Complete Care at Severna Park LLC

Inspectors wroteBased on review of facility-reported incident investigation, record review, policy review, and interview, it was determined that the facility failed to ensure that a resident remained free from abuse. This was evident for 1 (Resident #29) of 7 abuse investigations reviewed during the recertification and complaint survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to protect a resident's right to be free from misappropriation of property specifically involving the diversion of narcotic medication. This was evident for 2 (Resident #136 and Resident #137) of 2 resident Facility Reported Incidents reviewed for missing narcotic medications during the recertification/complaint survey.

Inspectors wroteBased on a review of facility investigative materials, medical records, and staff interviews, it was determined that the facility failed to thoroughly investigate a self-reported incident. This was evident for one (incident report #3003592) of 21 reports reviewed during this annual survey.

Inspectors wroteBased on medical record reviews and interviews with facility staff, it was determined that the facility staff failed to provide nursing care within professional standards of practice regarding safe medication administration. This deficient practice affected 1 resident (Resident #122) out of 6 residents reviewed for medication administration during the annual survey.

Inspectors wroteBased on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure that residents received medications and care in a timely manner. This deficient practice affected 1 resident (Resident #122) out of 21 residents reviewed for care provision during the annual survey.

Inspectors wroteBased on observations, medical record reviews, and interviews with facility staff, it was determined that the facility failed to ensure residents remained free from accidents and hazards. Specifically, the facility failed to: 1) thoroughly assess residents who smoke to ensure their safety, and 2) implement timely interventions for residents experiencing ongoing altercations with peers. This deficient practice affected 2 out of 5 residents reviewed for smoking (Residents #108 and #122), and 2 out of 2 residents reviewed for resident-to-resident altercations (Residents #56 and #81) during this annual survey.

Inspectors wroteBased on a review of medical records and staff interviews, it was determined that the facility failed to provide necessary care and follow required clinical protocols for a resident with an indwelling urinary (Foley) catheter. This failure was identified in one resident (Resident #122) out of two residents reviewed for Foley catheter care during the annual survey.

Inspectors wroteBased on record review, interview and Facility Reported Incident (FRI) #2980586, it was determined that the facility failed to ensure that pain management was provided to each resident with professional standards of practice. This was evident for 1 (Resident #139) of 3 residents reviewed for pain management during the survey process.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to 1) ensure the accurate documentation of controlled medications administered to residents by maintaining consistency between the Medication Administration Record (MAR) and the controlled substance record (narcotic book), and 2) ensure proper pharmaceutical procedures for the destruction of controlled substances. This was evident for 2 (Residents #71 and #108) of 3 residents reviewed for controlled medication administration and 1 (Resident #137) of 1 resident reviewed in a Facility Reported Incident (FRI) for destruction of discontinued narcotic medications during the recertification survey.

Inspectors wroteBased on interviews, and record review, it was determined that the facility failed to ensure that medications were administered as ordered. This was evident for one resident (Resident #5) out of 6 residents reviewed during the annual survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure residents' call bells were accessible to residents. This was found evident for 4 (Residents #15, #16, #17, and #20) out of 4 Residents reviewed for call bells during the complaint survey.

Inspectors wroteBased on observation and interview, it was found that the facility failed to have a functioning call bell system for residents. This was found to be evident for 7 (Resident #18, #19, #20, #22, #23, #24, and #25) out of 7 residents reviewed for call bell function during the complaint survey.

Inspectors wroteBased on review of facility-reported incident investigation, record review, and interview, it was determined that the facility failed to ensure that a resident remained free of abuse. This was evident for 2 (Resident #6 and #8) of 11 abuse investigations reviewed during the complaint survey.

Inspectors wroteBased on review of facility-reported incident investigation, record review and staff interviews, it was determined that the facility failed to report to the Office of Health Care Quality (OHCQ) within the required timeframe. This was evident for 2 (Resident #6 and #14) out of 2 residents reviewed for reporting abuse allegations during the complaint survey process.

Inspectors wroteBased on review of facility-reported incident investigation, record review, and interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse. This was evident for 1 (Resident #8) of 11 abuse investigations reviewed during the complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to have accurate documentation for a resident. This was found to be evident for 1 (Resident #2) out of 1 Resident reviewed for accurate documentation during the complaint survey.

Inspectors wroteBased on medical record reviews and staff interviews is was determined that the faciliy failed to ensure Care Plans were revised and Care Plan meetings were held as required. This was found to be evident for 2 (Residents #91 & #61) out of 2 Residents reveiwed for Care Plan revisions and 2 (Residents #110 and #56) out of 2 Residents reviewed for Care Plan meetings during the annual survey.

Inspectors wroteBased on the review of facility reported incidents,staff interview, and review of facility policy, it was determined that a facility staff member failed to treat a resident with respect and free from verbal and physical abuse. This was evident during the review of 2 ( Resident #127 and #90) out of 21 Residents reviewed for allegations of abuse.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to thoroughly investigate a complaint of abuse. This was evident for 1 (Resident #124) out of 64 residents reviewed during a complaint/annual survey.

Inspectors wroteBased on observation, facility staff and Resident interviews and surveyor record review it was determined that the facility staff failed to document the delivery of daily wound care for Residents with pressure ulcers. This was found to be evident in 2 (Residents #36 and #114) out of 2 Residents reviewed for treatment and services of pressure ulcers.

Inspectors wroteBased on observation, facility staff interviews and record reviews it was determined that the facility failed to ensure residents were free from accidents. This was found to be evident in 2 (Residents #70 and #91) out of 2 Residents reviewed for accident hazards during the recertification survey.

Inspectors wroteBased on medical record review and interview with facility staff it was determined that the facility failed to have an order to address and medicate different pain levels in a resident. This was evident during the review of a complaint for Resident #132 and the review of 1 of 6 residents' medication orders. (#132).

Inspectors wroteBased on medical record review and interview, the facility failed to provide trauma-informed care after a resident expressed past traumas to a facility staff member. This was evident for 1 (resident #24) of 64 residents reviewed during a complaint/annual survey.

Inspectors wroteBased on the review of a facility reported incident (FRI) #MD00205993 related to an allegation of abuse, a review of employee files and interviews, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 1 out of 3 employee files reviewed for competencies and skill sets.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the facility failed to: 1) monitor the behaviors of a resident on antipsychotic medications. 2) ensure residents were free from unnecessary medications. This was evident by 2 (Residents #61 and #111) out of 6 residents reviewed for unnecessary medication during the recertification and compliant survey.

Inspectors wroteBased on observation, staff interviews, and review of medical record documentation it was determined that the facility failed to maintain a safe and effective system for securing medication in their designated carts on nursing units with residents with documented cognitive deficits and wandering behaviors. This practice was noted on 2 separate random observations on 2 of 2 units.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to maintain complete and accurate resident records. This was found to be evident for 2 (Resident #111, #119) out of 2 residents reviewed for documentation accuracy during the survey during the survey process.

Inspectors wroteBased on the review of a facility reported incident and a complaint it was determined that the facility failed to appropriately document in a resident's medical record (resident #32 and #33) timely documentation of acute changes in condition, activities of daily living (adl) care, and resident information on the transfer record This was evident during the review of 2 of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, interview with facility staff and policies it was determined that the facility staff failed to immediately report an allegation of abuse to Administration. This was evident during the review of 1 of 47 facility reported incidents.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to throughly investigate a allegation of neglect as a result of facility nursing staff failing to obtain an accurate inventory of a resident's narcotic medication (Resident #9). This deficient practice affected 1 of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on review of medical record and interview, the facility failed to add soft offloading boots to a resident's heels as an intervention in the care plan (resident #22). This was evident for 1 out of 52 resident reviewed during a compliant survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to follow up with physician recommendations orders. This was evident during the review of a complaint.

Inspectors wroteBased on resident complaint # MD00181865, and review of medical records (GNA [NAME]) the facility failed to change resident # 4 that cannot due by self. This was evident for 1 out of 1 resident.

Inspectors wroteBased on a review of medical records, Controlled Medication Utilization Record sheets, Medication Administration Record (MAR), and interviews with staff, it was determined that the facility failed to consistently document the administration of an as-needed (PRN) pain medication on the electronic MAR and further monitor the resident's pain level and efficacy of the medication. This was evident during the complaint survey for Resident #30.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that facility nursing staff failed to have an accurate inventory of a resident's narcotic medication (Resident #9). This deficient practice affected 1 of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility records and interview with staff, it was determined the facility failed to revise and document an accurate up-to-date facility-wide assessment. This was evident during review of the sufficient and competent nurse staffing task of the annual survey. This had the potential to affect all residents within the facility.

Inspectors wroteBased upon staff interview and a review of facility documentation it was determined that facility staff failed to develop and implement a process to ensure that the Residents electrical or electronic equipment was inspected and failed to ensure that all the mechanical lifts used to transfer residents were inspected on a routine and as-needed basis for safe and effective operation.

Inspectors wroteBased on observation, review of resident medical records, and interview with residents and facility staff, it was determined that the facility staff failed to, 1) complete a resident's inventory of personal effects at the time of a resident's admission into the facility and update the inventory of personal effects document when a resident brings any new belongings into the facility, and 2) maintain the environment in a manner that was safe, clean, comfortable, and homelike. This was evident for 4 (Residents #42, #56, #76, #77) of 50 residents reviewed during the survey, and seven (Rooms E02, E06, E10, E12, E13, F02 and F12) of 30 rooms observed during the survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility staff failed to ensure that opened medications were documented with the date opened and included an expiration date for the medication. This was found to be evident in 2 out of 3 medication carts, 1 out of 2 treatment carts, and 1 of 2 medication storage rooms observed in the facility. The documentation of the medication refrigerator temperature in the medication storage was not compliant with the policies of the facility. This deficient practice had the potential to affect all residents.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to ensure the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 of (#53) of 1 resident reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was evident for 1 (#53) of 1 resident reviewed for hospitalization during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (#53) of 1 resident reviewed for hospitalization during the annual survey.

Inspectors wroteBased on review of resident medical record and interview with residents and facility staff, it was determined that the facility failed to ensure that resident Minimum Data Set (MDS) assessments accurately assessed the state of a resident's vision. This was evident for 1 (Resident #42) of 50 residents reviewed during the survey.

Inspectors wroteBased on review of resident medical record and interview with facility staff, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed by the interdisciplinary team and the resident or their representative at least quarterly. This was evident for 2 (Residents #23 and #42) of 50 residents reviewed during the survey.

Inspectors wroteBased on observation, review of resident medical record, and interview with residents and facility staff, it was determined that the facility failed to ensure that residents were provided with an activity program that, based on residents' care plans, was designed to meet all residents' expressed interests and support their physical, mental, and psychosocial well-being, as evidenced by Resident #42 being denied the opportunity to participate in group activities or go outside, in part because the resident was unnecessarily kept in bed. This was evident for 2 (Resident #42 and Resident #67) of 6 residents reviewed for activities.

Inspectors wroteBased on review of resident medical record, observation, and interview with residents and facility staff, it was determined that the facility failed to determine if Resident #42 had glasses or required glasses for reading. This was evident for 1 (Resident #42) of 2 residents reviewed for communication and sensory needs.

Inspectors wroteBased on record review, observation, and interviews the facility failed to apply a resident's resting hand splint as ordered. This was evident in 1 (Resident #77) of 2 resident charts reviewed for assistive devices.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication for Resident (#12). This was evident for 1 of 2 residents selected for pain assessment and 1 of 50 residents selected for review during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to have a process to ensure that pharmacy recommendations were timely acted upon. This was evident for 1 (#50) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure that food was prepared and stored in accordance with professional standards for food service safety. This had the potential to affect all residents in the facility.

Inspectors wroteBased on medical record review, observation, and interviews the facility failed to ensure that infection control practices were followed while providing wound care. This is evident in 1 (Resident #9) of 2 records reviewed for wounds.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure that hand rails were secured firmly to the wall. This was evident for 2 resident areas observed during the survey. This deficient practice has the potential to affect all residents, staff, and visitors on the unit.

Inspectors wroteBased on observations, review of daily staffing records, and staff interview it was determined the facility failed to post the total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides per shift and failed to have the staff data requirements available in an accurate, clear and readable format. It was identified that the facility did not have staffing information readily available in a readable format for residents and visitors for the first 4 days of the survey.

Inspectors wroteBased on medication cart observations and staff interviews it was determined the facility staff failed to ensure that the medical record was kept in a confidential manner. This was evident in 1 out of 3 medication carts.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to ensure that: 1) Resident #94 did not receive an unnecessary blood draw; and 2) blood pressure medication was held according to the physician's orders for Resident #57. This was evident for 2 of 49 residents reviewed during the survey.

Inspectors wroteBased on observations and staff interviews during an environmental tour, it was determined that the facility staff failed to provide housekeeping services, necessary to maintain the residents sit to stand lift devices in a sanitary and clean manner. This is evident for 4 out of 10 medical transfer equipment devices during the survey process. Facilities use various medical equipment to assist residents at patient transfers. The stand-up lift is a product that ensures the caregiver's security and aids in standing residents that need it.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or resident representatives were notified in writing that they are being transferred out of the facility to a hospital and the reason why the facility is transferring the resident out. This was found to be evident for 1 out of 4 resident's involving Resident #74 (R#74) reviewed during the investigative portion of the survey process.

Inspectors wroteBased on medical record review and staff interview it was determined facility staff failed to: 1) clarify an unclear physician order for Resident #94 and accurately document the treatment administration; and 2) document the status and resolution of a skin condition for Resident #371. This was evident for 2 of 49 residents reviewed during the survey.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure that personal hygiene equipment was properly stored to avoid possible cross-contamination. Residents #49 and #94 had the potential to have been affected by this. This was evident in the shared bathroom for 2 of 49 residents reviewed during the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility staff failed to ensure that personal privacy and confidentiality was maintained for 6 residents (#2, #16, #189, #223, #289, and #300) of 44 residents selected for review in the Stage 2 sample. This practice created the potential for individuals other than those providing care for the residents to read specific confidential medical information that pertained to these residents.

Inspectors wroteBased on observation and interviews, it was determined the facility staff failed to ensure that: 1) a resident's catheter drainage bag was covered, 2) that the environment was kept in a manner that enhanced the dignity of a resident, and 3) that an unwanted visitor was prevented from entering a resident's room without being invited. This practice affected 3 residents (#292, #6, and #25) of the 44 residents selected for review in the Stage 2 sample.

Inspectors wroteBased on observation while conducting the initial facility tour and confirmed while conducting environmental rounds with facility staff, the facility failed to ensure that resident areas were kept clean and in good repair.

Inspectors wroteBased on observation while conducting the initial facility tour and confirmed while conducting environmental rounds with facility staff, the facility failed to ensure that resident care items and toiletries were stored in a manner that reduces the risk of infection.

Inspectors wroteBased on observation, medical records, staff interviews, and a family member, It was determined that the facility staff failed to notify the physician that Resident #256 refused a medication that was obtained as an emergency because the resident had become agitated and restless. This was evident for 1 out of 44 residents surveyed during Stage II of the survey process.

Inspectors wroteBased on review of documentation and interviews it was determined that the facility failed to act on the residents request during their monthly meetings. This was evident in 2 consistent months of resident council meeting minute notes of complaints of dirty hallways and cold food being delivered.

Inspectors wroteBased on interview and medical record review, it was determined that the facility staff failed to initiate a nutrition care plan with the appropriate goals and interventions for 1 resident (#232) of the 44 residents selected for review in the Stage 2 sample.

Inspectors wroteBased on resident's family & facility interviews it is determined that the facility staff failed to maintain appropriate oral hygiene care for Resident # 95. This was evident for 1 out of 44 residents surveyed during Stage II of the survey process.