Autumn Lake Healthcare at Patuxent River

Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff failed to administer medications according to the physician orders. This was evident for 2 out 3 Resident (#16 and #7) reviewed during the complaint survey regarding medication administration.

Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to complete accurate assessments of a resident related to the functional use of extremities on the quarterly and annual minimum data set (MDS). This was determined during the review of an injury of unknown origin for 1 of 3 residents (Resident #1)

Inspectors wroteBased on record review and interview it was determined that facility staff failed to ensure that physician visits notes were available in the medical record for each resident. This was evident for 1 (#15) of 8 residents reviewed for complaints.

Inspectors wroteBased on random observations, interviews and medical record review, it was determined that the facility failed to ensure infection control orders were followed and consistent throughout the facility. This was evident for 1 (Resident #12) of 20 residents reviewed during the complaint survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure a resident had access to their call bell plunger. This was evident for 1 (Resident #8) out 8 residents that were part of the survey sample during the complaint survey.

Inspectors wroteBased on complaint #2635993, record reviews, observation, and interviews, it was determined that the facility failed to ensure the physician was notified of changes in resident condition. This was evident for 1 (Resident #4) of 6 complaints reviewed during the survey process.

Inspectors wroteBased on clinical record review, investigation of intake #2601797, and staff interview it was determined that the facility staff failed to 1) ensure a resident's refusal to receiving showers was addressed and 2) ensure an activity of daily living individualized comprehensive care plan included an intervention for transfer status. This was evident for 2 (Resident #8 and Resident #7) out of 11 resident that were reviewed during the complaint survey.

Inspectors wroteBased on review of the resident's medical record and interview with resident and facility staff, it was determined that the facility staff failed to maintain accuracy of medical record by not documenting the reason for missed dose of medication in the resident's medical record. This was evident for 1 (Resident #11) of 1 resident reviewed for medication administration during the complaint survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dignity of 2 of 3 residents (Residents #7 and #50) reviewed for dignity.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure: 1.) Residents' or family representative's request to implement an Advance Directive was addressed; 2.) Resident's advanced directive was obtained and followed; and 3.) Information regarding advance directives was offered. This was evident for 3 (#10, #117, #106) residents out of 66 residents investigated during the survey.

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure the care plan for Resident #117 was comprehensive. This was evident for 1 out of 4 residents reviewed for urinary catheters during the facility's recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to clarify residents pain medication orders and ensure residents' medications were administered and physician's orders were followed in accordance with professional standards. This was evident for 2 (#14 and #24) residents out of 66 residents investigated during the survey.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide and document individualized activities to support the physical, mental, and psychosocial well-being of 1 (Resident #6) of 1 resident reviewed for activities.

Inspectors wroteBased on record review and interview it was determined the facility failed to ensure a resident's care was reviewed by the physician. This was evident for 1 out of 10 residents reviewed for advanced directives during the facility's recertification survey.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure that a resident must be seen by a physician at least once every 60 days after the first 90 days after admission. This was evident for 1 (#24) resident out of 8 residents investigated during the facility's annual survey.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the accuracy and completeness of Resident #117's medical record. This was evident for 1 out of 10 residents reviewed for advanced directives; and failed to ensure accuracy of room numbers on resident medical records This was evident for 5 out of 32 residents located on the lighthouse nursing unit during the facility's recertification survey.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to: 1.) maintain infection prevention designed to prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Resident #1) of 2 residents reviewed for Trach Care; 2.) maintain proper infection control practices to prevent cross-contamination with Foley catheters. This was evident for 1 (Resident #7) of 3 residents reviewed for Foley Care; and 3.) ensure infection control precautions were followed. This was evident for 2 residents (Resident #117, and Resident #125) of 2 residents reviewed for infection control precautions during the survey.

Inspectors wroteBased on review of complaints, tray tickets, observation, and interview, it was determined the facility failed to serve residents food that was palatable and appealing and failed to follow the selections residents had chosen. This was evident for 13 (#10, #65, #63, #61, #68, #67, #66, #58, #70, #64, #62, #17, #71) of 73 residents reviewed during a complaint survey.

Inspectors wroteBased on review of a complaint, observation of resident wheelchairs, and interviews, it was determined the facility failed to provide maintenance services necessary to keep all wheelchairs in a sanitary, comfortable, and well maintained condition. This was evident on 2 of 3 nursing units observed.

Inspectors wroteBased on medical record review, documentation review and interview it was determined the facility failed to report allegations of abuse, neglect, or an injury of unknown origin within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) (Resident #7, #8). This was evident for 2 of 24 residents reviewed for allegations of abuse, neglect or an injury of unknown origin during a complaint survey.

Inspectors wroteBased on review of facility reported incidents, medical records, and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 3 (#10, #9, #8) of 24 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on complaint, record review, and interview, it was determined the facility failed to have documentation that residents were offered and/or received a shower on the resident's assigned shower day. This was evident for 1 (#20) of 25 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure neurological evaluations were comprehensively conducted per facility policy/procedure after falls for 1 (Resident #30) of 2 sampled residents reviewed for falls.

Inspectors wroteBased on medical record review and interview, the facility staff failed to ensure a resident received podiatry services as ordered (Resident #12). This was evident for 1 of 3 residents reviewed for podiatry care during a complaint survey.

Inspectors wroteBased on observation, interview, and facility documentation review, it was determined that facility staff failed to keep a medication cart locked when unattended. This was evident on 1 of 4 nursing units observed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to obtain outside services for residents in a timely manner (Resident #6). This was evident for 1 of 73 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #12). This was evident for 1 of 73 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that a resident with a noted change in condition and documented pain for a fracture, was not medicated with ordered pain medication or hospitalized timely. This was evident for 1 of 1 Resident (#119) reviewed during the investigative portion of the survey.

Inspectors wroteBased on observations and interviews it was determined that the facility: 1) failed to ensure that medication carts were locked, code carts were locked, and medications were secure inside the medication cart. This was found to be evident for 3 out of 5 carts observed during the recertification survey and, 2) failed to ensure that medications were stored properly as evidenced by unopened insulin pens stored in medication carts. This was found to be evident for 2 out of 2 medication carts observed during medication storage observation.

Inspectors wroteBased on a resident concern, interviews and the sampling of 2 test trays, it was determined that the facility failed to prepare a palatable meal for residents. This was evident in 1of 2 test trays.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to: 1) ensure that food was prepared and stored in accordance with professional standards for food service safety, 2) properly label and date food items and remove expired food items, and 3) to maintain food service equipment in a manner that ensures sanitary food service operations. This was evident through multiple observations and has the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility staff failed to ensure the dignity of a resident (#68) as evidenced by the resident's urine catheter bag attached to the arm rest of a wheelchair. The was found to be evident for 1 out of 2 residents observed for catheter care.

Inspectors wroteBased on medical record review, review of pertinent facility documentation and interview with facility staff, it was determined that the facility staff failed to: 1) report a fall to the resident's physician and representative (RP). This was evident for 1 of 3 residents reviewed for falls/accidents (#19) and 2) report glucose levels outside acceptable parameters. This was evident for 1 of 5 residents reviewed related to complaints and facility reported incidents about general care (# 122).

Inspectors wroteBased on Beneficiary Protection Notification Review and interview with the facility staff, it was determined that the facility failed to document notification to a resident or representative (RP) regarding notification and explanation of their rights regarding a pending discharge from Medicare. This was evident in 1 of 3 (resident#101), residents reviewed regarding liability notices.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure that resident rooms were maintained in a homelike environment as evidenced by brown stained ceiling tiles. This was found to be evident facility wide during the recertification survey.

Inspectors wroteBased on medical record review, facility policy and training review and interview with facility staff, it was determined that the facility failed to implement their policy on abuse as evidenced by failing to complete in-services on all employees after alleged incidents of abuse occurred in the facility. This was evident during the review of 1) 2 of 2 facility reported incidents on abuse (FRI), 2) 2 of 2 in-services that were given to the survey team as evidence of completed in-services trainings and 3) 1 of 5 annual employee trainings on abuse (#11).

Inspectors wroteBased on observation, medical record review and interview with facility staff, it was determined that the facility failed to develop a baseline care plan related to a resident's pain. This was evident in 1of 3 Residents (#19) reviewed for pain during the investigative portion of the survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to update a care plan with interventions after a resident had a fall. This was evident during the review of 1 of 3 Resident (#19) falls/accidents during the investigative portion of the survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure that appropriate care was provided to a resident with a tracheostomy and contractures as evidenced by: 1) oxygen tubing removed during hygiene care and, 2) physician ordered assistive devices was not placed on the resident. This was found to be evident for 1 (Resident #27) out of 1 resident reviewed for Tracheostomy care.

Inspectors wroteBased on observation, interviews, and record review, it was determined that the facility staff failed to ensure appropriate urinary catheter care as evidenced by a urine catheter bag placed above the urinary bladder. This was found to be evident for 1 (Resident #68) out of 2 residents observed for catheter care.

Inspectors wroteBased on observations, interviews, and record reviews it was determined that the facility failed to ensure that a resident medication was administered as ordered as evidence by delayed administration of insulin. This was found to be evident for 1 (Resident #321) out of 4 residents reviewed for insulin administration.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide a safe, sanitary environment to prevent the development and transmission of an airborne disease as evidenced by: 1) staff did not practice hand hygiene, and 2) staff did not wear a face mask appropriately. This was found to be evident for 3 out of 3 staff observed during a facility tour.

Inspectors wroteBased on observation of all rooms on all units, the facility failed to keep a safe sanitary and comfortable environment for residents, staff and visitors by not cleaning the air-condition and heating vents (PTAC UNITS) in all rooms. This was evident for all rooms on all units.

Inspectors wroteBased on record review and staff interview, it was determined that the facility staff failed to: 1) follow the Health Care Decisions Act when determining a surrogate decision maker, 2) Notify a resident's guardian when a new MOLST form was created, 3) Properly void an old MOLST form when a new one was created, and 4) Complete incapacity forms in a timely manner. This was evident for 6 (Residents #46, #53, #68, #75, #100, #422) of 6 residents reviewed for advance directives during an annual recertification survey.

Inspectors wroteBased on surveyor observation, it was determined that the facility failed to provide a safe environment for staff, residents and the public by not maintaining a safe desk top and counter top on the 200 and 300 Halls nurses station.

Inspectors wroteBased on observation, it was determined that the facility staff failed to provide a dignified environment for a resident. This was evident for 1 (Resident #53) of 2 residents reviewed for dignity during an annual recertification survey.

Inspectors wroteBased on observation and staff interview during the annual survey the facility failed to provide housekeeping services in order to maintain a sanitary, safe, orderly, and comfortable environment.

Inspectors wroteBased on medical record review it was determined the facility staff failed to notify the resident and/or the resident's representative(s) in writing the reason for a transfer to the hospital. This was evident for 1 of 43 sampled residents selected for review. Resident #100 was affected by the deficient practice.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to screen a resident (#85) to determine if the resident had or may have had a mental disorder (MD), intellectual disability (ID), or related condition. This was identified for 1 of (Resident #85) of 4 residents reviewed for pre-admission screening and resident review (PASARR) requirements during an annual recertification survey. A review of Resident #85's medical record on 09/17/18 revealed a psychiatric assessment, dated 03/20/18, that indicated that Resident #85 was suffering from a Bipolar I disorder. This was, also, reflected in the 05/18/18 Minimum Data Set (MDS) assessment under section, active diagnoses, section I 5950 the box was checked ,yes, for an identified psychiatric disorder. [...]

Inspectors wroteBased on medical record review, it was determined the facility failed to develop a baseline care plan for a resident within 48 hours of readmission to the facility. This was evident for 1 (Resident #105) of 43 residents reviewed during an annual recertification survey.

Inspectors wroteBased on observation and medical record review it was determined the facility staff failed to ensure that residents received the necessary services to maintain good grooming. This was evident for 3 of 43 sampled residents selected for review. Resident #7, Resident #41 and Resident #100 were affected by the deficient practice.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide adequate activities as indicated on the MDS assessment for a resident (#27). This was evident for 1 of 43 residents selected for review during the survey process. The MDS (Minimum Data Set) is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure that each resident receives the care they need. MDS assessments are completed upon admission, quarterly and for any significant change in condition. Categories of MDS are: [...]

Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to provide care which promoted the highest practicable well-being for Residents (#71 and #103). This was evident for 2 of 43 residents selected for review during the annual survey process.

Inspectors wroteBased on resident and staff interview and reviews of a medical record, it was determined the facility nursing staff failed to document a skin assessment for Resident #105 upon readmission to the facility. This failure to complete a skin assessment for Resident #105 upon readmission on [DATE], lead to the development of a stage III sacrum wound and bilateral heal wounds that were not being treated for 3 days after readmission. This was evident for 1 (Resident #105) of 6 residents reviewed for pressure wounds during an annual recertification survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to: 1) take steps to maintain emergency equipment by a resident's bedside, and 2) administer oxygen as ordered by the physician. This was evident for 2 (Resident #73, #92 ) of 6 residents reviewed for proper respiratory care during an annual recertification survey.

Inspectors wroteBased on medical record review it was determined the facility staff failed to appropriately address the Consultant Pharmacist's recommendations in a timely manner. This was evident for 1 of 43 sampled residents selected for review. Resident #71 was affected by the deficient practice.

Inspectors wroteBased upon resident interview, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine dental care. This was evident for 1 of 43 residents (#107) selected for review during the survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for Residents (#50, #67 and #116). This was evident for 3 of 43 residents reviewed in the annual survey.

Inspectors wroteBased on observation, interview of facility staff and medical record review it was determined the facility staff failed to ensure that a procedure was in place for adequate surveillance of infections and infectious organisms and failed to ensure that residents' toothbrushes were stored in a manner to prevent contamination. This was evident for 2 Residents (#71 & #107) of 43 residents reviewed in the annual survey. 1. Review of the facility's surveillance activities revealed that the facility did not have a procedure that would enable the facility to adequately identify and track infections and infectious organisms.

Inspectors wroteBased on observation and staff interview during the annual survey the facility failed to have firmly secured handrails on the corridor walls.