Asbury Solomons

Inspectors wroteBased on a review of facility investigation documents, medical records, and staff interviews, it was determined that the facility failed to provide adequate supervision to a resident identified as a wandering risk. This was evident in 1 (Resident #17) out of 1 resident reviewed for supervision during the recertification and complaint survey.

Inspectors wroteBased on observations, interviews and record reviews it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility's kitchen.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure an effective infection prevention and control program by failing to ensure that staff utilized personal protective equipment (PPE) in a manner that met minimum standards and minimized risk for infectious spread. The noncompliant practice within the facility infection prevention and control program left all residents, staff, and visitors at increased risk for infection.

Inspectors wroteBased on medical record review and interview it was determined the facility failed to have an effective system in place to assess residents' pneumonia vaccination status, adequate assessment of a resident's previous pneumonia vaccine administration is required in order to determine which pneumococcal vaccine is indicated and when it should be administered. This was found to be evident for 5 ( #34, #41, #18, #6,#33) of 5 residents reviewed for immunization status during the survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to provide a resident with dignity and respect by dressing the resident in clothing that was labeled with the resident's name prominently displayed. This was evident for 3 (#42, #38, #33) of 3 residents observed wearing slipper socks during the annual survey.

Inspectors wroteBased on observations and staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 1 of 3 nursing wings observed during the survey.

Inspectors wroteBased on review of facility investigative material and interview with staff, it was determined that the facility failed to ensure that residents were free from abuse when Resident #521 was verbally abused by Geriatric Nursing Assistant (GNA) #24. This was evident for 1 (Resident #521) of 14 residents reviewed for facility reported incidents of abuse during the annual survey.

Inspectors wroteBased on review of facility investigation documentation, abuse policies and interviews with staff it was determined that the facility's policy on Resident Rights - Abuse of Residents failed to include the timeframe for sending the final investigation of alleged abuse to the state survey agency, the Office of Health Care Quality (OHCQ) within 5 days of the alleged incident. This had the potential to affect all residents of the facility. Additionally, it was determined that the facility failed to ensure all allegations of abuse were reported to OHCQ within the required time period. This was found to be evident for 1 (#501) of 13 residents reviewed for abuse during the survey.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to have documentation that the final report was submitted within 5 days of the allegation. This was evident for 1 (#501) of 13 residents reviewed for abuse during the annual survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to provide the written transfer notice to the resident and or the responsible representative. This was found to be evident for one out of three residents (Resident #52) selected for closed record review.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to provide the bed hold policy when a resident was discharged to the hospital. This was found to be evident for one out of three residents (Resident #52) selected for closed record review during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#34) of 1 resident reviewed for tube feedings, and 2 (#31, #41) of 7 residents reviewed for unnecessary medications and 1 (#34) of 1 resident reviewed for tube feedings.

Inspectors wroteBased on medical record review and staff interview it was determined that facility staff 1) failed to develop and initiate a comprehensive, resident centered care plan for a resident who received oxygen, and 2) failed to follow the care plan. This was evident for 2 (#12, #34) of 3 residents reviewed for respiratory care during the annual survey, and 1 (#100) of 3 residents reviewed for complaints.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for a Resident (#25) with dysphagia. This was evident for 1 (#25) of 3 resident reviewed for dining during the annual survey.

Inspectors wroteBased on observation and medical record review, it was determined the facility staff failed to provide nursing care with the standards of practice as evidenced by 1) failing to follow physician orders, and 2) failing to accurately document in a resident's treatment record. This was evident for 3 (#12, #21, #34) of 3 residents reviewed for respiratory care and 1 (#38) of 13 residents reviewed for abuse.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined the facility staff failed to follow the physician's order for a Resident (#25) with dysphagia. This was evident for 1 (#25) of 3 resident reviewed for dining during the annual survey.

Inspectors wroteBased on observation, medical record review and interview it was determined the facility 1) failed to follow physician's orders for labeling and dating oxygen tubing when changed, 2) failed to develop and implement a person-centered comprehensive care plan with resident centered goals for respiratory care to include oxygen therapy, and 3) failed to consistently document if a resident was administered oxygen. This was evident for 2 (#34, #12) of 3 residents reviewed for respiratory care during the annual survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed 1) to ensure staff completed the controlled drug count at the change of shift as evidenced by documentation by nursing staff that the count had been completed prior to the end of the shift; 2) to ensure regularly scheduled medications were re-ordered and obtained in a timely manner to prevent missed doses; and 3) to ensure medications available in the interim supply were accessed to prevent missed doses. This was found to be evident for of 1 out of 2 medication carts reviewed and 3 (#100, #41, #201) out of 34 residents reviewed during the survey

Inspectors wroteBased on observation, interview and medical record review it was determined that the facility failed to ensure residents were free from significant medication errors as evidenced by failure to administer medication for the treatment of atrial fibrillation as ordered on 3 occasions over a 3 day period. This was found to be evident for 1 (#201) of 4 residents observed during the medication observation task.

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 3 (#12, #21, #34) of 3 residents reviewed for respiratory care, 1 (#38) of 13 residents reviewed for abuse, and 5 (#41, #34, #18, #6, #33) of 5 residents reviewed for immunizations.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to accurately post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Medicine Aides (CMA) and Certified Geriatric Nurse Aides (GNA) per shift. This was evident on 2 of 2 days observed during an annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to ensure that a physician dated a Medical Order for Life-Sustaining Treatment (MOLST) for Resident #32. This was evident for 1 of 17 residents reviewed during the survey.

Inspectors wroteBased on medical record review, it was determined that the facility staff failed to develop a Care Plan for Resident #188, related to the resident being on an anticoagulant medication. This was evident for 1 out of 17 residents investigated during the survey process.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility failed to ensure that a Geriatric Nursing Assistant (GNA) wore appropriate Personal Protective Equipment (PPE) when handling soiled linens from Resident #138 who was in isolation. This was evident for 1 of 17 residents reviewed during the survey.