Creekside Center for Rehabilitation and Nursing

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure kitchen staff used hair nets during food preparation and failed to ensure potentially hazardous food items were cooled according to acceptable standards. These findings have the potential to affect all residents of the facility.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to provide residents with information to formulate an advanced directive. This was evident for 4 (Resident #53, #52, #22, and #2) of 4 residents reviewed for advanced directives.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to treat residents with dignity. This was evident for 2 (Resident #48, #22 ) of 24 residents screened during the initial pool portion of the recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to notify the resident's physician of a significant change in condition and a decision to transfer the resident from the facility. This was evident for 1 (Resident #83) of 2 residents reviewed for neglect.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to report an alleged violation involving abuse. This was evident for 1 (R#88) of 1 residents reviewed during the annual recertification survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to ensure admission Minimum Data Set assessments were completed timely. This was evident for 1 (Resident #32) of 1 resident reviewed for respiratory care.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to perform required resident assessments. This was evident for 1 (Resident #2) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to conduct care plan meetings after the completion of the comprehensive and quarterly assessments. This was evident for 1 (Resident #1) of 3 residents reviewed for care planning and 1 (Resident #2) of 6 residents reviewed for unnecessary medications and 1 (Resident #47) of 1 residents reviewed for activities.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure showers were provided/offered as scheduled to dependent residents. This was evident for 1 (Resident #89) of 2 residents reviewed for neglect.

Inspectors wroteBased on record review and interview it was determined that the facility failed to obtain a physician's order for oxygen and failed to perform a follow up assessment after a resident was treated for shortness of breath. These failures were evident for 1 (Resident #83) of 3 residents whose closed records were reviewed during the recertification survey.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure residents at risk for developing pressure injuries receive appropriate services for treatment and prevention. This was evident for 1 (Resident #3) of 2 residents reviewed for pressure injuries.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to monitor a resident's safety device. This was evident for 1 (Resident #51) of 1 resident reviewed for wandering/elopement.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to residents according to professional standards of practice. This was evident for 2 (Resident #52, #19) of 2 residents reviewed for pain management.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure the provider had a response and rationale to a medication regimen review recommendation and/or identified irregularity and that the response was documented in the resident's permanent medical record. This was evident for 2 (Resident #48, #3) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review it was determined that the facility failed to administer medications timely. This was evident for 1 (Resident #48) of 1 resident reviewed for insulin.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure that 1) staff performed hand hygiene during 8 of 8 breakfast observations and 2) failed to perform hand hygiene during 2 (R#37 and R#55) of 3 medication administration observations, and 3) failed to maintain a sanitary medication storage environment in 1 of 2 medication storage rooms observed.

Inspectors wroteBased on interview and record review it was determined that the facility failed to offer COVID-19 vaccinations to staff and residents and failed to educate staff and residents regarding the COVID-19 vaccination. This was evident for 7 (Staff #6, #11, #12, #16, #17, #18, #19) of 7 staff members, and 4 (Resident #2, #8, #48, and #51) of 5 residents, reviewed for vaccinations during the infection control task during the recertification survey.

Inspectors wroteBased on observation and resident interview, the facility failed to ensure the call bell system was accessible. This was evident for 1 (Resident #45) of 1 residents reviewed during the annual recertification survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNA) received required training. This was evident for 2 (Staff #11, #12) of 2 agency GNAs reviewed for training requirements during the recertification survey.

Inspectors wroteBased on record review and interviews with the resident and staff it was determined the facility staff failed to ensure the doors to the facility laundry room and the mechanical/boiler room were locked when unattended by staff, to prevent unauthorized access by residents and others. This was evident for 1 (Resident #1) of 1 resident reviewed for accident hazards during the complaint survey. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this complaint survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of [DATE].

Inspectors wroteBased on interviews and record review it was determined that the facility failed to 1.) provide sufficient supervision, prevent an avoidable accident, follow appropriate safety procedures and to utilize the use of two staff persons and 2) provide an appropriate mattress and bed to prevent a fall. This was evident for 2 residents (R10 and R23) of 4 residents reviewed who required a bariatric bed and mattress. The deficient practice resulted in harm to both R10 and R23. The facility implemented effective and thorough corrective measures following the incidents and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance. Findings Include: [...]

Inspectors wroteBased on interviews, observations, and record review the facility failed to ensure alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made and not later than 24 hours to other officials (including to the State Survey Agency and Adult Protective Services in accordance with State law through established procedures for 4 of 10 residents reviewed for abuse (R#11, R#2, R#6, and R#19). Findings Include: Record review of the abuse policy titled, Abuse Prevention Program last revised on 11/30/2022 documented, the administrator was responsible for the overall coordination and implementation of the facility's abuse prevention program policies and procedures. The administrator had the authority to delegate, coordinate and implement various components of the abuse policies and procedures to other individuals within the facility. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to maintain documentation that an abuse allegation was thoroughly investigated. This deficient practice was identified for 1 of 10 residents reviewed for abuse (Resident #2).

Inspectors wroteBased on observation and staff interviews it was determined that the facility failed to follow infection control practices and guidelines by failing to notify the local health department of a gastrointestinal outbreak and failed to post a sign in the facility and at the entrance to inform staff and visitors of the outbreak. This was evident for 1 day of a complaint survey.

Inspectors wroteBased on observation and medical record review, it was determined that facility staff failed to develop a comprehensive, resident centered care plan for a resident with a prosthetic eye. This was evident for 1 (#3) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to renew cleaning of a resident's prosthetic eye after the resident returned from the hospital on multiple occasions. This was evident for 1 (#3) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to hold a medication when outside of physician ordered parameters and failure to notify the physician when the blood pressure was outside of physician ordered parameters. This was evident for 1 (#3) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to recognize and address changes in the condition of residents. This was evident for 2 of 14 residents reviewed for hospitalizations and quality of care. (#127 and #921) This failure resulted in an immediate jeopardy.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure the Director of Nursing (DON) was working in that capacity on a full-time basis due to currently being assigned the duties of the infection prevention nurse in addition to being the Director of Nursing. This practice has the potential to affect all residents in the facility.

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months. This was evident for 5 of 5 (Staff #29, #31, #32, #33, #34) Geriatric Nursing Assistant (GNA) staff reviewed and has the potential to affect the care received by all residents.

Inspectors wroteBased on reviews of medical and administrative records, observations and interviews, it was determined the facility administration failed to develop and implement procedures based on the regulatory requirements to effectively attain and maintain the highest practicable wellbeing of each resident. This was evident for 6 (R#932, R#937, R#933, R#938, R#940 and R#931) of 43 residents reviewed during the revisit survey and has the potential to affect all residents in the facility.

Inspectors wroteBased on review on record review of facility documentation and staff interview, it was determined that the facility staff failed to conduct and document a comprehensive facility-wide assessment as evidence by failing to address: 1) the facility's average number of residents, 2) staff competencies necessary to provide the level and types of care needed for the resident population, 3) an evaluation of the facility's training program to ensure that any training needs are met for all new and existing staff, and contractual individuals providing services and volunteers, consistent with their expected roles and 4) Failed to have a facility-based and community-based risk assessment, utilizing an all hazards approach. This was evidenced during a Sufficient and Competent Nurse Staffing review, and extended survey review. [...]

Inspectors wroteBased on surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement plans of action to correct quality deficiencies identified during the prior recertification survey.

Inspectors wroteBased on observation, records review, and interview, it was determined that the facility failed develop and implement infection prevention and control policies and prodedures as evidenced by 1) facility staff's failure to don appropriate personal protective equipment (PPE) before giving direct care to 1a) a resident with a central line (an IV access to a person's veins), and 1b) a resident with an open wound, 2) facility staff's failure ot follow infection prevention and control practices during medication administration, 3) the failure to process laundry in a manner that prevents the spread of infection, 4) the failure to have a system in place to identify and prevent the growth of legionella in the facility's water system, and 5) the failure to review infection prevention and control policies and procedure annually. [...]

Inspectors wroteBased on review of employee files, pertinent documents and interview, it was determined that the facility failed to include effective communications as mandatory training for direct care staff. This was evident for 5 of 5 (Staff #29, #31, #32, #33, #34) employees reviewed for the extended survey.

Inspectors wroteBased on review of employee files, pertinent documents, and staff interviews, it was determined that the facility failed to ensure that required training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management was completed. This was evident for 3 (#29, #31, #41) of 5 staff members reviewed during the survey.

Inspectors wroteBased on review of employee files, pertinent documents and interview, it was determined that the facility failed to provide infection prevention and control training mandatory training that included the written standards, policies, and procedures for the program. This was evident for 4 (Staff #29, #31, #32, #34) of 5 employee records reviewed for the extended survey.

Inspectors wroteBased on the review of employee records and staff interview, it was determined that the facility failed to have documentation that Geriatric Nursing Assistance's (GNA) were given 1) in-service training no less than 12 hours per year, 2) abuse prevention and dementia management training, 3) a yearly performance review, and 4) training for GNA's that provide services to residents with cognitive impairments. This was evident for 5 of 5 (Staff #29, #31, #32, #33, #34) GNA employee records reviewed for sufficient and competent nursing staffing reviewed during the survey and has the potential to affect the care received by all residents.

Inspectors wroteBased on review of employee files, pertinent documents and interview, it was determined that the facility failed to include effective communications as mandatory training for direct care staff. This was evident for 5 of 5 (Staff #29, #31, #32, #33, #34) GNA employee records reviewed for during the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain the residents' dignity by staff hovering over residents while assisting them to eat. This was evident for 3 (Resident #127, #62 and #14) of 3 residents observed being fed by staff.

Inspectors wroteBased on record review and interview with staff, it was determined the facility staff failed to notify the resident and his/her representative in writing when the resident was transferred to the hospital. This was evident for 3 (#924, #45, and #33) of 4 residents reviewed for hospitalization during the survey.

Inspectors wroteBased on observation, interview, and medical record review, it was determined the facility failed to ensure a medication error rate of less than 5%. This was found to be evident based on errors identified during medication observations of 4 residents (Resident #5, #11, #54, and #476) out of 5 residents observed. The observations were made on each of the three hallways of the facility and involved three different staff members including an agency certified medication aide, one agency Licensed Practical Nurse (LPN), and one staff LPN.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to accommodate resident needs by 1) failing to ensure that a resident's call bell was within reach and 2) failing to respond to call bells in a timely manner. This was evident for 1(#64) of 24 residents reviewed in the initial pool and 4 (room [ROOM NUMBER], #501, #512, #503) of 4 rooms observed with activated call bells on 2 of 3 nursing units observed during the survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to resolve repeated concerns that were reported during Resident council meetings. This was evident in resident council meetings between January 2024 and June 2024.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure that residents were verbally provided with a notice of their rights and services during their stay. This was evident during a resident council meeting conducted during the annual survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to have a system in place to ensure that an advanced directive was obtained for each resident and that there is only one active MOLST for each resident. This was evident for 2 (Resident # 59 and #127) of 4 residents reviewed for advanced directives.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to monitor and prevent the misappropriation of resident property. This was evident for 1 (#21) out of 2 residents reviewed for neglect.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to develop a process to ensure that injuries of unknow origin and allegations of abuse were reported to the state agency. This was evident for 1 (#9) of 5 residents reviewed for injuries of unknown origin and 2 (#376 and #59) of 13 residents reviewed for abuse.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to notify residents and/or their representatives in writing of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 3 (#33, #45, #68) of 3 residents reviewed for hospitalization.

Inspectors wroteBased 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 for a resident who was admitted to hospice care. This was evident for 1 (#45) of 3 residents reviewed for hospitalization.

Inspectors wroteBased on record review, interviews, and observations, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADL) were provided with showers. This was evident for 2 (#59 and #64) of 4 residents reviewed for ADL.

Inspectors wroteBased on pertinent document review, observation, and interview, it was determined that the facility failed to implement preventative measures to prevent pressure injuries. This was evident for 4 residents (Resident #25, #47, #2, #75), out of 43 residents reviewed during a survey.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure that a resident with a limited range of motion received treatment and services as ordered by the attending provider to prevent further decline in the range of motion. This was evident for 1 (#24) of 4 residents reviewed for position and mobility.

Inspectors wroteBased on interviews, and record reviews, it was determined that the facility failed to accurately document a resident's dietary consumption to ensure the resident received adequate nutritional intake. This was evident for 1 Resident (Resident #12) out of 3 residents reviewed for nutrition during the survey.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to 1) administer respiratory therapy (oxygen) according to professional standards and 2) maintain respiratory care equipment for residents who required continuous oxygen via nasal cannula. This was evident for 2 (#25 and #68) of 2 residents reveiwed for respiratory care.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure that a resident received pain medication according to an attending provider's order and failed to document pain assessments to include the location of the pain and type of pain for a resident reporting pain. This was evident for 1 (#64) of 1 Resident reviewed for pain management.

Inspectors wroteBased on medical record review, observation, and interviews, it was determined that the facility staff failed to obtain pre- and post-dialysis treatment records for a resident. This was evident for 1 (#68) of 1 resident reviewed for dialysis.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that the resident's care was overseen by a physician. This was found to be evident for 3 (#905, #920, and #9) of 6 residents reviewed for quality of care during the investigation of a complaint conducted during a recertification survey and 1 (#57) of 4 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, pertinent document review and staff interview, it was determined that the facility staff failed to maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This was evident during a review for sufficient and competent nurse staffing and has the potential to affect all residents.

Inspectors wroteBased on medical record review, interview, and observation, it was determined that the facility failed to ensure a resident's behaviors were being monitored and documented consistently. This was found to be evident for one (#62) of one resident reviewed for behavioral health care.

Inspectors wroteBased on review of medical records and interview, it was determined that the facility failed to ensure that narcotic medications were consistently reconciled by two nurses at the change of shift. This was evident for three out of the three medication carts reviewed for medication storage during the survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility pharmacist failed to comprehensively review the medical record and identify medication errors and alert the staff; and and the facility failed to develop policies and procedures for the monthly Medication Regimen Review (MRR) that include time frames for different steps in the process. This was evident for 1 (Resident #911) of 13 residents reviewed for medication concerns.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure residents received their medications according to the attending physician's orders. This was evident for 2 (#24, #72) out of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to maintain complete and accurate medical records. This was evident in 1 (Resident #127) of 26 residents reviewed during the survey.

Inspectors wroteBased on review of facility documentation, it was determined the facility staff failed to ensure thatthe Infection Preventionist (IP) attended and participated in the facility's quality assessment and assurance (QAA) committee at least quarterly. This was evident during a review of the Quality Assurance Program (QAPI) and has the potential to affect all residents in the facility

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that residents were offered the pneumococcal vaccine. This was evident in 1 (Resident #54) out of 5 residents reviewed for immunizations during the survey process.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to protect residents after substantiating that GNA staff that restrained a resident (#926) continued to have access to other vulnerable residents. This was evident during the review of 1of 13 incidents involving abuse.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to have a process in place to ensure that staff 1.provided care in a manner to ensure residents were not injured. 2. provide safe equipment for residents and 3. provide care in a safe and professional manner. This was evident during the review of 1 (Resident #928) of 5 falls with injury. This deficient practice resulted in harm to resident #9 and resident #928. This was evident for 1 (#9) of 10 residents reviewed for accidents/hazards.

Inspectors wroteBased on review of facility and medical records and interview with staff, it was determined the facility staff failed to provide discharge planning for a resident requesting transfer to another facility. This was evident for 1 (Resident #903) of 28 residents reviewed in relation to facility reported incidents.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that thorough investigations were completed for injuries of unknown origin and allegations of abuse and neglect. This was found to be evident for 5 (Resident #917, #928, # 926, #922, and #900) out of 28 residents reviewed in relation to facility reported incidents.

Inspectors wroteBased on medical record review, interview with complainants and facility staff, it was determined that the facility failed to have a process in place to ensure that physician notes were available in the medical record and failed to ensure that a review of the residents' total treatment was completed each visit. This was evident for 4 (Resident #911, #921, #9 and #914) of 6 residents reviewed for quality of care during a complaint survey conducted during the recertification survey.

Inspectors wroteBased on interviews, review of medical records, complaint allegations, and facility policies, it was determined that the facility failed to ensure that staff timely notified resident representatives and physicians of a changes in condition and the occurance of a resident falls. This was evident for 2 (Resident #915 and #900) of 5 residents reviewed for of an allegation of neglect with injuries of unknown origin and 1 (Resident #914) of 11 residents reviewed for falls.

Inspectors wroteBased on record review and interview with staff, it was determined the facility staff failed to provide the minimal information required to the receiving provider at the time of transfer. This was evident for one (Resident #924) of four residents reviewed for hospitalization during the survey.

Inspectors wroteBased on medical record review of a facility reported incident and interview with facility staff, it was determined that the facility failed to develop a care plan related to a resident's elopement potential. This was evident for 1 (Resident #922) of 6 residents reviewed for elopement.

Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to conduct an assessment and neurological checks according to standards of professional practice after a resident had a fall. This was evident for 1 (Resident #914) of 11 residents reviewed for falls.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to have a process in place to ensure that physicians visits were conducted every 30 days for the first 90 days and at least every 120 days after, and the nurse practitioner (NP) visiting in between to ensure the resident had a visit every 60 days. This was evident for 2 (Residents #9 and #914) of 6 residents reviewed for quality of care.

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined that the facility failed to implement appropriate interventions for a resident with identified elopement potential on a resident with documented altered mental status. This was identified during the review of 1 of 6 residents (#922) reviewed for elopement.

Inspectors wroteBased on review of facility investigation documentation and medical records; observations and interviews, it was determined that the facility failed to 1. provide adequate supervision to prevent vulnerable residents from exiting the facility unsupervised and 2. have a system in place to ensure that those residents not identified as at risk for elopement are leaving the facility only through the main exit. This was found to be evident for two out of eight residents (Resident #10 and #181) reviewed for accidents during the survey. On 7/19/19 at 9:44 AM, a determination of immediate jeopardy was made in regard to risk for elopement. On 7/19/19 at 4:25 PM, the facility provided an abatement plan which was accepted by the Office of Health Care Quality. [...]

Inspectors wroteBased on record review, observation, and staff interview, it was determined that the facility failed to keep residents free of misappropriation of medications. This was evident for 6 (#18, #42, #228, #229, #30, and #129) of 18 residents reviewed.

Inspectors wroteBased on resident interview, medical and investigation report review, and resident interview it was determined that the facility staff failed to thoroughly investigate 1) an injury of unknown injury and 2) misappropriation of controlled substances. This was evident for 6 of 18 residents reviewed. 1 (#67) of 3 residents reviewed for skin conditions (non-pressure) 5 (#18, #42, #228, #229, and #30) of 18 residents reviewed.

Inspectors wroteBased on medical record review and interview with staff, it was determined that the facility staff failed to develop and implement comprehensive person centered care plans including measurable objectives. This was evident for 8 (#10, #70, #68, #181, #23, #11, #62 and #67) of 43 residents reviewed during the investigation phase of the survey. 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.

Inspectors wroteBased on review of the medical record and interview with staff, it was determined that the facility staff failed to review and revise the resident's plans of care based on changing goals, preferences and needs and in response to current interventions. This was evident for 1 (#68) of 1 residents reviewed for dementia care, and for 1 (#23) of 5 residents' reviewed for pressure ulcer/injury. 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.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to 1) have an effective system in place to ensure the implementation and provision of functional maintenance programs as recommended by the therapists for 2 (#10 and #70) of three residents reviewed for activities of daily living and 2) failed to have a process in place to continue restorative therapy to allow residents to maintain their highest level of functioning and prevent contractures for 2 (#67 and #12) of 2 residents reviewed for rehabilitation and restorative care.

Inspectors wroteBased on observations, record review, and resident and staff interview, it was determined that the facility failed to have sufficient staffing to 1) answer call lights during meals and shower times and 2) provide restorative care for residents to make sure they maintained their highest functional level. This was evident for 5 (#59, 39, 49, 70, and 31) of 5 residents attending Resident council meeting. This was evident for 2 (#67 and #12) of 29 residents reviewed for Rehabilitation and Restorative services.

Inspectors wroteBased on review of pertinent documentation, observation and interview, it was determined that the facility failed to have a process in place to monitor pharmacy provision of controlled drugs received into the facility and to ensure that each resident receiving a controlled drug had a corresponding physician's order. This was evident for 2 (#MDOO132061 and #MD00134506) of 2 facility reported incidents of misappropriation of medication.

Inspectors wroteBased on medical record review and interview with staff, it was determined the facility failed to ensure each that resident's drug regimen was free from unnecessary drugs by: 1) failing to follow the physician's order for pain management, 2) Administering insulin when none was indicated, 3) Administering a narcotic outside of ordered parameters and 4) failing to identify and eliminate duplicate and conflicting medication orders. This was evident for 3 (#179, #128 and #181) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review, observation and interview, it was determined that the facility failed to ensure a medication error rate below 5% as evidenced by 2 errors identified out of 29 opportunities for error, resulting in a medication error rate of 6.9 %. The errors were found to be evident for medications administered to two out of the four residents (Resident #35 and #9) observed during medication administration observations.

Inspectors wroteBased on observation, resident and staff interview, it was determined that the facility failed to provide adequate staff to serve residents in the dining room in a timely manner. This was evident for 2 of 2 observations in the dining room.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards. This was evident for 4 (#10, #128, #68 and #181) of 43 residents reviewed during survey investigations.

Inspectors wroteBased on interviews, reviews of records, current survey findings and the facility's prior annual and complaint surveys, it was determined that the facility failed to have an effective Quality Assessment Performance Improvement program to develop and implement effective plans of action to correct identified quality deficiencies. This was evident during review of the Quality Assurance Program.

Inspectors wrote2) On 7/9/19 at 10:05 AM, an observation was made of Resident #179's room. There was a bedside toilet wedged between the resident's bed and the wall on the left side, which was blocking the bedside stand that was sitting behind it. Furthermore, at the time of the observation, the resident was interviewed and when asked about the room and his/her ability to get around, the resident reported that since the bedside toilet was placed there, he/she could not get in the bedside stand drawers without assistance. He/she stated that staff had been made aware of the concern but did not move the bedside commode. During a walk through with the Chief Executive Officer (CEO) and Housekeeping Manager on 7/19/19 at 2:03 PM, the CEO was made aware of and acknowledged the concern. [...]

Inspectors wroteBased on review of facility records and interview with staff it was determined the facility failed to ensure residents were free from abuse. This was evident for 1 (#183) of 3 residents reviewed for Abuse.

Inspectors wroteBased on review of facility reports and medical records and interview with staff and resident's family, it was determined that the facility failed to have an effective system in place to ensure appropriate reporting of abuse and neglect as evidenced by: [...]

Inspectors wroteBased on record review and interview with residents and staff, it was determined the facility staff failed to provide written notice to the resident/representative upon transfer to the hospital. This was evident for 2 (#76 and #5) of 4 residents' reviewed for hospitalization.

Inspectors wroteBased on record review and interview with staff, it was determined the facility staff failed to provide written notice of bed hold policy to the resident/representative upon transfer to the hospital. This was evident for 1 (#5) of 4 residents' reviewed for hospitalization.

Inspectors wroteBased on medical record review, resident interview, and staff interview, it was determined that the facility failed to have a process in place to ensure that residents received a summary of their baseline care plan and a list of their medications within 48 hours of admission. This was evident for 1 (#179) of 18 residents reviewed for care plans.

Inspectors wroteBased on review of the resident record and interview with the resident and facility staff, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan by failing to recognize and avoid a resident's documented food allergen. This was evident for 1 (#11) of 3 residents reviewed for Nutrition.

Inspectors wroteBased on medical record review and interview with staff, it was determined that the facility failed to ensure resident received interventions to prevent the development of pressure ulcers. This was evident for 1 (#47) of 5 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, review of the medical record and interviews with staff, it was determined the facility staff failed to implement measures to ensure the resident received the required number of calories and total fluid volume per the dietitian recommendation. This was evident for 1 (#181) of 3 residents reviewed for nutrition.

Inspectors wroteBased on medical record review and interview with staff, it was determined that the facility 1) failed to ensure that pharmacy reviews were addressed by attending physicians in a timely manner, 2)failed to ensure that recommendations were made for the correct resident and 3) the facility's clinical pharmacist failed to identify the facility's failure to address a GDR (gradual dose reduction) for a resident receiving psychotropic medications. This was evident for 3 (#31, #128, and #68) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on review of the medical record and interview with staff, it was determined that the facility staff failed to ensure that a resident who used psychotropic drugs received a gradual dose reduction unless clinically contraindicated, and documented as per standards of practice, in an effort to discontinue these drugs. This was evident for 1 (#68) of 5 residents reviewed for Unnecessary Meds, Psychotropic Meds, and Med Regimen Review.

Inspectors wroteBased on review of pertinent documentation, observation and interview, it was determined that the facility administration failed to 1) address the need for upgraded doors to assist in the prevention of resident elopements for 7 out of 9 exits accessible to residents, 2) keep residents free of misappropriation of controlled drugs for 6 (#42, #228, #229, #18, #129, and #30) of 6 Resident identified in the facility's investigation reports and 3) provide dining services in a timely manner. This was evident for 7 months of Resident Council Meeting Minutes out of 12 months reviewed.

Inspectors wroteBased on facility documentation review and staff interview, it was determined the facility failed to maintain the posted daily nurse staffing data in a clear and readable format that was readily accessible and up to date.

Inspectors wroteBased on record review, resident and staff interview, it was determined that the facility failed to have a process in place to ensure that concerns and suggestions from the resident group were reviewed and responses provided to the group in writing. This was for 12 of the 12 months of meeting minutes reviewed during survey.