, the Nursing Home Administer (NHA) was made aware of the concerns expressed by the complainant, and the identified concerns with to failing to provide snacks per the resident's care plan and as recommended by the dietician. The NHA acknowledged the concerns and offered no further comments at that time.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observations, record review, and interviews, it was determined that the facility failed to 1) wear proper personal protective equipment (PPE) before giving direct care to a resident with an indwelling foley catheter and an open wound, 2) store a nebulizer mask in a sanitary manner to prevent the spread of infection. This was evident for 1 (#286) of 2 residents reviewed for respiratory care. The findings include: 1) An observation on 6/17/24 at 11:24 AM noted a signage on Resident #286's door that indicated Resident #286 was on enhanced barrier precautions, which required wearing gowns and gloves during high-contact resident care activities. Enhanced Barrier Precautions are infection control interventions designed to reduce transmission of infection in nursing homes. It involves gown and glove use during high-contact Resident care activities like dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for residents with central line, urinary catheter, feeding tube, tracheostomy, or any skin opening requiring dressing. Continued observation found that the Resident had used an indwelling Foley catheter. During a subsequent observation on 6/27/24 at 10:00 AM, staff #27, a geriatric nurse aide, was noted providing direct care to Resident #286. Staff #27 had put on gloves, however, the observation failed to show that staff #27 wore a gown. A medical record review later that day contained an admission evaluation assessment that noted Resident #286 was admitted with open wounds to the sacral and left hip areas. Further review found an attending provider's order to change dressing daily to Resident #286's left hip wound. The review also noted an MDS assessment, dated 6/7/24, which recorded that Resident #286 required maximal assistance or depended on staff for most of his/her self-care needs. In an interview on 6/27/24 at 10:02 AM, staff #27 stated she would typically put on a gown before direct contact with Resident #286, however, she forgot to wear it before providing care to the Resident. During a subsequent interview on 6/27/24 at 11:48 AM, the director of nursing was informed of the concern that staff was not wearing a gown during direct contact with Resident #286. The DON responded that staff #27 had already notified her of the concern. 2) On 6/17/24 at 11:37 AM, Resident #286 was observed wearing oxygen through a nasal cannula tubing attached to an oxygen concentrator set at 2L(Liters). The observation also found a nebulizer mask dated 6/12/24 lying bare on top of a nebulizer machine without any covering. A nebulizer is a small machine that turns liquid medicine into a mist to be inhaled through a mouthpiece or mask and enters the lungs directly. After use, the mask or mouthpiece is washed with mild soap, rinsed under running water, dried on paper, and kept in a sealable plastic bag. A medical record review, on 6/17/24 at 12:50 AM, showed that Resident #286 was admitted to the facility in May 2024 with diagnoses including acute hypoxemic respiratory failure (acute hypoxemic respiratory failure is a condition where the body does not have enough oxygen in the tissues of the body). A continued review found Resident #286's order summary report for June 2024 contained an attending provider's order, dated 6/1/24, for ipratropium-albuterol inhalation Solution via nebulizer four times a day for shortness of breath. In an interview on 6/17/24 at 1:50 PM, staff #38, a licensed practical nurse, stated that the mask should have been kept in a plastic bag after use and that she would discard it immediately after the surveyor's intervention. In a subsequent interview on 6/25/24 at 10:25 AM, the assistant director of nursing said the nebulizer mask was expected to be rinsed, dried, and kept in a plastic bag after each use to prevent infection

CONCERN (E) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

2) Review of Resident #104's medical record on 6/28/24 revealed that the resident resided at the facility for a month, needed partial to maximal assistance with Activities of Daily Living (ADLs), was alert and sometimes oriented, and able to verbally communicate. Review of MD00169154, a facility self report of an abuse allegation, revealed that, on 7/5/21 Resident #104 reported that a staff member slapped his/her wrist during morning ADLs and that the facility initiated an investigation. Further review of facility documentation for MD00169154 revealed a final report from 7/6/21 summarizing the incident and concluding that, based on their investigation, they were unable to substantiate the allegation of abuse. This final report indicated the alleged staff was GNA Staff #30. Further record review on 6/28/24 of the facility documentation provided for the investigation revealed that Resident #104 reported to Geriatric Nursing Assistant (GNA, Staff #26) on 7/5/21 at around 7:00 AM that she/he did not like how the night GNA took care of her/him, furthermore, that he was rough. Further review of documentation on 6/28/24 failed to reveal staffing schedules for the shift in which the alleged abuse occurred or how the alleged staff member was identified. On 06/28/24 at 12:48 PM, an interview with the Nursing Home Administrator (NHA, Staff #1) revealed that, when the surveyor asked about abuse allegations and what was the status of alleged employee during the investigation, he indicated that they were suspended. On 6/28/24 at 01:30 PM, an interview with the NHA revealed that there was no further documentation. On 6/28/24 at 02:40 PM, the surveyor reviewed the concern with the NHA that the documentation provided for MD00169154 failed to include staffing assignments and requested to see the schedules from the night shift on 7/4/21 and 7/5/21. Review of interviews with residents revealed that they were asked about GNA (Staff #25) by name, not GNA (Staff #30). Review of the 7/4/21 staffing sheets revealed GNA (Staff #25) was working with the resident on the 7/4/21 night shift. No documentation was found to indicate Staff #30 was working the 7/4/21 night shift. Further review of the staffing sheets revealed GNA (Staff #25) again worked the night shift on 7/5/24. On 07/03/24 at 11:10 AM, the surveyor reviewed the concern with the NHA that GNA (Staff #25) was the one that was working night shift 7/4/21 and then came back to work for night shift 7/5/21. 3) Review of Resident #107's medical record on 7/1/24 revealed that the resident resided at the facility for a month, needed partial to maximal assistance with Activities of Daily Living (ADLs), was alert and somewhat oriented, and able to verbally communicate. Review of MD00196992, a facility self report of a neglect allegation, revealed that, on 9/14/23, Resident #107's family member reported that, on 8/5/23, it took 45 to 60 minutes for someone to come in and change Resident #107 after the family member had asked and that the facility initiated an investigation. Review of the final report indicated that staff interviews were conducted. On 7/03/24, review of MD00196992's investigative documentation revealed that Licensed Practical Nurse (LPN) and Geriatric Nursing Assistant (GNA) who were assigned to the resident on 8/5/23 were identified and a document titled Coaching/Counseling Form signed by both staff members of alleged neglect (LPN, Staff #12 and GNA, Staff #26) indicating that they agreed to answer call lights in a timely manner. However, no documentation of interviews with either of the staff were found. Final review of MD00196992 revealed that the facility was unable to substantiate the alleged neglect. On 07/03/24 at 03:25 PM, the surveyor reviewed the concern with the NHA (Staff #1) that there was no documentation provided to indicate that an interview was conducted with the staff to determine what had occurred that day. 4) Review of Resident #108's medical record on 06/26/24 at 09:53 AM revealed that the resident resided at the facility for over a year, needed partial to maximal assistance with Activities of Daily Living (ADLs), was alert and oriented, and able to verbally communicate. Review of MD00163688, a facility self report of an abuse allegation, revealed that, on 2/12/21, Resident #108 reported that she/he was punched in the leg by a night shift nurse aid and that the facility initiated an investigation. Further review of MD00163688 revealed that the alleged staff perpetrator was identified, but the documentation provided failed to reveal the name of the staff member or any interviews with the alleged staff member and that there is no documentation of the residents that were interviewed or what they had reported. Final review of the documentation provided by the facility on MD00163688 revealed the facility concluded there was no evidence to substantiate the allegation of the abuse incident. On 06/28/24, an interview with the Nursing Home Administrator (NHA #1) revealed that there was no further documentation pertaining to MD00163688. On 06/28/24 at 02:40 PM, the surveyor reviewed the concern with NHA #1 that the facility documentation provided for the incident failed to show documentation identifying the staff of alleged abuse and there was no documentation of any interviews. Based on medical record review, pertinent documenatation and staff interviews, it was determined that the facility failed to complete a thorough investigation of an allegation of abuse potential abuse. This was evident for #4 (#137, #104, #107, #108) of 12 residents reviewed for abuse. The findings include Review of Resident #137's medical record on 6/22/24 revealed that the resident had a brief admission to the facility in January 2022. 1) Review of MD00182200, a facility self report of an abuse allegation, revealed that the resident's family had submitted a concern form alleging rough handling by staff while at the facility. Review of the final report by the facility, received by the State Survey Agency on 2/2/22, revealed the alleged events took place on 1/23/22 - 1/24/22 but failed to include a specific shift or name a specific staff member involved. The final report included: Interviews with staff assigned to [him/her] revealed the patient was neither physically or verbally abused . Further review of the facility investigation documentation revealed staffing sheets for evening and night shift of 1/23/22 and day and night shift for 1/24/22 (no sheet was found for 1/24 evening shift). Review of the staffing sheets revealed the resident was cared for by at least 3 different nurses and 3 different geriatric nursing assistants (GNA) on those two days. Further review of the documentation provided by the facility revealed a total of four witness statements: one by a nurse (Staff #12) and three by residents. No documentation was found to indicate that interviews were conducted with any of the other multiple staff that worked with the resident on 1/23 and 1/24/22. Further review of the documentation failed to reveal the concern form that the family had submitted to the facility. It is unclear from the facility report as to when the allegation was initially made to the facility. On 6/21/24 at 2:43 PM, the Nursing Home Administrator (NHA) reported there was no additional documentation regarding this facility report. Surveyor reviewed the concern that, based on the documentation provided, there was a concern form but it was not included, the NHA indicated he would look for the concern form. Surveyor also reviewed that the report indicated that interviews were conducted with staff assigned to the resident but only one staff interview was found despite staffing sheets indicating several different staff were assigned to care for the resident. As of time of survey exit on 7/11/24 at 3:30 PM, no additional documentation was provided regarding these concerns.

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

5) Review of Resident #67's medical record revealed the resident had resided at the facility since January 2024 to present, used a wheelchair independently, needed partial to maximal assistance with ADLs,was alert and oriented, and able to verbally communicate. Further record review of the initial assessment note, completed on 1/24/24 at 08:49 PM, revealed that Resident #67's skin was intact upon admission. Record review revealed that, on 2/2/2024 at 11:29 PM, a change of condition progress note was completed indicating that during a shift assessment, there was a wound noted on Resident #67's left buttocks and that the wound doctor (Staff #40) was notified. Record review revealed that on 4/19/24 at 01:40 PM, Unit Nurse Manager (Staff #14) completed a nursing progress note which indicated, right lateral heel eschar was noted . Eschar is dead tissue that sheds or falls off from the skin and is commonly seen with pressure ulcer wounds. Further record review revealed that, on 4/19/24 at 02:20 PM, an eINTERACT SBAR Summary for Providers progress note was completed, which indicated that Resident #67 had an open area on the left ischium and left heel. The ischium is part of the pelvis bone that forms the lower and back part of the hip bone. Record review revealed on 4/26/24, a wound note by Medical Doctor (Staff #40) that indicated they were managing Resident #67's wound on the left ischium. Further record review revealed an MDS, with an assessment reference date of 4/28/24, which indicated that Resident #67 had one pressure wound and that the wound was present upon admission. On 06/24/24 at 02:17 PM, an interview with MDS coordinator (Staff #9) revealed that she used the nursing assessments and notes from the wound doctor to complete the skin section of MDS assessments. The surveyor explained that, according to the 4/28/24 MDS for Resident #67, he/she had 1 wound and it was marked as being present upon admission. Staff #9 explained she would look into it and get back to the surveyor to confirm. On 06/24/24 at 02:47 PM, an interview with Staff #9 confirmed that Resident #67 developed the wound at the facility and the coding of it being present upon admission was an error. Surveyor requested clarification from Staff #9 regarding the number of pressure wounds that were present at the time of the 4/28/24 admission. On 6/24/24 at 3:40 PM, Staff #9 confirmed Resident #67 had two additional wounds that were not captured on the 4/28/24 MDS assessment. On 06/27/24 at 02:01 PM, the surveyor expressed the concern to the Director of Nursing that an MDS assessment failed to correctly reflect a resident's status. Based on interviews and medical record review, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#24) of 4 residents reviewed for position and mobility, 1 (#37) of 3 residents reviewed for vision/hearing, 1 (#84) of 4 residents reviewed for hospitalization, and 2 (#35, #67) of 4 residents reviewed for pressure injuries. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. MDS assessments must be accurate to ensure that each Resident receives the care they need. 1) In an interview on 6/17/24 at 12:25 PM, Resident #24 was asked about having any limitation in his/her range of motion (ROM). The resident responded that he/she could not lift his/her right leg. A medical record review on 6/28/24 at 1:14 PM contained a physical therapy evaluation and plan of treatment dated 12/9/23, that recorded that Resident #24 had a limited range of motion in the left and right legs. Continued review, on 6/28/24 at 2:40 PM, found three MDS assessments for Resident #24 dated 12/20/23, 3/20/24, and 5/3/24. The MDS assessments had recorded that Resident #24 could not walk, required assistance from staff with transferring from one surface to another, and had no limitation in range of motion in section GG0115. In an interview on 6/28/24 at 2:47 PM, staff #9, an MDS coordinator, stated that her process for assessing a resident's limited ROM was through observation and review of documentation by physical therapy, occupational therapy, and nurses. Staff #9 continued to say that she would record the limitations on a resident's MDS assessment if the impaired ROM affected the resident's movement or ability to move. In a subsequent interview on 7/1/24 at 9:46 AM, staff #36, a physical therapist, said a resident's impaired ROM to his/her legs would affect the resident's ability to transfer or walk. However, Resident #24's MDS assessments for 12/20/23, 3/20/24, and 5/3/24 failed to capture his/her limitation in range of motion to the legs. 2) In an interview on 6/17/24 at 2:46 PM, Resident #37's representative reported that Resident #37 had poor vision and hearing. A record review on 6/24/24 at 1:58 PM found an admission MDS assessment, dated 7/1/20, that recorded Resident #37 had moderately impaired vision in section B and blindness to the right eye in section I. Continued review contained an attending provider's note, dated 11/17/2022, which documented that Resident #37 had right eye blindness. A subsequent record review, on 6/24/24 at 3:58 PM, contained a nutritional assessment, dated 12/4/23, which recorded that Resident #37 was edentulous (edentulous is having no natural teeth or tooth fragments in the mouth). Further review found an MDS assessment, dated 2/23/24, which recorded in section L-Oral/Dental status that Resident #37 was not edentulous and in section B that Resident #37 had adequate vision. However, the MDS assessment failed to capture Resident #37's edentulous and impaired vision status. In an interview on 6/26/24 at 8:38 AM, staff #9, an MDS coordinator, reported that she documented sections B and L of Resident #37's MDS assessment, dated 2/23/24 in error. 4) On 6/20/24, review of records revealed that Resident #35 had been a long-term resident of the facility for several years. On 6/25/24 at 11:20 PM, an observation was made of a wound care treatment for resident # 35. The observation revealed that Resident #35 had contractures in both legs. On 6/26/24, review of Resident #35's physical therapy discharge documentation, dated 1/13/2020, was reviewed. Review failed to reveal that Resident #35 had any contractures of his/her right or left legs. On 6/28/24 at 12:12 PM, The hospice visit notes, written by Nurse Practitioner Staff #47, dated 3/20/2021, were reviewed. Review revealed that the resident had a significant contracture of the right knee. On 6/26/24 at 7:55 PM, the MDS for Resident # 35, with the following assessment reference dates, were reviewed for section G0400, Functional Limitations in Range of Motion. The noted dates were: 4/18/21, 10/17/21, 1/17/22, 6/29/22, and 8/13/22. The review failed to reveal that the significant contracture was coded. 06/28/24 at 3:11 PM, MDS Coordinator Staff #9, was interviewed to determine what data sources had been used to document the information in section G0400, Functional Limitations in Range of Motion. The MDS coordinator reported she reviews the following: Residents chart, any physical examinations, nurses' notes, and the GNA documentation. The MDS coordination agreed that 40 percent contracture of the knee was significant and confirmed that it was an error in coding. 3) On 6/20/24, review of Resident #84's medical record revealed a Minimum Data Set discharge assessment, with an assessment reference date of 3/25/24, that included documentation that the resident was discharged to a short term general hospital. Further review of the medical record failed to reveal documentation to support that the resident was discharged to a hospital. Review of the medical record revealed a My Transition Home document, dated 3/25/24, which included in Section D Social Services, which was signed by Director of Social Service (Staff #17), the reason for the discharge was the completion of therapy and discharge goals met. The transfer setting was listed as Home/Community (eg.private home/apt., board/care, assisted living, group home, transitional living, other residential care arrangements). The area for discharge address was noted to be blank. The section titled My Discharge Goals included that the goal was discharge to ALF. An ALF is an assisted living facility which is a less intense level of care than a skilled nursing facility. Review of a 3/25/24 11:59 AM nursing note revealed .Resident schedule to be discharge to ALF today Review of a 3/25/24 at 4:24 PM nursing note revealed: Resident has an order to be transferred to ALF - [name of a skilled nursing facility]. Transportation arrived and Resident left in stable condition. Review of a 3/25/24 at 4:46 PM social service note, written by Staff #17, revealed: Resident was discharged to another SNF [skilled nursing facility] ([name of the other facility]) on 3/25/24 .Resident was set up with home health services with [name of a home health agency] . Further review of the My Transition Home document, which was signed by the resident's responsible party, failed to reveal documentation to indicate the resident was being discharged to a skilled nursing facility or a hospital. Review of a 3/26/24 at 12:27 PM nursing note, written by the unit nurse manager (Staff #14) revealed: Post discharge and transition home call was made spoke with resident's one of [his/her] daughter, how was how was the first day of discharge home, daughter stated thank you for every thing. On 6/20/24 at 2:59 PM, the MDS nurse (Staff #9) reported she reads the notes to determine where a resident is discharged to. After surveyor reviewed the concern that the discharge MDS indicated the resident went to a hospital, the MDS nurse reported that must have been an error, let me check, I'll do a correction now. On 6/20/24 at 4:26 PM, surveyor reviewed the concern with [NAME] President of Clinical Operations (Staff #20) that based on record review, surveyor cannot determine where the resident went after discharge. Staff #20 indicated she would investigate. On 6/21/24 during a 10:00 AM interview, the Nursing Home Administrator (NHA) reported that he spoke with the family this morning and confirmed the resident was currently at [name of the SNF referenced in SS note]. He confirmed this SNF is not an ALF. On 6/21/24 at 12:15 PM, review of the modified MDS revealed documentation that the resident went to a home/community setting, not a SNF. This assessment was locked but had not yet been submitted. When asked about this discharge assessment, the MDS nurse reported there was some confusion due to documentation that indicated the resident went to an ALF, but that social work reports the resident went to a nursing home. MDS nurse indicated she will change the assessment again. On 6/21/24, surveyor confirmed with the state licensing office that, according to the receiving SNF MDS submission, the resident was admitted to a SNF on 3/25/24.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on medical record review and resident and staff interview, it was determined that the facility failed to provide the resident or resident representative with a summary of their baseline care plan and a summary of their medications on admission. This was evident for 1 (#64) of 5 residents reviewed for unnecessary medications. The findings include: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is given to the resident and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. 1.1) On 6/20/24 at 12:30 PM, a review of Resident #64's medical record revealed that Resident #64 was admitted to the facility towards the end of April 2024, Review of Resident #64's admission assessment with an assessment reference date (ARD) of 4/28/24 revealed documentation that Resident #64 was able to make him/herself understood and was able to understand others, and the resident was moderately cognitively impaired. Review of an Admission/readmission Evaluation form, with an effective date of 4/24/24 at 9:59 PM, revealed nurse documentation that Resident #64 had been evaluated and a base line care plan had been developed. On 4/24/24 at 4:42 PM, in a care plan progress note, the nurse documented that when asked, Resident #64 indicated it was okay for the nurse to review the baseline care plans the resident, and the nurse reviewed the baseline care plans, and medications with the resident. There was no documentation to indicate that a copy of their baseline care plan, along with a summary of their medications was offered and/or provided to Resident #64 at that time. Continued review of Resident #64's medical record failed to reveal documentation to indicate that the facility offered or provided the resident and/or the resident representative with a copy of their baseline care plan along with a summary of their medications. 1.2) Further review of the medical record revealed Resident #64 was transferred to the hospital in the beginning of May 2024 and readmitted to the facility in mid to late May 2024. Review of an Admission/readmission Evaluation form, with an effective date of 5/21/24 at 6:18 PM, revealed nurse documentation that a readmission evaluation of Resident #64 was completed and a baseline care plan for the resident had been developed. There was no documentation in the form to indicate that Resident #64 had been provided a copy of their baseline care plan. On 5/23/24 at 4:31 PM, in a care plan progress note, the nurse documented that on that date, baseline care plans were reviewed with Resident #64. No documentation was found in the progress note to indicate that Resident #64 had been provided a copy of the baseline care plan. Continued review of Resident #64's medical record failed to reveal documentation to indicate that the facility offered or provided the resident and/or the resident representative with a copy of their baseline care plan along with a summary of their medications. The Director of Nurses was made aware of the concerns on 6/21/24 at 11:02 AM and offered no further comments at that time.

CONCERN (E) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on medical record review and staff interview, it was determined that the facility staff failed to develop and implement comprehensive, resident centered care plans. This was evident for 1 (#22) of 1 residents reviewed for rehab and restorative and 1 (#64) of 5 residents reviewed for unnecessary medication. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) During an interview with Resident #22 on 6/17/24 at 3:01 PM, s/he reported that s/he was not doing any kind of therapy and was told that it was not doing him/her any good. Functional mobility is a person's ability to move around independently and safely in their environment to participate in daily activities. This includes movements like standing, bending, walking, climbing, sitting down, and scooting around in bed. Functional mobility can take place at home, work, and in the community, and can contribute to a person's quality of life. On 6/20/24 at 12:22 PM, Resident #22's care plan was reviewed and revealed a functional mobility care plan that indicated a goal to improve as evidenced by blank. Blank was an area where the facility staff was supposed to indicate the evidence of the resident's improvement in functional mobility. Further review of this care plan history indicated that it was initiated as part of the baseline care plan and has had a revision 7 times. All 7 revisions failed to indicate evidence for improvement in the functional mobility goal. On 6/25/24 at 11:07 AM, the Physical Therapist (PT) was interviewed about his involvement in care planning. The PT reported that either he or the Director of Rehab (DOR) participate in care plan meetings but do not update the resident's care plan. The PT also indicated that he thinks it was the social workers who updated the care plan. Later that day at 2:03 PM, the DOR confirmed in an interview the PT's statement that they do not update the care plan and that it was the social services department who updated them. On 6/26/24 at 8:56 AM, the Social Services Director was interviewed, and she denied responsibility of updating the resident's care plan regarding functional mobility stating, I don't update the care plan for that, I wouldn't have any idea about their mobility. The Director of Nursing (DON) was then interviewed on 6/26/24 at 9:59 AM. Resident #22's functional mobility care plan was reviewed with the DON, and she stated, it looks like it came from a template. The DON confirmed that the care plan was not resident-specific. On the same day at 10:17 AM, the DON, together with Nursing Home Administrator, (NHA) discussed the care plan concern with the surveyor. Resident #22's care plan was again reviewed with both staff and confirmed that it did not reflect the resident specific information to convey appropriate treatment and services to maintain, restore or improve abilities with functional mobility. Also, the care plan has had several revisions but the only thing that changed were the revision dates. Both the DOR and the NHA acknowledged the concern. 2) On 6/20/24 at 12:30 PM, a review of Resident #64's medical record revealed that Resident #64 was initially admitted to the facility in April 2024, then, following an acute hospitalization, Resident #64 was readmitted to the facility in mid to late May 2024 with diagnoses which included depression. Review of Resident #64's June 2024 MAR revealed an active 5/22/24 order for Mirtazapine (Remeron) (antidepressant) tablet by mouth at bedtime for an anti-depression that was documented as given every day as ordered from 6/1/24 - 6/19/24. Review of Resident #64's care plans revealed, a care plan, [Resident #64] may have the potential of feeling down/depressed or potential for depression, with the goal, Resident will be given opportunity to ventilate feelings within next 90 days, that had the interventions, 1) Encourage family involvement and visits when able, and 2) Psychology services as needed. The care plan was not comprehensive, with a resident centered, measurable goal and interventions to address the resident's depression and Resident #64's use of the psychotropic medication Mirtazapine, including monitoring the resident's response or lack of response to the medication for the targeted behaviors for which the psychotropic medication had been prescribed, and monitoring for adverse consequences and side effects of the medication. The above care plan concerns were discussed with the Director of Nurses (DON) on 6/21/24 at 11:02 AM. The DON acknowledged the concern and offered no comments at that time

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Review of Resident #67's medical record revealed the resident has resided at the facility since January 2024 to present, uses a wheelchair independently, needs partial to maximal assistance with (Activities of Daily Living ) ADLs, is alert and oriented, is able to verbally communicate and has an age-related cognitive decline diagnosis. Review of the 1/28/24 Minimum Data Set (MDS) assessment revealed Resident #67 had a BIMS (Brief Interview for Mental Status) score of 13; and the 4/28/24 MDS revealed a BIMS score of 12. BIMS is a tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. The total BIMS score ranges between zero to fifteen points. A score of 8-12 indicates mild cognitive impairment. On 06/18/24 at 10:03 AM, an interview with Resident #67 revealed she/he had asked about having a walker but indicated this was to be determined by therapy. On 06/24/24 at 03:13 PM, review of the therapy discharge summaries for Resident #67 revealed that she/he had been discharged from occupational therapy on 4/10/24 and from physical therapy on 5/1/24, both which included recommendations for a home exercise program. Further review of the medical record failed to reveal any specific information regarding what the home exercise program consisted of. Review of medical record revealed a care plan for Resident #67 addressing a need for assistance with ADL function and a goal that ADL function would improve. The review of interventions for this goal failed to reveal an intervention that would assist in improvement of ADL function, and instead were statements about the amount of assistance the resident required for certain ADLs. Further review of the medical record revealed the care plan addressing cardiac disease included an intervention, initiated on 1/24/24, for therapy evaluation and treatment as ordered for physical and/or occupational therapy. Further review of the care plans failed to reveal documentation to indicate the care plans were updated to reflect the PT and OT recommended home exercise programs. On 06/25/24 at 09:49 AM, an interview with Director of Rehabilitation (Staff #34) revealed that, if a resident is cognitively intact, they are given a print out of the exercises they are supposed to do for the home exercise program. If a resident is not cognitively intact then therapy would provide education by an inservice to the nursing staff on the shift when discharged from therapy. Staff #34 further explained that once the nursing staff receives the education that they should be passing it on from shift to shift and if it was a verbal explanation, that the provider should document what they did. Further interview with Director of Rehabilitation (Staff #34) revealed that a home exercise program is something provided verbally to the resident once they are discharged from therapy and they do not document it. The surveyor expressed the concern to Staff #34 that the discharge papers do not include what the home exercise program consists of when a resident is discharged from therapy when a resident has some cognitive impairment. On 06/25/24 at 11:45 AM, Resident #67 reported that his/her Physical Therapist told her/him the exercises to continue doing after discharge but that they did not give a paper listing them. Resident #67 reported he/she thinks she/he remembered them and was able to list 3 exercises and reported that she/he does them every other day. On 06/27/24 at 02:01 PM, the surveyor reviewed the concern with the Director of Nursing (Staff #2) about the recommendations from therapy not being incorporated into residents' care plan. 5) Review of Resident #5's medical record on 6/24/24 revealed that the resident had been residing at the facility since March 2024, needs partial to maximal assistance with Activities of Daily Living (ADLs), is alert and oriented, and able to verbally communicate. The resident has a BIMS of 15. On 06/17/24 at 02:28 PM, an interview with the resident revealed that he/she was able to walk when he/she came into the facility and was currently not walking because the staff was scared he/she would break a bone in his/her knee. On 06/24/24 at 03:13 PM, review of the therapy discharge summaries for Resident #5 revealed that she/he had been discharged from occupational therapy on 4/30/24 and from physical therapy on 3/27/24, both of which included recommendations for a home exercise program. Review of the medical record, revealed a care plan addressing the resident's fall risk which included a goal of having no injuries from falls. This care plan included therapy evaluation as needed of PT and OT as an intervention which was initiated on 12/3/23. Further review of Resident #5's care plan failed to reveal any update to the care plan based on the home exercise program which was recommended in the discharge summary from therapy. Interview with Physical Therapist (PT, Staff #36) on 06/25/24 at 11:05 AM revealed that either the Physical Therapist or Director of Rehab (Staff #34) would attend resident care plan meetings. When the surveyor asked about the home exercise program, he indicated that the exercises that the residents had been doing while in therapy should continue and that residents are given a paper upon discharge of the exercises they are to continue on their own at home. When the surveyor asked Staff #36 if he could provide details of the exercises recommended for Resident #5, he was not able to. Further interview with Physical Therapist (PT, Staff #36) on 06/25/24 at 11:05 AM revealed that they communicate the exercises of the home exercise program to the staff if the resident being discharged has cognitive impairment. He further explained that, if they are holding a session in a resident room, they would call in the Geriatric Nursing Assistant and the Nurse assigned to the resident that shift, and show them the exercises. Further interview revealed that they were not documenting what education they were providing to the staff nor which staff received the home exercise program education for the resident. On 06/25/24 at 11:20 AM, an interview with Physical Therapist, (Staff #36), revealed that Resident #5 was given a copy of the home exercise program. Staff #36 explained that he believed the resident still had it in his/her room and that he had given Resident #5 several copies of the home exercise program. Staff #36 indicated that he was not sure how to answer when the surveyor asked if the discharge recommendations from therapy should be a part of a resident's care plan. On 06/25/24 at 11:54 AM, Resident #5 denied knowledge of any exercise that he/she should be doing and denied having received papers for a home exercise program On 06/25/24 at 12:52 PM, during an interview with Director of Rehabilitation (Staff #36), the surveyor made her aware that Resident #5 was not aware of any home exercise program even though PT (Staff #36) indicated he had given the resident several copies. Surveyor reviewed the concern that the care plan was not updated to reflect the home exercise program. On 06/27/24 at 02:01 PM, the surveyor reviewed the concern with the Director of Nursing (Staff #2) about the recommendations from therapy not being incorporated into the resident's care plan. 7) A review of Resident #43 medical records revealed that s/he had been a resident of the facility since mid-2021. On 6/27/24 at 10:03 AM, a review of the complaints related to MD00175781 stated, the facility has never gone over a care plan with us. The event date of the allegations was April of 2022. On 7/8/24 at 3:17 PM, Resident #43's medical records were reviewed and revealed the mosr recent comprehensive assessment before the allegation was made had an assessment reference date of 2/18/22. The Nursing Home Administrator (NHA) was asked to provide documentation for the care plan meeting that was held after the completion of the comprehensive assessment. On 7/9/24 at 9:00 AM, the NHA provided the care plan meeting documentation. The document was reviewed with the NHA and revealed that the care plan meeting was held on 4/19/22. The NHA confirmed that the care plan meeting was held outside of the required time frame and reported his understanding of the regulation that care plan meetings must be done within 7 days after completion of the comprehensive assessments. Based on medical record review and interviews, it was determined that the facility staff 1) failed to ensure that interdisciplinary team care plan meetings were held to review and revise the care plans following each MDS assessment, and 2) failed to have a system in place to ensure that therapy recommendations are incorporated into resident care plans. This was evident for 4 (#286, #24, #64, #43) of 9 residents reviewed for care planning, 1 (#10) of 4 residents reviewed for unnecessary medications, and 2 (#67, #5) of 4 residents reviewed for activities of daily living. The findings include: The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility with the information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. A care plan is a guide that addresses each Resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. Participation in care planning by a resident and Resident representative can take many forms, such as holding care planning conferences (meetings) when the resident representative is available to participate, conference calls, or videoconferencing. 1) A medical record review on 6/17/24 at 10:42 AM, showed that Resident #286 was admitted to the facility in May 2024. Further review found that Resident #286 was alert and oriented, able to make his/her own decisions, and cognitively intact per an MDS assessment dated [DATE]. Continued review of the MDS assessment showed that it was completed on 6/12/24 however, the review failed to show that a care plan meeting occurred following the Resident's admission to the facility and completion of the Resident's admission MDS assessment. In an interview on 6/17/24 at 11:24 AM, Resident #286 responded, Not yet, no meeting of that sort, when asked if she/he participated in her/his care plan meeting after admission to the facility. An interview on 6/18/24 at 3:11 PM with staff #17, the director of social services, showed that care plan meetings for newly admitted residents were scheduled within 14 days of their stay in the facility. However, the interview failed to show that Resident #286's care plan meeting had been done since his/her admission to the facility in May 2024. In a subsequent interview on 6/27/24 at 10:16 AM, staff #17 stated that she usually schedules care plan meetings for new residents 7-14 days after their admission to the facility. Staff #17 confirmed that a care plan meeting had not yet been held for Resident #286 since his/her admission to the facility in May 2024. 2) A record review on 6/17/24 at 12:20 PM showed that Resident #24 was admitted to the facility in July 2022. The review revealed that Resident #24 was responsible for making his/her own decisions. A continued record review found two MDS assessments, dated 3/20/24 and 5/3/24, which were completed on 3/21/24 and 5/8/24. However, further review failed to show that care plan meetings had been conducted following the completion of the MDS assessments. In an interview on 6/17/24 at 12:25 PM, Resident #24 stated, I've never been invited to any care conference meeting, and I am my own responsible party. During a subsequent interview on 6/26/24 at 10:42 AM, staff #17 reported that care plan meetings were usually conducted seven days after completing a resident's MDS assessment. However, the interview failed to show that care plan meetings had been conducted for Resident #24 after the completion of his/her two most recent MDS assessments. In an interview on 6/26/24 at 11:20 AM, staff #17 was asked to provide documentation for all the care plan meetings held in 2024 for Resident #24. She handed to surveyor care conference documentation with an effective date of 11/16/2022. Staff #17 stated, That's all the documentation I found for care plan meetings. Staff #17 continued to say that she could not deny or confirm any care plan meetings were conducted for Resident #24 after 11/16/2022. In a subsequent interview on 6/26/24 at 1:34 PM, staff #16, a social worker, stated that she could not prove that care plan meetings were conducted for Resident #24 since the last one on 11/16/22. 3) A record review on 6/26/24 at 8:12 AM showed that Resident #10 was admitted to the facility in October 2022. A subsequent review on 6/28/24 at 10:47 AM found a medication care plan, which was initiated on 7/19/2016 and revised on 4/16/2024, that stated that Resident #10 was At risk for adverse effects related to the use of anti-depression medication and use of hypnotic medication. Continued review found an MDS assessment, completed on 6/10/24, which documented that Resident #10 was receiving antidepressant medication. Further review showed an attending provider's order for an antidepressant medication for Resident #10, however, the review failed to show the Resident's use of a hypnotic medication. In an interview on 6/28/24 at 10:58 AM, staff #13, a unit manager, reported that when an annual, quarterly, or significant change in condition MDS assessment is completed, a resident's care plan is also updated to reflect any changes. In a subsequent interview on 6/28/24 at 11:31 AM, the assistant director of nursing (ADON) confirmed that Resident #10 did not receive hypnotic medications. The ADON stated that having a hypnotic medication on Resident #10's current care plan was an error. 6) On 6/20/24 at 12:30 PM, a review of Resident #64's medical record revealed that Resident #64 was initially admitted to the facility in mid to late April 2024, then, admitted to the hospital for a change in condition, and readmitted to the facility later in May 2024 following the acute hospitalization. Review of Resident #64's assessments revealed a revealed a 5 Day scheduled MDS assessment with an assessment reference date (ARD) of 5/27/24 that was signed as completed on 6/3/24. In a social services note, on 6/14/24 at 11:04 AM, the SSD (social services director) documented s/he had contacted Resident #64's son to meet with the resident to discuss care conference meeting and the SSD scheduled the meeting. There was no documentation found in the social service note or in the medical record to indicate that a care conference was scheduled. Continued review of Resident #64's medical record failed to reveal documentation to indicate that a care plan conference had been conducted with the resident and/or representative following the resident's re-admission to the facility or following the resident's admission assessment ARD 5/27/24. On 6/21/24 at 10:10 AM, during an interview, Staff #17 was made aware that no documentation was found in the medical record to indicate that a care plan meeting had been held with Resident #64 since his/her admission to the facility and following the resident's admission MDS. At that time, the SSD responded that a care plan meeting was supposed to be yesterday but needed to be rescheduled with no further explanation or comments offered. The Director of Nurses was made aware of the above concerns on 6/21/24 at 11:02 AM, and offered no comments at that time.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on medical record review and staff interview, it was determined the physician 1) failed to write, sign, and date progress notes at each visit, and 2) failed to review the resident's total program of care, including medications and treatments, at each visit. This was evident for 2 (#64, #73) of 5 residents reviewed for unnecessary medications, and 1 (#86) of 11 residents reviewed for neglect. The findings include: 1) On 6/21/24 at 9:00 AM, a review of Resident #64's electronic health record (EHR) revealed physician progress notes that were not written and, in the resident's medical record on the day the resident was seen: - There was a physician/practitioner progress note with an effective date of 5/14/24 at 9:51 AM that had a created date of 6/18/24 at 1:19 PM and - There was a physician/practitioner progress note with an effective visit date of 5/27/24 at 5:52 PM that had a created date of 6/18/24 at 1:47 PM. On 6/21/24 at 3:05 PM, the Nursing Home Administrator (NHA) was made aware of the physician visit notes that were not written, signed and dated on the day of the physician's visit. The NHA acknowledged the concerns offered no further comment at that time. 2) On 6/26/24 9:00 AM, a review of Resident #73's medical record revealed on 6/10/24 at 9:58 PM, in a lab/radiology note, the nurse documented that the physician was called to address the resident's lab results and the physician gave an order for Metformin two times a day; check fingerstick and if it is less than 150, hold Metformin. A review of Resident #73's June 2024 MAR revealed a 6/11/24 order for Metformin HCL (Glucophage) (antidiabetic medication) tablet by mouth two times a day for Diabetes, finger stick before giving Metformin and hold if it is less than 150. The MAR documented the Metformin was given to Resident #73 twice a day, every day, from 6/11/24 to 6/26/24. There was no documentation in the MAR to indicate the Resident #73's blood glucose (sugar) level was monitored via finger stick prior to administering the Metformin to Resident #73. Review of Resident #73's progress notes revealed a physician/practitioner progress note with an effective date of 6/10/24 at 8:54 PM and a created date of 6/11/24 at 8:56 PM that documented Resident #73 had a past medical history of diabetes with an assessment/plan that documented Resident #73 was on insulin for diabetes and the resident's metformin, glipizide (anti-diabetic) and detemir (long-acting insulin) medications were discontinued due to hypoglycemic (low blood sugar) episodes during hospitalization. Continued review of Resident #73's physician/practitioner progress note revealed that the attending physician had written progress notes related to resident visits made to Resident #73 on 6/14, 6/17, 6/21, and 6/24/24, and on each of those dates the attending physician documented that Resident #73's metformin, glipizide and detemir medications were discontinued due to hypoglycemic episodes during hospitalization. There was no documentation found to indicate the attending physician assessed the resident's diabetes status, or that the physician was aware the resident received Metformin twice a day for diabetes. There was no documentation found to indicate the attending physician was aware of Resident #73's 6/11/24 order for Metformin and that the resident received Metformin twice a day for diabetes. On 6/27/24 12:30 PM, the concerns with the physician failing to review the resident's total plan of care at each visit were discussed with the DON, who acknowledged the concerns and offered no further comment. 3) On 7/10/24 at 1:36 PM, a review of Resident #86's medical record revealed physician progress notes that were not written and, in the resident's, medical record on the day the resident was seen: - There was a physician/practitioner progress note with an effective date of 1/10/24 at 9:35 AM, that had a created date of 3/1/24 at 1:30 PM. - There was a physician/practitioner progress note with an effective date 11/13/23 at 6:11 PM that had a created date of 11/28/23 at 12:57 AM. - There was a physician/practitioner progress note with an effective date 10/12/23 at 5:40 PM that had a created date of 11/28/23 at 12:34 AM. - There was a physician/practitioner progress note with an effective date 9/21/23 at 5:30 PM that had a created date of 10/6/23 at 12:40 AM. - There was a physician/practitioner progress note with an effective date 8/14/23 at 6:22 AM that had a created date of 10/6/23 at 12:27 AM. - There was a physician/practitioner progress note with an effective date 7/14/23 at 9:55 AM that had a created date of 8/19/23 at 11:40 PM. On 7/10/24 at 2:55 PM, the DON was made aware of the concerns with Resident #86's physician visit notes which were not written, signed, and dated on the day of the physician visit. The DON acknowledged the concerns at that time and offered no further comments.

CONCERN (E) 📢 Someone Reported This

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

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interviews, it was determined that the pharmacist failed to identify irregularities with resident medication orders, and failed to develop, maintain, and implement policies and procedures that address the time frames for each step in the medication regimen review process. This was evident for 2 (#44, #73) of 5 residents investigated for unnecessary medication review. The findings include: 1) A review of Resident #44 medical record revealed that the resident had been residing in the facility since May 2022. On 6/24/24 at 11:10 AM, further review of Resident #44's medical records revealed monthly Medication Regimen Reviews (MRR) were done by the pharmacist (Staff #45). Staff #45 documented in her progress notes that indicated an irregularity was identified and stated MRR complete see report for the month of April. Succeeding progress notes of Staff #45 for the month of May and June stated MRR complete no irregularities noted. Continued review of the resident's medical records failed to reveal the reports generated by the April MRR. On the same day, the report for the MRR was requested from the Nursing Home Administrator (NHA) and was provided at 12:39 PM. The report indicated that Resident #44 was receiving multiple pain medications without a pain scale to specify when each should be administered. The physician responded by adding a pain scale of 1 to 5 to the Tylenol 650 mg every 6 hours as needed for pain, and pain scale of 5 to 10 to the Oxycodone 5 mg every 6 hours as needed for pain. Resident #44's pain medication orders were reviewed later that day at 1:00 PM and revealed current orders of a) Tylenol 325 mg give 2 tablets every 6 hours as needed for pain with a start date of 4/25/24 and b) Tramadol 50 mg give 1 tablet every 6 hours as needed for pain with a start date of 4/25/24. Neither pain medication orders did not have a pain scale to specify when each medication should be administered. Further review of the pain medication order history indicated that the initial order of Tylenol and Oxycodone was changed to indicate the pain scales as instructed by the physician on 4/9/24 but was later discontinued because the resident was sent out to the hospital on 4/19/24. Resident #44 was readmitted on [DATE] with the current pain medication orders. On 6/24/24 at 1:40 PM, the Registered Nurse (RN Staff #46) who was assigned to Resident #44 was interviewed. Staff #46 was asked about what medication she would give the resident if s/he had complaints of pain. Staff #46 reported that she would give the Tylenol if the resident had a pain level of 1 to 3 and would call the physician for any pain complaints higher than 3. Staff #46 was asked if she knew what the pain medication orders were. Staff #46 reviewed Resident #44's orders in the computer and reported that s/he had Tylenol and Tramadol pain medications, but the orders had no pain scales to specify when each medication should be administered and stated, I would call the doctor to clarify which pain medication to administer first. On 6/26/24 at 11:56 AM, the pharmacist (Staff #45) was interviewed and explained her process with MRR. Staff #45 was asked about Resident #44's current pain medication orders and specifically about which pain medication should the nurse administer first? Staff #45 indicated that the staff nurses are aware of the resident's pain medication. The earlier interview with RN Staff #46 was reviewed with staff #45 and the concern was discussed that if Resident #44 was to complaint of pain, the current orders for as needed pain medications did not have a pain scale to specify which medication to administer first. Furthermore, the 2 MRR that was conducted after the resident was readmitted failed to identify these irregularities. Staff #45 acknowledged the concerns and indicated that they were missed. On 6/26/24 at approximately 12:30 PM, the facility's policy and procedure for MRR was reviewed and failed to specify a timeframe for the physician to respond to an identified irregularity. Later that day at 1:01 PM, the concerns were discussed with the Director of Nursing (DON) that the pharmacist failed to identify an irregularity with a resident's pain medications, and the facility's policy and procedures for MRR did not specify a timeframe for the physician to respond to an identified irregularity. The DON acknowledged the concerns. 2) On 6/26/24 at 9:00 AM, a review of Resident #73's medical record was conducted. Review of Resident #73's progress notes revealed on 6/10/24 at 9:58 PM, in a lab/radiology note, the nurse documented that the physician was called to address the resident's lab results and the physician gave an order for Metformin two times a day; check fingerstick and if it is less than 150, hold Metformin. A review of Resident #73's June 2024 MAR revealed a 6/11/24 order for Metformin HCL (Glucophage) (antidiabetic medication) tablet by mouth two times a day for Diabetes, finger stick before giving Metformin and hold if it is less than 150. The MAR documented Resident #73 received the Metformin twice a day, at 9:00 AM and 5:00 PM every day, from 6/11/24 to 6/26/24. There was no documentation in the MAR to indicate the Resident #73's blood glucose (sugar) level was monitored via finger stick prior to the resident being administered the Metformin. Review of Resident #73's Pharmacy Consultant Notes revealed on 6/17/24 at 3:01 PM, in a pharmacy consultant note, the pharmacist documented Resident #73's medication regimen review was complete with no irregularities noted. The pharmacist failed to identify the irregularity related to the facility staff failing to monitor Resident #73's FS prior to administering Metformin twice a day. On 6/26/24 at 11:57 AM, during an interview, when made aware of the above concern, the Pharmacist (Staff #45) indicated that when Resident #73's medication regimen review was completed, the pharmacist not seen the directions for finger sticks in the residents Metformin order. The pharmacist stated she had never seen finger sticks ordered prior to receiving Metformin and thought the order for finger sticks within the Metformin order may not have been intended. The above concern with the pharmacist failing to identify the irregularities related to Resident #73's Metformin order was discussed with the Director of Nurses (DON) on 6/27/24 at 12:30 PM, and the DON offered no further comments at that time.

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 F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

4) Blood pressure (BP) is often written as an upper and lower number. Systolic blood pressure (SBP) is the upper number. It measures the pressure in the arteries during heart muscle contraction. Diastolic BP is the lower number. It measures the pressure in the arteries when the heart rests between beats. Heart rate (HR) is the number of times the heart beats per minute. A medical record review on 6/24/24 at 10:53 AM showed that Resident #37 had been residing in the facility since June 2022 and had diagnoses that included hypertension (high blood pressure). Continued record review found attending provider's orders for Resident #37 for antihypertensive medications. One order was initiated on 6/25/20 for Lisinopril 40mg to be given daily and had parameters to hold (not to give) the medicine for an SBP less than 110 mmHg (millimeters of mercury) or HR less than 55. Another order initiated on 2/7/24 was for hydralazine 50mg to be given with 25mg every 8 hours. The order had parameters to hold the medication for SBP less than 110 or HR less than 60. Resident #37's medication administration records (MAR)for April 1- June 24, 2024, were reviewed on 6/24/24 at 10:56 AM. The review showed that Resident #37's medications were administered as follows: 4/12/24 Hydralazine 50mg was administered for a HR of 58 4/26/24 Hydralazine 50mg was administered for a HR of 59 4/30/24 hydralazine 50mg was administered for a HR of 59 5/5/24 lisinopril 40mg was administered for a HR of 55 5/6/24 lisinopril 40 mg was administered for a HR of 58 5/15/24 Lisinopril 40mg was administered for a HR of 2 5/29/24 Hydralazine 50mg was administered for a HR of 56 5/30/24 hydralazine 50mg was administered for a HR of 53 6/4/24 hydralazine 50mg was administered for a HR of 58 6/23/24 Hydralazine 50mg was administered for a HR of 57 During an interview on 6/26/24 at 9:30 AM, staff #38, a licensed practical nurse, stated she would not give the medications per the attending provider's orders to hold them if the resident's HR was below 55 and 60. In a subsequent interview on 6/26/24 at 9:38 AM, the director of nursing confirmed that, per the MARs, Resident #37's antihypertensive medications were given to him/her on 4/12/24, 4/26/24, 4/30/24, 5/5/24, 5/6/24, 5/15/24, 5/29/24, 5/30/24, 6/4/24 and 6/23/24 even though the attending provider's orders were to hold the medications for a HR below 55 and 60. The DON stated that her expectation of the nurses was to hold the medicines per the attending provider's orders. Based on record review and staff interviews, it was determined that the facility failed to ensure that a resident received medications according to the physician's order, as evidenced by 1) by failing to ensure orders were accurately transcribed, and 2) failing to implement physician orders for parameters prior to administering medication. This was evident for 2 (#64, #73) of 5 residents reviewed for unnecessary medications, 1 (#95) of 4 residents reviewed for discharge, 1 (#37) out of 3 residents reviewed for behavior/mood, 1 (#94) of 11 reviewed for neglect, and 1 (#190) of 2 residents reviewed for death. The findings include: 1) On 6/20/24 at 12:30 PM, a review of Resident #64's medical record revealed that Resident #64 was initially admitted to the facility in mid to late April 2024, then readmitted to the facility in late May 2024, following an acute hospitalization. The medical record review revealed that, on 6/17/24 at 1:58 PM, in a skilled nursing note, the nurse indicated that Resident #64 had been out of the facility for a follow-up medical appointment, then returned to the facility with a new order and the resident's attending physician was updated. On 6/17/24 at 2:01 PM, in a skilled nursing note, the nurse documented that Resident #64 was to have a urinalysis (UA) in the morning and then start Cipro (Ciprofloxacin) (antibiotic). Review of a 6/17/24 consultant physician notes for Resident #64 revealed physician recommendations that included the resident have a UA for a urinary tract infection (UTI) and to start Ciprofloxacin twice a day for 14 days. Review of Resident #64's June 2024 Medication Administration Record (MAR) revealed a 6/18/24 order for Cipro by mouth two times a day for UTI which was documented as given every day as prescribed on 6/18/24 to 6/20/24, with no indication in the order when to discontinue the antibiotic. The facility staff failed to accurately transcribe the consultant physician's order for the resident to receive the Cipro for 14 days. On 6/21/24 at 11:02 AM, the concerns with the above antibiotic order failing to have a stop date was discussed with the Director of Nurses (DON). The DON acknowledged that the Cipro order should have had a stop date and offered no further comments at that time. 2) On 6/26/24 at 9:00 AM, a review of Resident #73's June 2024 MAR revealed an order for Metformin HCL (Glucophage) (antidiabetic medication) tablet by mouth two times a day for Diabetes, finger stick before giving Metformin and hold if it is less than 150. The MAR documented that Resident #73 received the Metformin twice a day, every day, from 6/11/24 to 6/26/24. There was no documentation in the MAR to indicate the Resident #73's blood glucose (sugar) level was monitored via finger stick prior to the resident being administered the Metformin. The facility staff failed to follow the physician's order by failing to monitor Resident #73's blood sugar via FS prior to administering the Metformin. The above concern with the facility staff failing to follow the physician's order to monitor the resident's finger stick prior to administering metformin was discussed with the DON on 6/26/24 at 9:44 AM. The DON acknowledged the concern and offered no further comments at that time. 3) On 7/11/24 at 9:00 AM, a review of Resident #95's August 2022 Medication Administration Record (MAR) revealed an 8/3/22 order for Diltiazem (Cardizem) (antihypertensive drug) tablet by mouth to be given every 6 hours for hypertension (HTN) (high blood pressure). The order stated to hold for systolic blood pressure (SBP) (top number of a blood pressure reading) less than 110 or heart rate (HR) (pulse) less than 60. 3a) The MAR documented that the Diltiazem medication was given to Resident #95 on 3 days in August 2022 when it was outside of parameters. The MAR documented Resident #95's BP and/or HR was outside of parameters and that medication was given and not held on: 8/6/22 at 6:00 AM - BP 107/61, HR 59 8/11/22 at 12:00 PM - BP 102/55 8/19/24 at 6:00 PM - BP 109/68 3b) the MAR documented that on 8/19/22 at 6:00 PM, Resident #95's BP was 107/68 and HR 52 and coded 9 (other/see nurses note). Review of Resident #95's nurses notes failed to reveal a correlating nurses note to indicate whether the Diltiazem was given outside of the parameters, or the medication was held per the physician's order. 3c) On 8/11/22 at 12:00 AM, the MAR indicated Diltiazem was not administered to Resident #95 and coded 6 (no insulin required per orders). The code was inapplicable to the order, and there was no BP or HR documented to indicate why the Diltiazem was not administered to the resident. 3d) On 8/15/22 at 12:00 AM, the MAR indicated that Diltiazem was not administered to Resident #95 and coded 4 (pulse below 60), with no BP documented and no HR documented to indicate why the Diltiazem was not administered to the resident. 3e) Further review of Resident #95's August 2022 MAR revealed multiple Diltiazem administration times that there was no BP or HR documented and was coded 5 (Hold/see nurses notes) indicating the Diltiazem was not given. This was evident for 18 Diltiazem administration times (8/3 at 12 PM, 8/4/22 at 12 PM, 8/6/22 at 12 PM, 8/7 at 12 PM, 8/9 at 12 AM, 8/9 at 12 PM, 8/10 at 12 AM, 8/14 at 12 AM, 8/15 at 12 PM, 8/17 at 12 AM, 8/18 at 12 AM, 8/19 at 12 AM, 8/19 at 12 PM, 8/23 at 12 AM, 8/25 at 12 AM, 8/26 at 12 AM, 8/28 at 12 AM, and 8/29 at 12 AM) in August 2022. Continued review of Resident #95's nurse's notes revealed eMAR (electronic MAR) notes, which populated the Diltiazem order into the note, at the time of administration, the medication was coded 5 in the MAR. Review of the eMAR notes for each of the administration times that were without parameters and coded 5 failed to reveal further documentation to indicate why the Diltiazem had not been administered to Resident #95. On 7/11/24 at 11:29 AM, the Nursing Home Administer (NHA) was made aware of the above concerns with with staff failing to to implement physician orders for parameters prior to administering medication and by failing to document a resident's BP or Pulse in the MAR, and failing to document the reason a medication was not given. The NHA acknowledged the concerns at that time and offered no further comments. 5) Review of complaint MD00183126 on 07/01/24 revealed an allegation that Resident #94 did not receive quality of care while he was residing at the facility from 05/10/22 through 06/13/22. A review of Resident #94's closed medical record revealed a physician order, dated 05/18/22, that instructed the nursing staff to administer the blood pressure medication, hydralazine, 25 mg, orally, three times a day, and to hold the blood pressure medication if the systolic blood pressure reading is less than 110 mm/hg or the heart rate is less than 60 beats per minute. The nursing staff failed to follow the physician's order on the following days: 5a) 05/18/22, 10 pm dose, the nurse documented Resident #94's heart rate at 57 beats per minute. 5b) 05/30/22, 10 pm dose, the nurse documented Resident #94's heart rate at 56 beats per minute. 6) Review of complaint MD00201837 on 07/01/24 revealed an allegation Resident #190 did not receive quality of care while they were residing at the facility from 07/07/23 through 12/06/23. A review of Resident #190's closed medical record revealed a physician order dated 07/27/23 that instructed the nursing staff to administer the diuretic medication, Lasix, 20 mg, orally, every day, and to hold the Lasix medication if the systolic blood pressure reading was less than 110 mm/hg or the heart rate was less than 60 beats per minute. The nursing staff failed to follow the physician's order on the following days: 6a) 07/30/23, 9 am dose, the nurse documented Resident #190's blood pressure to be 100/69. 6b) 05/30/22, 10 pm dose, the nurse documented Resident #94's heart rate at 56 beats per minute.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) Review of Resident #5's medical record on [DATE] revealed that the resident has been residing at the facility since [DATE], needs partial to maximal assistance with Activities of Daily Living (ADLs) is alert and oriented, able to verbally communicate, and has an allergy to sulfa. On [DATE] at 02:32 PM, during an interview with Resident #5, he/she reported having blisters on the back of her/his legs. Record review revealed that on [DATE] there was an order for Silver Sulfadiazine Cream 1% to be applied to the area of blisters every day shift and as needed. Review of the Medication Administration Record revealed that on [DATE], Silver Sulfadiazine Cream 1% was administered. On [DATE] at 03:05 PM, Divisional Director of Quality Assurance (Staff #5) provided the surveyor with an email receipt which revealed the pharmacy alerted the facility on [DATE] that the resident has an allergy to sulfa. Staff #5 further indicated that the medication was then discontinued on [DATE] and the pharmacy never sent it. Further interview with Staff #5 on [DATE] at 3:05 PM revealed that when asked about the [DATE] documentation that Silver Sulfadiazine Cream 1% was administered, Staff #5 reported this was an error, it was never delivered, and she further indicated they were still investigating. On [DATE] at 11:00 AM, the NHA presented documentation that indicated that Licensed Practical Nurse (Staff #33) had signed the administration of the medication on [DATE] in error and an Employee Disciplinary Form dated [DATE], concerning the error which was signed by Staff #33. On [DATE] at 11:00 AM, the surveyor reviewed the concern with NHA that staff signed off a medication that was not actually administered. Based on records review and interviews, it was determined that the facility failed to maintain resident medical records in accordance with accepted professional standards by failing to ensure accurate documentation. This was evident for 2 (#22, #59) of 9 residents reviewed for care planning, 2 (#84, #83) of 3 residents reviewed for closed records, 1 (#36) of 5 residents reviewed for medication administration, and 1 (#5) of 6 residents reviewed for general concerns. The findings include: 1) Resident #22 had been a resident of the facility since 2022. On [DATE] at 2:06 PM, a quick review of Resident #22's medical record indicated that a care plan meeting had taken place earlier that day at 9 :17 AM, with the Nursing Home Administrator (NHA), Social Service Director (SSD), Ombudsman and the resident. This was documented in Resident #22's progress notes by the SSD. To ensure that a resident-centered care plan is developed, a care plan meeting is held by a group of individuals including the resident and/or resident representative, if applicable, with the knowledge of the resident's needs and preferences to make decisions about the resident's care. Later at 2:41 PM, Resident #22 was interviewed about the different aspects of care s/he was receiving as a resident of the facility. The resident was asked to confirm if s/he attended the meeting that was documented by the SSD and stated, We didn't have a meeting today, we had a meeting last week and indicated that it was in the afternoon. On [DATE] at 9:12 AM, the NHA was interviewed about Resident #22. The NHA reported that the Ombudsman did come in for the care plan meeting, but it was not held last Monday (6/17), it was held last week and indicated that it was in the afternoon as well. On the same day at 9:41 AM, the SSD accompanied by the NHA was interviewed about her process with care planning. The SSD was asked specifically about her note regarding the care plan meeting with an effective date of [DATE] at 9:17 AM. She reported that it was documented in error and confirmed that the meeting was held on [DATE] at approximately 3:30 PM. The concern was discussed with both staff regarding maintenance of accurate documentation in resident records. Both NHA and SSD acknowledged the concern. 2) The MOLST (Maryland Medical Order for Life Sustaining Treatment is a portable and enduring medical order form that includes medical orders for Emergency Medical Services and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. On [DATE] at 10:58 AM, a review of a binder containing the active MOLST for each of the residents residing on Unit 1 revealed Resident #59 had an active MOLST, which was signed and dated [DATE], that documented Resident #59 elected No CPR, Option B, Palliative and Supportive care, indicating if cardiac and/or pulmonary arrest occurred, do not attempt resuscitation (No CPR) and allow death to occur naturally. On [DATE] at 10:13 AM, a review of Resident #59's electronic health record (EHR) revealed an uploaded MOLST dated and signed on [DATE], that documented Resident #59 elected No CPR, Option B, Palliative and Supportive care, No CPR. Further review of Resident #59's medical record revealed, on [DATE] at 3:41 PM, in a Social Services Note, the Social Service Director (SSD), Staff #17 documented Resident #59 was alert and oriented x 3 (oriented to time, person and place). The SSD further documented the resident's MOLST was addressed and is Full Code, indicating the resident had elected to receive CPR, if cardiac and/or pulmonary arrest occurred, and all medical efforts that are indicated during arrest. The SSD's documentation contradicted Resident #59's [DATE] MOLST which indicated the resident did not want CPR. Continued review of Resident #59's EHR revealed a [DATE] a care conference note, signed by Staff #17, SSD, that included a check off list with multiple topics that could potentially be discussed with a resident. The topics, Advanced Directive, and POLST (Physician Orders for Life Sustaining Treatment)/MOLST were not checked off, indicating the topics were not discussed with Resident #59 during the care conference. In addition, no other documentation was found in the EHR to indicate that Resident #59's MOLST and/or the resident's right to formulate advanced directives had been discussed with Resident #59. Review of Resident #54's care plans revealed a care plan with the focus, [Resident #59's] advanced directive is Full Code, which was initiated on [DATE] and had a revision date [DATE]. The care plan focus was inaccurate, as Resident #59's active MOLST documented the resident elected No CPR. On [DATE] at 10:16 AM, during an interview, Staff #17, SSD, was made aware that the SSD's care conference note documentation on [DATE] indicating the resident was a full code contradicted Resident #59's active MOLST in which the resident elected No CPR, and Resident #59's care plan focus, Advanced Directive is a full code, contradicted the resident's active MOLST in which the resident elected No CPR. The SSD acknowledged the concerns and indicated the discrepancy in the documentation of the resident's code status needed to be addressed, and the SSD offered no explanation or further comments at that time. The above concerns were discussed with the Nursing Home Administrator (NHA) on [DATE] at 1:54 PM, and the NHA offered no further comments at that time. 3) On [DATE], review of Resident #84's medical record revealed a social service note, written by Staff #17 and dated [DATE] at 4:46 PM, that included: Resident was discharged to another SNF [skilled nursing facility] ([name of the other facility]) on [DATE] .Resident was set up with home health services with [name of a home health agency] . Further review of the medical record failed to reveal documentation to indicate home health services were set up, or indicated, in relation to the [DATE] discharge to another skilled nursing facility. On [DATE] at 11:00 AM during an interview with Director of Social Service (Staff #17) regarding the [DATE] note, She/he confirmed the note contained incorrect documentation regarding .set up with home health services with [name of agency] . Staff #17 confirmed that she documented something that she did not do. 4) On [DATE], review of Resident #83's medical record revealed the resident had resided at the facility for several years. Further review of the medical record revealed the presence of two unvoided MOLST forms. Maryland Medical Orders for Life Sustaining Treatment (MOLST) is a form that includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR)and other life-sustaining treatment options for a specific patient. It is valid in all health care facilities and programs throughout Maryland. Section 1 includes orders to Attempt CPR or No CPR. Included in the No CPR section are three options: A-1 Intubate; A-2 Do Not Intubate but comprehensive efforts may include limited ventilaroty support by CPAP or BiPAP; or Option B No CPR, Palliative and Supportive Care, do not intubate or use CPAP or BiPAP. The first MOLST, dated [DATE], included orders for No CPR [cardiopulmonary resuscitation] Option A-2 Do Not Intubate: Comprehensive efforts may include limited ventilatory support by CPAP or BiPAP, but do not intubate. The second MOLST, dated [DATE] revealed an order for No CPR Option B Palliative and Supportive Care: Prior to arrest , provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use CPAP or BiPAP. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. On [DATE] at 4:26 PM, surveyor reviewed with [NAME] President of Clinical Operations (Staff #20) the concern regarding multiple active MOLSTs that had not been voided when a new MOLST was established. Staff #20 indicated that she understood the concern. 5) Review of Resident #36's medical record revealed the resident was admitted in 2023 and whose diagnoses included but was not limited to, rheumatoid arthritis. On [DATE] at 8:55 AM, surveyor observed nurse (Staff #35) prepare and administer Resident #36's medications. The nurse prepared a total of 10 medications, which included two lidocaine patches. Surveyor observed the nurse remove an old patch from the resident's left knee and one from right knee. After the observation, the nurse confirmed that the patches that were removed did not include a date. On [DATE] at 10:09 AM, review of the medical record revealed there was one order, with a start date of [DATE], for Lidoderm Patch 5% apply to both knees, R.[right] thigh/groin topically one time a day for pain management and remove per schedule. Review of the Medication Administration Record revealed an area for nursing staff to document the removal of these patches at 2100 (9:00 PM). Staff had documented the removal of these patches for the evening of [DATE]. On [DATE] at 10:39 AM, surveyor reviewed the concern with the unit nurse manager (Staff #14) that staff had documented the removal of the patches to the knees yesterday but they were observed on the resident this morning.

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

Read full inspector narrative →

Based on observations and interviews with facility staff, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: 1) During an initial tour on 6/17/24 at 8:52 AM of the facility's walk-in refrigerator with staff #32, corporate food services manager, the following observations were made: - an opened thickened lemon-flavored water with an open date of 6/10/24 and a use-by date of 6/17/24. Staff #32 stated that once opened, the thickened water must be used in 5 days. Staff #32 then said, I will discard it. - an opened cranberry cocktail juice from concentrate with an expiration date of 9/12/23; staff #32 stated, I will discard it. - an opened thickened apple juice from concentrate, dated 5/24. Staff #32 stated that it was delivered on 5/24. However, it did not indicate an open date or use-by date. Staff #32 stated it should have an open date and use-by date. - opened thickened pomegranate flavored water with no open date and use-by date. - opened thick and easy milk dated 2/7. Staff #32 indicated 2/7 was the delivery but should also have an open and use-by date. - sliced American cheese in a zip-lock bag dated 6/8/24 and a use-by date 6/30/24. Staff #32 stated it should say use by 6/29/24 because we keep it for 21 days from the open date. - sliced ham labelled 6/8/24, and use by 6/30/24. Staff #32 stated, The use-by date should have been 6/22/24. - opened gold medal heavy duty (1 gallon) mayonnaise and not dated; staff #32 stated, It has no open or use by date. - sweet pickle relish (1gal) labeled opened 5/1 and had no use-by date. Staff #32 stated that it should have been thrown away on 6/1. - Half-cut fresh tomato and lettuce in saran wrap had no use-by date. Staff #32 stated, It's not fresh. Every fresh produce should be dated from the date we received it, and we have two weeks from that date to use it. I will discard them. - Cabbage in a box with no use-by date; staff #32 stated it should have been dated with a use-by date. 2) On 6/24/24 at 9:22 AM, the surveyor observed the short-stay unit snack/refreshment refrigerator. The observation revealed pineapple slices in a plastic container not labeled with an open date or use-by date. Staff #22, a registered nurse, was present and stated, It's for a resident; it should have been labeled and dated. 3) An observation on 6/24/24 at 9:51 AM of the long-term care Unit snack/refreshment refrigerator with staff #13, a unit manager showed the following: -opened Thickened pomegranate berry flavored water with an open date of 5/29/24. Staff #13 stated he does not know how long it should be kept once opened. -cake in a gift bag with no use-by date. Staff #13 stated, It's from a family, but it has no date. Before staff take it and put it in the fridge, they should date it. -opened pineapple slices in a container with no date opened. Staff #13 stated, It's for a resident; it should have been labeled and dated. In an interview on 6/24/24 at 9:41 AM, staff #14, the unit manager for the skilled unit, stated that foods to be kept in the snack/refreshment refrigerators had to be labeled, dated, and discarded after three days. In a subsequent interview on 7/1/24 at 1:05 PM, staff #39, the General manager for food services, stated that they labeled the food items when they were to expire upon receiving them. Staff #39 added that the kitchen refrigerators were checked daily to see what items were due to be discarded.

Sept 2019 7 deficiencies

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on review of clinical records and staff interview, it was determined that the facility staff failed to report to the appropriate authorities a resident's elopement (#135). Elopement is defined per the Centers for Medicare and Medicaid Services as occurring when a resident leaves the premises or a safe area without authorization (i.e. an order for discharge or for a leave of absence) and/or any necessary supervision to do so. The findings include: On 09-27-19, review of the clinical record for resident #135 revealed that he/she was admitted for short term rehab on 09-13-19. Further review of the clinical record revealed that, on 09-20-19 at 5:55 AM, facility staff were unable to locate resident #135 and an unrelated visiting family member confirmed by viewing a photograph that he/she had let resident #135 out upon entering the facility that morning. Facility staff made a search of the surrounding community and notified the police of the resident's elopement. The resident returned to the facility via a privately owned vehicle at approximately 11:30 AM. The resident was immediately assessed and no concerns were identified. The facility initiated interventions to further prevent visitors from unknowingly facilitating resident elopement. Resident #135 continued his/her rehab as per the plan of care, and was discharged on 09-26-19 without incident. The facility staff failed to report to the appropriate authorities, that resident #135 had left the premises/safe area without authorization which may have placed the resident at risk of (or having the potential to experience) heat or cold exposure, dehydration and/or other medical complications, or being struck by a motor vehicle. Upon surveyor intervention, a report was submitted to the appropriate authorities notifying of the resident's elopement and the interventions implemented. On 09-27-19, after submission of the report of elopement, interview with the facility administrator revealed no additional information.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on surveyor review of the clinical record and interview with facility staff, it was determined that the facility failed to ensure standards of nursing practice for a resident receiving pain medication. This finding was evident for 1 of 3 residents selected for pain review during the survey (#69) The findings include: On 09-26-19 at 3:15 PM, surveyor review of a resident #69's record revealed 3 physician orders for pain medication, 1) Acetaminophen 325mg, two tablets by mouth every 6 hours as needed for mild pain, not to exceed 3gm in 24 hours, written on 07-01-19, 2) Oxycodone 5mg to be administered in the amount of one tablet every 6 hours as needed for moderate pain written on 07-24-19 and 3) Oxycodone 5mg to be administered in the amount of two tablets every 6 hours as needed for sever(e) pain, also written on 07-24-19. The facility utilized a numeric pain scale between 0 and 10, with 0 being free of pain and 10 being severe pain, in order to assess resident #69's pain levels. On the morning of July 25, 2019, 2 tablets of Oxycodone were given for severe pain rated by the resident as 9 out of 10. However, on the morning of July 27th, 2 tablets were given for severe pain, rated 4 out of 10 in the morning. On that evening, resident #69 received 2 tablets for severe pain, rated 5 out of 10. Surveyor review of resident #69's Medication Administration Record (MAR) revealed that, in the month of July 2019, 2 tablets of Oxycodone 5mg (for severe pain) were administered 7 times for pain values ranging between 4 and 9 out of 10. In the month of August, the same medication and dose were administered 17 times for the resident's pain values ranging between 4 and 8 out of 10. Additional review revealed that neither Acetaminophen (2 tablets of 325mg) for mild pain or Oxycodone (1 tablet of 5mg) for moderate pain were administered in either July or August 2019. Further record review revealed that nursing staff failed to clarify pain medication orders with the physician to determine what level of pain on the pain scale correlates to mild, moderate, or severe pain. Code of Maryland Regulation 10.27.09.03 F (Collaboration) of the Maryland Nurse Practice Act states the Registered Nurse shall collaborate with the client, family, significant others, and other health care providers in the formulation of overall goals, the plan of care, and decisions related to care and the delivery of services. Surveyor interview with the Director of Nursing on 09-25-19 at 4 PM revealed no additional information.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on surveyor observation, review of the clinical record and resident and staff interviews, it was determined that the facility staff failed to provide adequate assistance with activities of daily living (ADL's). This finding was evident for 1 of 1 residents reviewed during survey for the ADL care area (#71). The finding includes: On 09-24-19 at 12:02 PM, surveyor interview of resident #71 revealed a complaint that the facility staff should be using a lift to get me up, but they don't on the rare occasion that they do get me out of bed. The resident also stated that he/she has facial hair that staff won't shave off. On 09-27-19, review of the care plan for resident #71 stated transfer via mechanical lift only, however, facility staff transferred resident with two person assist on 09-25-19 and 09-26-19, and not via mechanical lift as the care plan stated. The transfer via mechanical lift had been recommended by the rehab department. There was no information in the clinical record to indicate this requirement was no longer necessary. On 09-27-19 at 1:35 PM, surveyor observation of resident #71 verified the presence of a significant growth of facial hair (beard), under the resident's chin. After surveyor intervention, facility staff shaved the resident as the resident requested. Review of the self-care deficit care plan for resident #71 stated that the facility staff would assist the resident with daily hygiene and grooming as needed. The facility staff failed to follow the plan of care related to the grooming of resident #71. On 09-27-19 at 3:50 PM, surveyor interview with the Director of Nursing revealed no additional information.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on surveyor observations, review of the clinical record (s) and resident and staff interviews, it was determined that the facility staff failed to adequately manage pain and discomfort for residents with significant pressure injury. This finding was evident for 2 of 3 residents reviewed for pain management during the survey (#40 and #71). The findings include: 1. On 09-25-19 at 11:28 AM, surveyor observed resident #40 moaning repeatedly. When asked if he/she was in discomfort, resident #40's response was my leg, my leg hurts so bad. The resident began rubbing their right leg. Review of the clinical record revealed that resident #40 had a stage 4 sacral pressure ulcer. (A stage 4 pressure ulcer is a wound that extends deep, exposing underlying muscle, tendon, cartilage or bone). Review of the care plan for the sacral ulcer listed administer analgesics as needed as an intervention initiated on 07-26-19, however, further review of the clinical record revealed that no analgesic (pain medication) had been ordered for the resident either routinely, or as needed, for wound care or other pain. The resident did have a physician's order for Neurontin, a medication used to treat neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness). Upon surveyor intervention, RN charge nurse #1 came in and assessed resident #40, and then contacted the attending physician to report the resident's complaint of pain. A new order was received for Tylenol 325 mg 2 tablets every 8 hours routinely, and Tylenol 325 mg 2 tablets by mouth 30 minutes prior to wound care. On 09-26-19 at 3:10 PM, surveyor interview with resident #40 revealed I'm feeling a whole lot better now after having received the routine Tylenol as ordered. 2. On 09-25-19 at 12:19 PM during surveyor observation of a wound care dressing change for a stage 4 sacral pressure ulcer, resident #71 was noted to be moaning. The surveyor asked the resident if he/she was having pain, and the resident responded, yes. The surveyor then asked resident #71 to rate the pain he/she was experiencing during the dressing change on a scale of 1 to 10 with 10 being excruciating and resident #71 rated the pain as a 9 on a scale of 1 to 10. Surveyor then immediately halted the dressing change. Review of the clinical record for resident #71 revealed that the resident was initially seen by the wound doctor on 09-03-19 who decided that mechanical debridement (removal of dead tissue with a surgical instrument) would be the appropriate course of treatment. This mechanical debridement would occur once weekly per the wound doctor's plan of care. Between mechanical debridements, a treatment order was given for the nursing staff to perform dressing changes twice daily to aid in healing and/or attempt to prevent the wound from worsening. On 09-14-19, the treatment order was changed to a different product to be applied once daily. Further review of the clinical record revealed no order for pain medication for resident #71 until 09-24-19. On 09-24-19, an order for Tylenol 325 mg was written with instructions for facility staff to administer 30 minutes prior to dressing change. Prior to the wound care observation, RN charge nurse #1 had administered the Tylenol 325 mg 2 tabs as ordered, however, the resident was still experiencing significant pain during the dressing change. RN charge nurse #1 notified the attending physician of the severe pain that resident #71 was experiencing during the treatment, and a new order was received for Tramadol 50 mg every 8 hours. RN charge nurse #1 administered the Tramadol upon obtaining the order, and the surveyor went back to observe completion of the dressing change at 2:00 PM. At this time, resident #71 denied any pain or discomfort during the dressing change and stated this medicine is so much better. That Tylenol wasn't doing anything!

CONCERN (D)

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

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on surveyor review of the clinical record and staff interview, it was determined that the facility staff failed to ensure that the attending physician addressed a resident's significant weight loss. This finding was evident for 1 of 6 residents reviewed for the nutrition care area during survey (#9). The findings include: On 09-25-19, surveyor review of the clinical record for resident #9 revealed a 10% weight loss since 06-01-19. Review of physicians progress notes, dated 08-23-19 and 09-23-19, revealed no mention by the attending physician of the significant weight loss or any attributable causes or immediate care needs related to the significant weight loss. On 09-25-19 at 9:12 AM, surveyor interview with the facility dietitian revealed interventions initiated by him/her that included supplements and double portions at meal time with family also agreeing to bring in foods that resident #9 enjoys. The dietitian described the resident as being severely underweight and stated the resident had a past history of oropharyngeal cancer (cancer in the tissues of the throat) along with hepatocellular cancer (cancer arising from the liver cells) and was scheduled for a follow up with their oncologist within a week or two. The dietitian stated the attending physician was aware of the weight loss, however, he/she could find no documentation in the clinical record to reflect the physician's awareness or plan for treatment related to the significant weight loss.

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on surveyor observation, resident and staff interview, and review of clinical records, it was determined that the facility staff failed to revise the plan of care to adequately reflect the needs of the resident. This finding was evident for 2 of 3 residents reviewed for revision of care plans. (#40 and #71) The findings include: 1. On 09-25-19 at 11:28 AM, observation of resident #40 revealed the resident moaning repeatedly. When asked if he/she was in discomfort, resident #40's response was my leg, my leg hurts so bad. The resident began rubbing their right leg. The responsible party who was at the bedside at the time of the observation replied, sometimes the pain is from the bedsore, sometimes it's the leg. I've told the nurses a few times before about it since she got here. Review of the clinical record revealed that resident #40 had a stage 4 sacral pressure ulcer. Review of the care plan for the sacral ulcer listed administer analgesics as needed as an intervention initiated on 07-26-19. However, further review of the clinical record revealed that no analgesic (pain medication) had been ordered for the resident either routinely or as needed for wound care or other pain. The resident did have a physician's order for Neurontin, a medication used to treat neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness). The care plan listed an intervention which could not be implemented, as there was no order for an analgesic, resulting in a plan of care that did not adequately reflect the needs of the resident. Further review of the care plan for resident #40 revealed a care plan, initiated on 07-29-19, which stated that the resident was reliant on total parenteral nutrition (TPN) to meet 100% of nutrition needs. The facility staff failed to revise the care plan to reflect that the resident was assisted with meals and was no longer 100% reliant on the TPN to meet his/her nutritional needs. On 09-27-19 at 3:50 PM, surveyor interview of the Director of Nursing revealed no additional information. 2. On 09-24-19 at 12:02 PM, surveyor interview of resident #71 revealed a complaint that the facility staff should be using a lift to get me up, but they don't on the rare occasion that they do get me out of bed. The resident also stated that he/she has facial hair that staff won't shave off. On 09-27-19, review of the care plan for resident #71 stated transfer via mechanical lift only, however facility staff transferred resident with two person assist on 09-25-19 and 09-26-19, and not via lift as the care plan stated. On 09-27-19 at 10:30 AM, surveyor interview with the Director of Nursing revealed that the resident had improved and could be transferred with a two person assist, however, the care plan had not been revised to reflect this change in status. On 09-27-19 at 1:35 PM, surveyor observation of resident #71 verified the presence of a significant growth of facial hair (beard), under the resident's chin. After surveyor intervention, facility staff shaved the resident as the resident had requested. Review of the self-care deficit care plan for resident #71 stated that facility staff would assist the resident with daily hygiene and grooming as needed. The facility staff failed to follow the plan of care related to the grooming of resident #71. On 09-27-19 at 3:50 PM, surveyor interview of the Director of Nursing revealed no additional information.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected most or all residents

Read full inspector narrative →

Based on surveyor observation of the facility's lobby and common areas, and facility staff interview, it was determined that the facility failed to provide the results of the most recent survey of the facility in a place readily accessible to residents, family members and legal representatives of residents. The findings include: On 09-24-19 at 9 AM, surveyor tour of the lobby area revealed that the facility's survey materials were not readily accessible for public review. Individuals wishing to examine survey results would be required to ask to see them, as the materials were housed in binders behind a staffed reception desk, which otherwise had no open access. On 09-25-19 at 8:45 AM, surveyor's revisit of reception desk area revealed that survey materials remained stored behind the reception desk in a restricted area requiring assistance to review them. On 09-25-19 at 3 PM, surveyor interview with Director of Nursing and the facility Administrator provided no additional information.

Aug 2018 16 deficiencies

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

2. a. On 08-15-18 review of the clinical record for resident #33 revealed that on 08-08-18, resident #33 had an elevated temperature of 101.3 degrees Fahrenheit. There was no evidence in the clinical record that the family/responsible party had been made aware of the residents' temperature elevation. b. Further review of the clinical record revealed resident #33 had a significant weight loss of 7.5% of his/her body weight between 06-30-18 and 07-30-18, and weight loss of 5.4% of body weight between 07-08-18 and 08-18-18. There is no evidence in the clinical record that the physician or responsible party were made aware of the significant weight losses. On 08-15-18 at 2:38 PM, interview with the director of nursing revealed no additional information. Based on surveyor review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to notify resident #34's legal guardian when there was a change in treatment and failed to notify the physician and/or family member/responsible party of significant changes in medical condition, #33. This finding was evident for 2 of 4 residents selected for review during the survey (#34 and #33). The findings include: 1. On 08-15-18, review of resident #34's clinical record revealed that the resident's daughter had the durable power of attorney for all resident clinical decisions due to the resident's health condition. Additional record review revealed a physician order written on 08-13-18 for a new medication, Atorvastatin 40 mg, (medication used to treat high cholesterol level) to be given daily at bedtime. An additional order was written to draw blood for labs the next morning to monitor resident #34's cholesterol levels. However, there was no evidence that resident #34's guardian was notified about the new medication and/or lab draw that was ordered. Review of a nurse's note written on 08-13-18 at 7:58 PM, revealed resident is self-responsible and made aware of new medication and labs when actually, all clinical care decisions were supposed to be made by resident #34's daughter. On 08-15-18 at 8:30 AM, surveyor interview with resident #34's daughter who is the responsible party and makes all clinical decision on behalf of the resident revealed that she was not aware of the new medication and lab orders. On 08-15-18 at 11:30 AM, interview of the Director of Nursing (DON) revealed no additional information.

CONCERN (D)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on surveyor observation and interview of staff and family, it was determined that the facility staff failed to ensure that contracted nursing assistants/companions had the appropriate abuse training. This finding was evident in 3 of 3 contracted nursing assistants/companions selected for review of this requirement during the survey. The findings include: On 08-13-18 at 11:10 AM, surveyor observation revealed resident #33 in bed asleep with a visitor at the bedside. The visitor was identified as a companion by facility staff. Interview of the companion revealed that he/she is a nursing assistant who was hired by the family of resident #33 through a staffing agency to spend 40 hours per week with the resident. The companion/nursing assistant informed the surveyor that the resident has 2 other companions that assist in providing the 24 hour a day services as contracted by the family. On 08-14-18 at 2:20 PM, the companion/nursing assistant also stated he/she provided resident #33 with activities of daily living assistance to include bathing, dressing, transferring and assistance with meals. The companion/nursing assistant informed the director of nursing in the presence of the surveyor that he/she bathes, dresses, transfers, and assists resident #33 with meals. On 08-14-18 at 2:30 PM, interview with the director of nursing revealed the facility had no evidence of criminal background checks or abuse training for the companions/nursing assistants providing care for resident #33 24 hours a day. Following surveyor intervention, facility staff contacted the staffing agency and obtained evidence of abuse training for the nursing assistant/companions of resident #33.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on surveyor review of the clinical record, surveyor observation and interview with facility staff, it was determined that the facility failed to review a resident's quarterly plan of care. This finding was evident in 1 of 37 residents selected for review during the survey. (#34). The findings include: On 08-15-18, review of resident #34's clinical record revealed that the resident's daughter has the durable power of attorney for all resident clinical decisions due to the resident's health condition. On 08-15-18, surveyor review of the clinical record revealed the last care plan meeting held to review resident #34's plan of care was held on 03-28-18. On 08-15-18 at 08:30 AM, surveyor interview with resident #34's daughter revealed that she has not been invited or called on the phone to participate in a care plan meeting since March 2018. There was no evidence that a quarterly review of resident #34's care plan was done by the interdisciplinary team as required. Resident #34's representative was not given the opportunity to participate in the review of his/her plan of care. Surveyor interview with social worker revealed this was an honest mistake. I usually schedule a care plan meeting quarterly as required but forgot to do so this time. On 02-14-18 at 11:42 AM, surveyor interview with the director of nursing did not reveal any new information.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on surveyor observation, review of the clinical record and interview of the facility staff, it was determined that the facility staff failed to provide an on-going program based on an individual's interest. This finding was evident for 1 of 2 residents selected for review (#19). The findings include: On 08-13-18 at 2 PM, the surveyor overheard resident #19 cry out for help while interviewing resident #46 in the room. Resident #46 complained that resident #19 constantly yelled out loudly days and nights. On 08-13-19 at 11 AM, 08-13-19 at 2 PM, 08-14-18 at 9 AM and 08-15-18 at 12 noon, resident #19 was found in bed while the television was turned on On 08-15-18, review of the activity assessment, which was completed on 07-23-18 revealed that resident #19 required glasses for reading The resident was interested in music, drawing, painting, making things, cards/games, outdoor activities, religious involvement and talking/conversation. Further review of the July 2018 daily activity/recreation participation documentation revealed the activity staff provided resident #19 with the facility's daily flyer. In addition, the resident was reported watching TV daily. In August, the resident was reported watching TV and participated in music/singing daily, but music/singing activity was scheduled only once a month. There was no evidence that the resident wore eye glasses during observations on 08-13-18, 08-14-18 and 08-15-18. It was unknown whether the resident could read the facility's daily flyer or not when offered. In addition, there were no painting materials available in the room for resident #19 to complete on his/her own. On 08-15-18 at 2 PM, interview of staff #1 revealed the resident did not have a pair of glasses. Then, staff #1 informed the surveyor 15 minutes later that the glasses were found in the patient's room. On 08-15-18 at 6:30 PM, interview of the Director of Nursing and the facility administrator revealed no additional information.

CONCERN (D)

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

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

2. On 08-04-18, resident #223 received a TB skin test, per facility infection control procedures for new admissions. On 08-09-18, facility staff identified the results as positive and notified the physician on call who ordered a chest x-ray to rule out tuberculosis. On 08-10-18, the chest x-ray result revealed that resident #223 had a slight right lower lobe infiltrate. (Infiltrates are white spots seen on x-ray that identify an infection). Additionally, on 08-10-18, the attending physician documented in a progress note +PPD (TB skin test) Negative chest x-ray, asymptomatic, discussed with the on call infectious disease MD, and recommended outpatient follow up with primary care physician for latent tuberculosis treatment, On 08-13-18 at 2:16 PM, surveyor interviewed the infectious disease doctor regarding the results of the positive chest x-ray in the clinical record of resident #223. The infectious disease doctor, upon hearing the result, informed the surveyor that he/she would consider this a positive result for resident #223, who had a positive TB skin test, andhe/she would have recommended the resident be transferred to the emergency room for further evaluation to rule out a tuberculosis infection. The resident was started on the antibiotic Levaquin by the attending physician on 08-10-18 for presumptive pneumonia. The infectious disease doctor stated that he/she was informed by the attending physician that the chest x-ray was negative (as was documented in the attending physician's progress note on 08-10-18). The infectious disease doctor informed the surveyor that the facility should have also notified the local health department of the positive TB skin test, and positive chest x-ray. The infectious disease doctor stated he/she would contact the attending physician to follow up. The physician did not order any type of precautions to prevent the spread of infection until the tuberculosis could be ruled out. Following surveyor intervention, the local health department TB clinic was notified. Based on surveyor review of the clinical records and interview of the facility staff, it was determined that the attending physician failed to visit an individual routinely and the attending physician failed to document in the clinical record or communicate a positive chest x-ray result to a consulting physician. This finding was evident for 2 of 2 residents selected for review (#17 & 223). The findings include: 1. On 08-16-18, review of resident #17's clinical record revealed the attending physician, who was the facility's medical director, visited the resident every 2 months in the past 12 month period, except December 2017. Resident #17 was not seen by the attending physician between November 2017 and February 2018, in a 4 month period. On 08-16-18 at 11:50 AM, interview of the Medical Records Coordinator revealed no evidence that the attending physician visited resident #17 in December 2017. On 08-16-18 at 7 PM, interview of the Director of Nursing revealed no additional information.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on surveyor review of resident #17's clinical record and interview of the resident and facility staff, it was determined that the consultant pharmacist failed to identify an irregularity after conducted monthly drug regimen reviews. This finding was evident for 1 of 5 residents selected for review (#17). The findings include: On 08-16-18 at 12 noon, interview of resident #17 revealed the resident was alert and oriented, but required some assistance with activities of daily living. On 08-16-18, review of resident #17's clinical record and Medication Administration Record (MAR) revealed the attending physician ordered acetaminophen 500 mg 2 tablets (1 gram) twice a day for pain. In addition, the PRN (as needed) orders were written to administer 20 ml of acetaminophen 160 mg/5ml (640 mg) every 6 hours as needed (PRN) for pain and 2 tablets of Oxycodone-acetaminophen 5-325 mg every 8 hours as needed (PRN) for severe pain. A specific instruction was given that the resident should not consume more than 3 grams of acetaminophen in a 24 hour period. Based on the above physician's orders, resident #17 could only receive either one dose of acetaminophen 640 mg per day as needed for pain, or one dose of Oxycodone-acetaminophen 5-325mg per day as needed for severe pain, after taking acetaminophen 1 gram twice a day. The PRN orders were questionable, and required a clarification from the attending physician. See F 658. Further review of the MAR between June 2018 and August 2018 revealed that resident #17 received more than 3 gram of acetaminophen per day on 06-10-18, 07-15-18, 07-17-18, 07-28-18 and 08-12-18, which was inconsistent with the physician's orders. However, the consultant pharmacist documented on 06-07-18, 07-12-18 and 08-12-18 that there was no irregularity. On 08-16-18 at 7 PM, interview of the Director of Nursing revealed no additional information.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on surveyor review of the clinical record, staff and physician interviews,and review of infection control policies, it was determined that the facility staff failed to follow the established infection control standards. This finding was evident in 1 in 6 residents reviewed for compliance with infection control procedures.(#223) The findings include: On 08-04-18, resident #223 received a TB skin test per facility infection control procedure for new admissions. The result of the first step of the TB skin test was to be read within 48-72 hours of administration. However, review of the clinical record revealed that it was not read during the identified time frame, (08-06-18 or 08-07-18). Facility staff did not read the result until 08-09-18. (2 days late) On 08-09-18, facility staff identified the results as positive and notified the physician on call who ordered a chest x-ray to rule out tuberculosis. On 08-10-18, the chest x-ray result revealed that resident #223 had a slight right lower lobe infiltrate. (Infiltrates are white spots seen on x-ray that identify an infection). On 08-13-18 at 2:16 PM, surveyor spoke with a consulting infectious disease doctor and read the results of the chest x-ray which was in the clinical record of resident #223. The infectious disease doctor, upon hearing the result, informed the surveyor that he/she would consider this a positive result in this resident, who had a positive TB skin test, and would have recommended the resident be transferred to the emergency room for further evaluation to rule out a tuberculosis infection. Instead, the resident remained in the facility and was started on the antibiotic Levaquin by the attending physician on 08-10-18. On 08-13-18, following surveyor intervention, the facility staff contacted the local health department informing them that resident #223 has a positive TB skin test and chest x-ray. A follow up telephone call clarified the chest x-ray as positive. The facility staff did not transfer the resident out for further evaluation for a possible tuberculosis infection, nor did they implement any type of precautions to prevent the spread of infection until the tuberculosis could be ruled out.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on surveyor review of clinical records and staff interviews, it was determined that the facility staff failed to ensure that services provided by the facility met professional standards of quality. This finding was evident in 4 of 37 residents selected for review during the survey (#34, #17, #41 and #269). The findings include: 1. On 08-15-18 at 2:10 PM, surveyor review of resident #34's clinical record revealed a physician order written on 04-13-18 to check a Depakote (medication used for treatment of manic episodes associated with bipolar disorder) level every 4 months. Surveyor review of resident #34's Medication Administration Record (MAR) revealed that Depakote was not being administered to resident #34. Further record review revealed that resident #34 was ordered multiple medications including, but not limited to, Depakote 500 mg twice daily on 01-10-17. However, additional review of resident #34's physician order sheet revealed that Depakote 500 MG was discontinued on 01-17-17 at 10:55 PM. On 04-13-18, resident #34's primary physician a ordered Depakote level lab even though Depakote had not been administered to resident #34 in about 16 months. On 08-15-18 surveyor review of resident #34's labs revealed that blood was drawn on 08-13-18 to check the level of Depakote. The facility staff failed to notify the primary physician that resident #34's Depakote had been discontinued since January 2017 and was not currently on the medication and question why the level would need to be drawn. As a standard of nursing practice, a licensed nurse is required to clarify any unclear orders with the physician as indicated in section 10.27.09.01 of the Nurse practice act under collaboration of care. On 08-15-18 at 11:30 AM, interview of the Director of Nursing (DON) revealed no additional information. 2. On 08-16-18, review of resident #17's clinical record and MAR revealed the attending physician ordered acetaminophen 500 mg 2 tablets (1 gram) twice a day for pain. In addition, the PRN (as needed) orders were written to administer 20 ml of acetaminophen 160 mg/5ml (640 mg) every 6 hours as needed (PRN) for pain and 2 tablets of Oxycodone-acetaminophen 5-325 mg every 8 hours as needed (PRN) for severe pain. A specific instruction was also written to clarify that the total amount of acetaminophen the resident could consume in a 24 hour period should not be more than 3 grams. Based on the above physician's orders, resident #17 could only receive either one dose of acetaminophen 640 mg per day as needed for pain or one dose of Oxycodone-acetaminophen 5-325mg per day as needed for severe pain after taking acetaminophen 1 gram twice a day. Even though the PRN orders of acetaminophen 160 mg/5ml and Oxycodone-acetaminophen 5-325 mg were questionable, there was no evidence that the nursing staff clarified with the attending physician. Further review of the MAR between June 2018 and August 2018 revealed that resident #17 received more than 3 gram of acetaminophen per day on 06-10-18, 07-15-18, 07-17-18, 07-28-18 and 08-12-18, which was inconsistent with the physician's orders. See F 756. On 08-16-18 at 7 PM, interview of the Director of Nursing revealed no additional information. As Code of Maryland Regulations 10.27.10.02D (3), nurse practice act, Collection of data and reporting of problems that arise in the carrying out of the nursing plan is a nursing responsibility. 3. On 08-16-18 at 12:05 PM, interview of resident #41 revealed the resident was alert and oriented, but required assistance with activities of daily living. On 08-16-18, review of the consultant psychiatrist's progress note revealed an anti-depressant, Lexapro, was increased to 20 mg daily because of depression in February 2018. In addition, resident #41 was referred to individual therapy, but pending on the insurance approval. Further review of the care plan related to the use of the anti-depressant revealed the facility staff should provide psychiatrist consult and follow up as needed. However, there was no evidence that individual therapy was initiated as of 08-16-18. On 08-16-18 at 11 AM, interview of the Long Term Care Unit Manager revealed he/she did not have any knowledge related to the individual therapy order. On 08-16-18 at 11:30 AM, telephone interview of the consultant psychiatrist revealed he/she did not visit resident #41 after the referral for individual therapy was made in February 2018. There was no evidence that the facility staff followed up with the psychiatrist or insurance company regarding resident #41's referral until the surveyor asked on 08-16-18. On 08-16-18 at 6:30 PM, interview of the Director of Nursing (DON) revealed a psychotherapist met resident #41 in the facility at an unknown date and time. At that time, resident #41 declined the individual therapy services. However, there was no documentation to support the DON's statement. As Code of Maryland Regulations 10.27.10.02D (3), nurse practice act, Collection of data and reporting of problems that arise in the carrying out of the nursing plan is a nursing function. 4. This finding was identified during a complaint investigation of #MD00127325. On 08-14-18, review of resident #269's closed record revealed a physician's order that was written on 06-05-18 to administer a supplement, Sodium Bicarbonate, three times a day, and a short acting insulin twice a day. Further review revealed this physician's order was transcribed to the MAR on 06-06-18. Therefore, the first dose of Sodium Bicarbonate was given at 9 AM on 06-07-18 and the first dose of the short acting insulin was given at 6 PM on 06-06-18, more than 24 hours after the order was written. On 08-14-18 at 6:30 PM, and 08-16-18 at 7 PM, interview of the Director of Nursing and the facility administrator revealed no additional information. As Code of Maryland Regulations 10.27.10.02C.(3), nurse practice act, the plan of nursing care shall be communicated on records to other members of the health care team and the client when possible and appropriate.

CONCERN (E)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on surveyor observation, and review of the clinical record it was determined that the facility staff failed to administer a narcotic (opiod) pain reliever as ordered by the physician. This finding was evident in 1 in 3 records reviewed for compliance with pain management. (#223) The findings include: On 08-13-18 at 3:49 PM, surveyor observation of resident #223 revealed the resident to be moaning and grimacing. Upon surveyor intervention, the unit manager asked the resident if he/she had pain. (The resident did not speak English) The resident nodded yes and pointed to the right hip area. The unit manager later reported to the surveyor that the charge nurse administered pain medication to resident #223 immediately after the complaint of pain. On 08-16-18 at 12:21 PM, review of the physicians order sheet for resident #223 revealed that the resident had orders which specified the resident be given Percocet, 1 tablet for moderate pain greater than 5, and two tablets for pain greater than 8. In addition, a controlled substance prescription dated 08-10-18 ordered Percocet one tablet every 4 hours as needed for severe pain greater than 7, and one tablet 30 minutes prior to therapy for 5 days. There was no evidence in the clinical record that this order was implemented by facility staff. Percocet is a schedule II controlled drug pain reliever containing both an opiod narcotic and acetaminophen and is used for moderate to severe pain relief. Review of the medication administration record revealed that 2 Percocet tablets were administered to resident #223 for pain at a level 3 on 08-04-18 , 2 Percocet tablets were administered twice for pain at a level 3 on 08-05-18, and 2 Percocet tablets were administered for pain at a level 3 on 08-08-18. The resident should not have received Percocet, as the physician had ordered Tramadol for pain that was not greater than 5. Tramadol is a schedule IV narcotic pain reliever that has a lower risk for abuse and dependency than Percocet. The resident also received 2 Percocet tablets for pain at a level 7 on 08-05-18, instead of the 1 Percocet that was ordered for pain greater than 5. Facility staff also erroneously administered 1 Percocet for pain at a level 2 twice on 08-06-18, 1 Percocet for pain at a level 3 on 08-07-18 and 08-09-18, and 1 Percocet for pain at a level 4 on 08-09-18. In all instances, the resident should not have received any of the narcotic pain reliever Percocet based on the physicians order and reported pain level. In addition, review of the clinical record revealed there was no evidence that resident #223 received any of the Percocet ordered 30 minutes prior to therapy as ordered for 5 days. On 08-16-18 at 2:30 PM, interview with the director of nursing provided no additional information.

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on surveyor observation, and review of the clinical record, it was determined that the facility staff failed to administer a narcotic (opiod) pain reliever as ordered by the physician. This finding was evident in 1 in 3 records reviewed for compliance with pain management. (#223). The findings include: On 08-13-18 at 3:49 PM, surveyor observed resident #223 to be moaning and grimacing. Upon surveyor intervention, the unit manager asked the resident if he/she had pain.(The resident did not speak English) The resident nodded yes and pointed to the right hip area. The unit manager later reported to the surveyor that the charge nurse administered pain medication to resident #223 immediately after the complaint of pain. 08-16-18 at 12:21 PM, review of the physicians order sheet for resident #223 revealed that the resident had orders which specified the resident be given Percocet, 1 tablet for moderate pain greater than 5, and two tablets for pain greater than 8. In addition, a controlled substance prescription, dated 08-10-18, ordered Percocet one tablet every 4 hours as needed for severe pain greater than 7, and one tablet 30 minutes prior to therapy for 5 days. There was no evidence in the clinical record that this order was implemented by facility staff. Percocet is a schedule II controlled drug pain reliever containing both an opiod narcotic and acetaminophen and is used for moderate to severe pain relief. Review of the medication administration record revealed that 2 Percocet tablets were administered to resident #223 for pain at a level 3 on 08-04-18 , 2 Percocet tablets were administered twice for pain at a level 3 on 08-05-18, and 2 Percocet tablets were administered for pain at a level 3 on 08-08-18. The resident should not have received Percocet, as the physician had ordered Tramadol for pain that was not greater than 5. Tramadol is a schedule IV narcotic pain reliever that has a lower risk for abuse and dependency than Percocet. The resident also received 2 Percocet tablets for pain at a level 7 on 08-05-18, instead of the 1 Percocet that was ordered for pain greater than 5. Facility staff also erroneously administered 1 Percocet for pain at a level 2 twice on 08-06-18, 1 Percocet for pain at a level 3 on 08-07-18 and 08-09-18, and 1 Percocet for pain at a level 4 on 08-09-18. In all instances, the resident should not have received any of the narcotic pain reliever Percocet based on the physicians order. In addition, review of the clinical record revealed that resident #223 did not receive any of the Percocet ordered 30 minutes prior to therapy as ordered for 5 days. On 08-16-18 at 2:30 PM, interview with the director of nursing provided no additional information on these significant medication errors.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0555 (Tag F0555)

Minor procedural issue · This affected multiple residents

Read full inspector narrative →

Based on surveyor observation, review of the clinical record, and staff and family interviews, it was determined that the facility staff failed to provide the resident/ responsible party easy access to the attending physician's contact information. This finding was evident for 1 of 37 residents selected for review during the survey. (#33) The findings include: On 08-15-18 at 12:44 PM, a telephone interview with resident #33's family member revealed an inability for the resident and/or family to contact the attending physician for questions without involving facility staff. On 08-15-18 at 02:48 PM interview with the director of nursing revealed a procedure which requires the resident or family to notify facility staff of their request to speak with the physician, then the facility staff informs the physician of the request. The director of nursing confirmed this procedure was followed for the request made by resident #33's family member. On 08-15-18 at 3:00 PM, surveyor observation of resident #33's room revealed no evidence of the attending physician's name, address and telephone number readily accessible to the resident and/or responsible party to allow the resident or responsible party to contact the attending physicians office without facility staff intervention.

MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor review of the closed record and interview of the facility staff, it was determined that the facility staff failed to code the Minimum Data Set (MDS) assessments accurately. The MDS is an assessment tool to reflect an individual's physical and functional status. This finding was evident for 1 of 37 residents selected for review (#320). The findings include: On 08-16-18, surveyor review of the closed record revealed resident #320 was sent to a hospital on [DATE] because of altered mental status. In the same evening, the facility staff called the hospital and was informed that resident #320 had expired. However, review of an MDS assessment, which was signed on 05-14-18 (2 days after resident #320 expired), revealed resident #320 was coded to be discharged - return anticipated. On 08-13-18, the MDS coordinator signed off that resident #320 was discharged - return anticipated. On 08-16-18 at 2:40 PM, interview of the MDS coordinator revealed resident #320 was expected to return to the facility when he/she was sent out to the hospital on [DATE]. However, no return was expected on 05-14-18 and 08-13-18 when the two MDS assessments were completed. The interview revealed that the MDS was completed in August to correct an error on the May MDS. Resident #320 should be coded for discharge - return not anticipated when the MDS assessments were signed off on 05-14-18 and 08-13-18. On 08-16-18 at 6:30 PM, interview of the Director of Nursing revealed no additional information.

MINOR (B)

Minor Issue - procedural, no safety impact

Food Safety (Tag F0812)

Minor procedural issue · This affected multiple residents

Read full inspector narrative →

Based on surveyor observations and staff interviews, it was determined that the facility staff failed to store, prepare, and serve food under sanitary conditions. This finding was evident in the facility's kitchen during the surveyor's initial tour. The findings include: On 08-13-18 at 08:45 AM, surveyor tour of the kitchen revealed the following: A. Rotting, mold covered strawberries in a metal tray with other non spoiled vegetables, uncovered and unlabeled, middle shelf of walk-in refrigerator. B. 2% milk containers tested at 46.4F having been returned unopened after out for breakfast circulation; middle shelf walk-in refrigerator. C. Stacks of pre-cooked French toast, in an opened box, uncovered, unlabeled; discovered on middle shelf of walk-in freezer. D. Frozen corn-on-the-cobs in a opened box with freezer burn, uncovered, unlabeled; discovered on middle shelf of walk-in freezer. E. Frozen, pre-cooked hamburger patties in an opened box, uncovered, unlabeled; discovered on lowest shelf in walk-in freezer. F. Frozen, turkey links, in an opened box, uncovered, unlabeled; discovered on lowest shelf of walk-in freezer. G. Frozen hamburger meat, in an opened box, uncovered, unlabeled; discovered on lowest shelf of walk-in freezer. H. Dust and peeling paint found on ceiling pipes adjacent to drying rack for kitchen utensils. On 08-13-18 at 8:50AM, surveyor interview with the Dietary Manager revealed no further information.

MINOR (B)

Minor Issue - procedural, no safety impact

Garbage Disposal (Tag F0814)

Minor procedural issue · This affected multiple residents

Read full inspector narrative →

Based on surveyor observations and staff interviews, it was determined that the facility staff failed to dispose of garbage and refuse properly. This finding was identified during the surveyor's initial tour in the garbage area. The findings include: On 08-13-18 at 08:45 AM, surveyor tour of the garbage area revealed the following: Recycling dumpster containers filled with recycling paper and plastic, were sorted and stored for county collection in separate bins. However the dumpster was overfilled with cardboard; the lid was not able to shut. On 08-13-18 at 8:50AM, surveyor interview with the Dietary Manager revealed no further information.

MINOR (B)

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Based on surveyor review of the closed clinical record, it was determined that the facility staff failed to consistently document measures to prevent the development of pressure sores. This finding was identified during the investigation of complaint MD00129082. On 08-17-18, review of the closed clinical record for resident #270 revealed the resident was admitted on [DATE] from the hospital. At the time of admission, the resident was identified as being at a high risk for skin breakdown due to multiple comorbidities such as cognitive impairment, nutritional status, infectious process and immobility. Further review of the clinical record revealed no documented evidence that the facility staff consistently implemented measures to prevent the development of pressure sores for resident #270. A baseline care plan, initiated on 06-21-18, identified redness around the right hip related to impaired mobility. Additionally, the baseline care plan also identified a focus for resident #270 as being at risk for alteration in skin integrity related to incontinence and impaired mobility, with a goal to minimize skin breakdown risks and keep skin free of breakdown within the limits of the disease process. Interventions identified in the baseline care plan included: elevate heels as able, encourage to reposition as needed; use assistive devices as needed, observe skin condition with activities of daily living care; report any abnormalities, pressure redistributing device on bed (air loss mattress)/chair, provide preventative skin care routinely and as needed, check for incontinence frequently and provide incontinence care as needed, and use of pillows/positioning devices as needed. However, there was no evidence in the clinical record to consistently reflect implementation of these interventions. On 06-28-18, review of progress notes revealed that a nursing assistant reported to the charge nurse that resident #270 was observed with a pressure area to the sacrum. The physician was notified and the resident was scheduled to be evaluated by the wound team on 06-29-18. On 06-29-18, the wound care physician identified the wound as 50% obscured full-thickness skin and tissue loss, 20% slough (dead yellow tissue), and 30% dermis (undamaged deeper skin layer) with drainage and ordered silvadene cream to be applied daily. Additionally, on 06-29-18, the facility staff began to consistently document turning and repositioning resident #270 every two hours to prevent development of further wounds. On 08-15-18 at 1:00 PM, interview with the unit manager and director of nursing revealed that facility staff had turned and repositioned resident #270 every two hours, but failed to document the intervention until after the development of the sacral ulcer Interview with the director of nursing revealed resident #270 was declining rapidly which contributed to breakdown, however, there was no documentation to reflect or support the rapid clinical deterioration of the resident in the clinical record by nursing staff. A wound note, dated 07-06-18, mentioned resident to be discharged home to hospice. Based on surveyor review of the clinical records and interview of the facility staff, it was determined that the facility staff failed to document after medication and treatment administration and failed to consistently document measures to prevent the development of pressure sores. This finding was evident for 2 of 37 residents selected for review (#269 & #270). The findings include: 1. This finding was identified during a complaint investigation of MD00127325. On 08-14-18, review of resident #269's closed record and Medication Administration Record (MAR) revealed no evidence that the resident received his/her 9 AM scheduled medications including an anti-depressant, an antibiotic, anti-coagulant, a diuretic drug and two anti-hypertensive drugs on 06-04-18. In addition, there was no documentation to support that resident #269 received his/her short acting insulin and an inhaler before lunch on 06-04-18. On 08-14-18 at 6:30 PM, interview of the Director of Nursing and the facility administrator revealed no additional information.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0925 (Tag F0925)

Minor procedural issue · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation, and review of the closed clinical record, it was determined that the facility staff failed to maintain effective pest control measures. This finding was identified during the investigation of complaint MD00130087. The findings include: On 08-14-18 at 1:41 PM during initial rounds, resident #219 complained of ants in room [ROOM NUMBER], however, the surveyor did not observe ants during initial rounds in any of the rooms during the tour. On 08-16-18 at 11:15 AM, follow up with resident #219 revealed the resident had been discharged from the facility, however, the roommate (resident #221), and a family member at the bedside also complained of ants in room [ROOM NUMBER] and in the bathroom. The resident informed the surveyor that facility maintenance staff had sprayed the room and bathroom earlier that morning. Surveyor observed live and dead ants in the bathroom of room [ROOM NUMBER]. On 08-16-18 at 12:30 PM, interview with the director of maintenance revealed that approximately 5 ants were observed in room [ROOM NUMBER] at 8:00 that morning, and approximately 20-25 ants were observed in the bathroom of room [ROOM NUMBER]. The maintenance director informed the surveyor that the room and bathroom had been sprayed at that time, and a follow up visit to room [ROOM NUMBER] by the maintenance director also revealed the continued presence of ants so the room was sprayed for a second time around noon. The facility staff was unable to produce unit specific pest control logs to reflect staff's reporting of pest concerns. On 08-16-18 at 1:00 PM, upon surveyor request, the maintenance director produced the product which was used to spray room [ROOM NUMBER]. The product labeled for residential use only had been purchased from a local hardware store by the facility maintenance staff, to be used in the institutional setting of the nursing facility, (Ortho Home Defense Max Insect Killer for Indoor and Perimeter). The facility failed to contact the contracted pest control company who had last visited the facility on 07-16-18 to notify them of the complaint of ants. Additionally, the Material Safety Data Sheet requested and received by the surveyor was not for the product being used by facility staff. Upon surveyor intervention, the facility administrator obtained the correct Material Safety Data Sheet from the U.S. Department of Health and Human Services Household Products Database, and stated the facility would no longer use the product designated for residential use only. The complainant alleged widespread presence of ants. The investigation did not reveal a widespread presence of ants, however ants were observed in the same room (222) seventeen days after the resident was discharged .

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most Maryland facilities.
• 24% annual turnover. Excellent stability, 24 points below Maryland's 48% average. Staff who stay learn residents' needs.

Concerns

• 58 deficiencies on record. Higher than average. Multiple issues found across inspections.

Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.

Email me this report

About This Facility

What is Montcare At Wheaton's CMS Rating?

CMS assigns MONTCARE AT WHEATON an overall rating of 3 out of 5 stars, which is considered average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Montcare At Wheaton Staffed?

CMS rates MONTCARE AT WHEATON's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 24%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Montcare At Wheaton?

State health inspectors documented 58 deficiencies at MONTCARE AT WHEATON during 2018 to 2024. These included: 51 with potential for harm and 7 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 Montcare At Wheaton?

MONTCARE AT WHEATON is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 94 certified beds and approximately 88 residents (about 94% occupancy), it is a smaller facility located in WHEATON, Maryland.

How Does Montcare At Wheaton Compare to Other Maryland Nursing Homes?

Compared to the 100 nursing homes in Maryland, MONTCARE AT WHEATON's overall rating (3 stars) is below the state average of 3.0, staff turnover (24%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Montcare At Wheaton?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Montcare At Wheaton Safe?

Based on CMS inspection data, MONTCARE AT WHEATON has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Montcare At Wheaton Stick Around?

Staff at MONTCARE AT WHEATON tend to stick around. With a turnover rate of 24%, the facility is 22 percentage points below the Maryland average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.

Was Montcare At Wheaton Ever Fined?

MONTCARE AT WHEATON 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 Montcare At Wheaton on Any Federal Watch List?

MONTCARE AT WHEATON 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: 94
Avg. Residents: 88
Occupancy: 94.1%
Ownership: For profit - Limited Liability company
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
Low Turnover: +5
58 Deficiencies: -10
Final Score: 65/100

Nearby Alternatives

COMPLETE CARE AT SPRINGBROOK 5-star WILSON HEALTH CARE CENTER 5-star MONTCARE AT POTOMAC 5-star

View all in WHEATON →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 215048