Glenburnie Rehab & Nursing Center

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to serve food in a sanitary manner by failure to wear proper hair restraints in the main kitchen, which had the potential to affect residents on two of two units.

Inspectors wroteBased on observation and staff interview, the facility staff failed to uphold one resident's personal privacy to promote dignity for one resident (Resident #3-R3) in a survey sample of nine residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to accurately code an assessment for one resident (Resident #4-R4) in a survey sample of nine residents.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to revise the care plan for three of eight residents in the survey sample, Residents #2, #1, and #3.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent and treat pressure injuries (1) for three of eight residents in the survey sample, Residents #2, #1, and #3.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory services for one of eight residents in the survey sample, Resident #1.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to implement infection control procedures for one of eight residents in the survey sample, Resident #2.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care in a dignified manner for one of eight residents in the survey sample, Resident #4.

Inspectors wroteBased on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to ensure resident rights by accommodating the needs of one of eleven residents in the survey sample, Resident #104 (R104).

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain a homelike environment for one of 11 resident rooms observed, resident room [ROOM NUMBER]-B.

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed to develop a baseline care plan for one of 11 residents in the survey sample, Resident #103.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for one of eight residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for one of eight residents in the survey sample, Resident #1.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide incontinence care for one of eight residents in the survey sample, Resident #4.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain program for one of eight residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide 24 hour on-call physician services for one of eight residents in the survey sample, Resident #3.

Inspectors wroteBased on staff interview and clinical record review it was determined that the facility staff failed to maintain a complete and accurate record for two of 11 residents in the survey sample, Residents #101 and Resident #109.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to thoroughly investigate the circumstances surrounding a fire and to implement interventions to prevent future fires for a census of 116 residents. This resulted in a determination of Immediate Jeopardy (IJ). After Immediate Jeopardy was removed, the scope and severity were lowered to a level 2, widespread.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to implement an effective QAPI (quality assurance and performance improvement) program for one of one facility.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to evidence agreements for contractual services for one of one facility.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to provide timely physician visits for one of nine residents in the survey sample, Resident #5.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to post a complete record of nursing staffing for 30 of 30 days reviewed.

Inspectors wrote4. The facility staff failed to meet professional standards by administering medications timely for R5. R5 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute myeloblastic leukemia in relapse, bone marrow transplant, CHF (congestive heart failure) and renal insufficiency. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/3/25, coded the resident 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring max assist for bed mobility/transfers/bathing/dressing/toileting and supervision for eating. A review of the comprehensive care plan dated 2/7/25/24 revealed, FOCUS: GENERAL INFECTION: [...]

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor/follow medication administration orders to prevent unnecessary medications for two of 13 residents in the survey sample, Residents #8 and #2.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that facility staff failed to promote resident's dignity for one of 13 residents in the survey sample, Resident #10 (R10).

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that facility staff failed to maintain the resident's bathroom and room in a homelike environment for one of seven current residents in the survey sample, Resident #10 (R10).

Inspectors wroteBased on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to implement the care plan for one of 13 residents in the survey sample, R5.

Inspectors wroteBased on observation, resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to review and/or revise the care plan for three of 13 residents in the survey sample, Residents #12, #7 and #2.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services to promote a resident's highest level of well-being for two of 13 residents, R6 and R2.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a safe environment by monitoring and implementing fall prevention measures for two of 13 residents, R6 and R7.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide food in a form to meet resident needs for one of 13 residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the physician and responsible party that a medication was not available for administration for one of ten residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility failed to protect two of ten residents in the survey sample from verbal abuse by a staff member, Residents #9 and #10.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility failed to implement their abuse policy to protect two of ten residents in the survey sample from verbal abuse by a staff member, Residents #9 and #10.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence a complete investigation into an elopement for one of 10 residents in the survey sample, Resident #5.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to implement the baseline care plan for one of nine residents in the survey sample, Resident #104.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility failed to review and/or revise the comprehensive care plan for two of ten residents in the survey sample, Residents #9 and #10.

Inspectors wroteBased on clinical record review, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to maintain a resident's highest level of well-being for one of 10 residents in the survey sample, Resident #4.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, it was determined the facility staff failed to provide supervision to protect one of ten residents from a fire on 1/1/2025.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility failed to provide medically related social services after a verbal abuse incident for one of 10 residents in the survey sample, Resident #10.

Inspectors wroteBased on staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure medications were available at the scheduled time of administration for one of ten residents in the survey sample, Resident #2.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure one of six residents in the survey sample was free of unnecessary medications, Resident #1.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain an operational resident call system for seven of 72 resident rooms.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to maintain a safe, functional, and sanitary, environment for one of one rehab restroom.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident for four of 50 residents in the survey sample, Resident #377, #55, #88, #79.

Inspectors wroteBased on resident interview, observation, staff interview, and facility document review, the facility staff failed to provide a clean, comfortable, home like environment for five of 50 residents in the survey sample, Residents #47, #89, #38, #25, and #90.

Inspectors wroteBased on observation, resident interviews, staff interviews, clinical record reviews, and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 50 residents in the survey sample, Residents #36, #1, #25, #88, #83, #89, #47 and #117.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to prevent a decrease in range of motion (ROM) for two of 50 residents in the survey sample, Residents #89 and #100.

Inspectors wroteBased on resident interview, observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for an indwelling urinary catheter for two of 50 residents in the survey sample, Residents #89 and #83.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined facility staff failed to store and serve food in a sanitary manner in one of one facility kitchens.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for three of 50 residents in the survey sample, Resident #25, Resident #100 and Resident #119.

Inspectors wroteBased on staff interview, clinical record review, and staff interview, the facility staff failed to administer a complete influenza and pneumonia vaccination program for five of five resident records reviewed, Residents #38, #5, #88, #89, and #61.

Inspectors wroteBased on staff interview, clinical record review, and staff interview, the facility staff failed to meet COVID-19 vaccination requirements for five of five resident records reviewed, Residents #38, #5, #88, #89, and #61.

Inspectors wroteBased on observations, resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for three of 50 residents in the survey sample, Residents #38, #25, and #109.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to assess one of 50 residents in the survey sample for safe self-administration of medications, Resident #103.

Inspectors wroteBased on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the physician when medication was not administered as ordered for one of 50 residents in the survey sample, Resident #109 (R109).

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to implement the abuse policy for new employee screening for two of two employee records reviewed, CNAs (certified nursing assistants) #8 and #9.

Inspectors wroteBased on observations, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for two out of 50 residents in the survey sample, Resident #55 and Resident #5.

Inspectors wroteBased on clinical record review, staff interview, resident interview, and facility document review, it was determined that facility staff failed to review and revise the comprehensive care plan for three of 50 residents in the survey sample, Residents # 81, #1 and #94.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to meet professional standards of care for two of 50 residents in the survey sample; Residents #117 and #109.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for three of 50 residents in the survey sample, Residents #36, #89 and #47.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a safe environment for two of 50 residents in the survey sample, Resident #100 and #20.

Inspectors wroteBased on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to monitor weights as ordered for one of 50 residents in the survey sample, Resident #1.

Inspectors wroteBased on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to provide care and service for a complete dialysis (1) program for one of 50 residents in the survey sample, Residents #8.

Inspectors wroteBased on resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide trauma informed care for one of 50 residents in the sample Resident #88.

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide medically related social services for one of 50 residents in the sample Resident #88.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent administration of unnecessary psychoactive medications for one of 50 residents in the survey sample, Resident #42.

Inspectors wroteBased on the observations and staff interview, it was determined that the facility staff failed to post complete nurse staffing information for one of four days.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide respiratory care and services for one of 50 residents in the survey sample; Resident #117.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician and/or the RP (responsible party) of a need to alter treatment for four of 58 residents in the survey sample, Residents #114, #118, #112 and #6.

Inspectors wroteBased on observation and staff interview, it was determined that facility staff failed to maintain resident's rooms in good repair, and in a clean and sanitary manner for three of 12 resident rooms observed.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide evidence of the required transfer/discharge documents upon discharge/transfer for four of 58 resident in the survey sample, Residents #46, #116, #50, and #79.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to give written notification to the resident and/or responsible party and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer from the facility for four of 58 residents in the survey sample, Residents #46, #116, #50 and #79.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to develop and/or implement the baseline care plan for four of 58 residents in the survey sample, Residents #117, #114, #112 and #365.

Inspectors wroteBased on observation, resident and/or responsible party interviews, staff interview, clinical record review, and facility document review it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for three of 58 residents in the survey sample, Resident #6, #93, and #113.

Inspectors wroteBased on observation, resident and/or responsible party interview, clinical record review, staff interview, and facility document review it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents for five of 58 residents in the survey sample, Resident #93, #6, #114 #128, and #113.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to maintain residents' highest level of well-being for four of 58 residents in the survey sample, Residents #114, #22, #77 and #116.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for maintenance of a central venous access device for two of 58 residents in the survey sample, Residents #112 and #365.

Inspectors wroteBased on staff interview and employee record review it was determined that the facility staff failed to ensure CNAs (certified nursing assistants) received annual performance reviews for five of five CNA records reviewed.

Inspectors wroteBased on observation, resident interview, responsible party interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure that medications were available for administration for six of 58 residents in the survey sample, Residents #6, #77, #114, #112, #118, #365 and for one of six residents in the medication administration observation, Resident #416.

Inspectors wroteBased on staff interview and employee record review it was determined that the facility staff failed to ensure CNAs (certified nursing assistants) received annual retraining in the areas of dementia and abuse for four of five CNA records reviewed (CNAs #1, #6, #9, and #10).

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services in a dignified manner for two of 58 residents in the survey sample, Residents #128 and #96.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to respond to a resident council concern for one of one resident council meetings; the November 2022 meeting.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide personal privacy for two of 58 residents in the survey sample, Residents #128 and #98

Inspectors wroteBased on resident interview, staff interview and facility document review, the facility staff failed to evidence a response to a resident grievance for one of 58 residents in the survey sample, Resident #36.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when one out of 58 residents in the survey sample was transferred to the hospital; Residents #50.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to complete an admission MDS (minimum data set) assessment within the required time frame for one of 58 residents in the survey sample, Resident #112.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to complete an accurate MDS (minimum data set) assessment for two out of 58 residents in the survey sample, Residents #48 and #51.

Inspectors wroteBased on observations, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for one of 58 residents in the survey sample, Resident #101.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to clarify physician orders and follow professional standards of practice for three of 58 residents in the survey sample, Residents #113, #463, and #365.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide care and services to promote healing for two of 58 residents in the survey sample, Residents #113 and #93.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an environment free of hazards for two out of 58 residents in the survey sample, Residents #48 and #96.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for a colostomy for one of 58 residents in the survey sample, Resident #117.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to provide respiratory equipment per plan of care; and failed to store respiratory equipment in a sanitary manner for one of 58 residents in the survey sample, Resident #95.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to implement a pain management program for one of 58 residents in the survey sample, Resident #22.

Inspectors wroteBased on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to ensure ongoing communication with the dialysis facility for two of 58 residents in the survey sample, Resident #463 and #127.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement side rail safety procedures for one of 58 residents in the survey sample, Resident #363.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation, and clinical record review, the facility physician failed to initiate orders for a medication in a timely manner for one of six residents in the medication administration observation, Resident #416.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure timely physician visits for one of 58 residents in the survey sample; Resident #67.

Inspectors wroteBased on staff interview and facility document review, it was determined that the facility staff failed to ensure an RN (registered nurse) was on duty on one of 31 days reviewed.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence monthly drug regimen reviews were conducted by the pharmacist for one of 58 residents in the survey sample, Resident #42.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to administer medications in a manner free of medication errors less than five percent to two of six residents in the medication administration observation, Residents #56 and #416. There were two errors out of 33 opportunities, resulting in a medication error rate of 6.06%.

Inspectors wroteBased on observation, resident interview, staff interview, facility documentation, and clinical record review, the facility staff failed to prevent a significant medication error for one of six residents in the medication administration observation, Resident #416.

Inspectors wroteBased on staff interview and facility document review, it was determined the facility staff failed to have a written agreement for one of six contracted dialysis centers.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an accurate clinical record for one of 58 residents in the survey sample, Resident #117 (R117).

Inspectors wroteBased on observations, staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to maintain effective infection control practices for two of 58 residents in the survey sample, Resident #4 and #95.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to display the daily nurse staffing information on one of four days.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the required transfer or discharge documentation for seven of 49 residents in the survey sample, Residents #101, #83, #114, #80, #15, #23 and #52. The facility staff failed to ensure that comprehensive care plan goals for Residents #101, #83, #114, #80, #15, #23 and #52, were provided and communicated to the receiving health care institution upon transfer to the hospital.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide written notification of transfer to the resident and/or their representative for six of 49 residents in the survey sample, Residents #101, #83, #114, #15, #23 and #52.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a notice of bed hold prior to and or upon transfer for six of 49 residents in the survey sample, # 83, #114, #80, #15, #23 and #52.

Inspectors wrote11. The facility staff failed to develop the comprehensive care plan to include and address Resident #59's AV (arterial-venous) shunt care and dialysis. Resident #59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), ESRD [end stage renal disease] (inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2), heart failure (inability of the heart to pump enough blood to maintain normal body requirements) (3) and cerebrovascular accident (abnormal condition in which a hemorrhage or blockage of the blood vessels of the brain leads to a lack of oxygen) (4). [...]

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for four of 49 residents in the survey sample, Residents #105, #9, #114 and Resident # 82. The facility staff failed to review and/or revise Resident #105's comprehensive care plan for the use of bedrails, failed to review and revise Resident #9's comprehensive care plan to address an indwelling Foley catheter and failed to review and revise Resident #114's and Resident # 82's comprehensive care plans to address the use of antianxiety medication prescribed by the physician.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services per the physician orders and per the comprehensive care plan for three of 49 residents in the survey sample, Residents #172, #171 and #11.

Inspectors wroteBased on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to provide care and services related to dialysis for six of 49 residents in the survey sample, Residents #64, #114, #173, #80, #59, and #52. The facility failed to ensure an ongoing communication process with the dialysis centers for Resident #64, #114, #173, #80, #59 and #52, and failed to have a physician order for Resident #173 to receive dialysis, failed to ensure Resident #80's dialysis AV [arteriovenous] shunt was assessed and checked for a Bruit and Thrill every shift according to the physician's orders.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined the facility staff failed to ensure expired medication was disposed of and not available for use in one of two medication rooms, (the [NAME] unit medication room). Multiple expired IV (intravenous) medications were observed in the [NAME] unit medication room refrigerator available for resident administration.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a resident's dignity by appropriately placing a resident's catheter collection bag in a discreet location one of 49 residents in the survey sample, Resident # 104. The facility staff placed Resident # 104's catheter collection bag on the front of the control arm of their power wheelchair.

Inspectors wroteBased on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to ensure accommodation of resident needs maintain for two of 49 residents, Resident #45 and Resident #91. The facility staff failed to ensure the call bells for Resident #45 and 91 were positioned and maintained within reach.

Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that the facility staff failed to maintain a homelike environment in one of 126 resident rooms in the facility, (room [ROOM NUMBER]). The window sill in resident room [ROOM NUMBER] was observed with peeling paint and large chips of paint peeled up on the surface.

Inspectors wroteBased on staff interview and clinical record review, it was determined that the facility staff failed to ensure the assessment accurately reflected the status of one of 49 sampled residents, (Resident #104). The facility staff failed to accurately code Resident # 104's bladder status on the admission assessment MDS (minimum data set) with an ARD (assessment reference date) of 07/08/2021.

Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a baseline care plan for two of 49 residents in the survey sample, Residents #23 and #421. The facility staff failed to develop a baseline care plan for the use of an anti-anxiety medication and for the use of bed rails for Resident #23 and failed to develop a baseline care plan to address the physician ordered indwelling urinary catheter upon admission for Resident #421.

Inspectors wroteBased on clinical record review, staff interview and review of facility documentation it was determined the facility staff failed to ensure professional standards for two of 49 residents in the survey sample, (Resident #421 and # 82). 1. The facility staff failed to clarify Resident #421's as needed pain medication order. The 7/19/21, physician order documented the maximum amount of acetaminophen for a 24 hour period should not exceed 3 grams (3000 mg). The 7/20/21, physician order documented to administer Acetaminophen tablet, 975 mg by mouth every 6 hours for pain (4 times a day for a total of 3900 milligram of Acetaminophen per 24-hour period). 2. The facility staff failed to clarify Resident #82's physician orders for two as needed pain medications to determine which and when to administer each as needed pain medication.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to the implement assistive device safety measures to ensure an environment free of accident hazards for one of 49 residents in the survey sample, Resident #40. The facility staff failed to implement Resident #40's fall mat on 7/26/21, 7/27/21, the morning of 7/28/21 and 7/29/21 per the comprehensive plan of care.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure the appropriate care and services for a urinary catheter for three of 49 residents in the survey sample, Residents #3, #9 and #104. 1. The facility staff failed to secure Resident #3's indwelling urinary catheter and failed place the urinary catheter collection bag below the level of the bladder. 2. The facility staff failed to maintain Resident #9's urinary catheter bag in a manner to prevent infection. The catheter bag was observed lying on the floor during the dates of the survey. 3. The facility staff failed to position Resident # 104's catheter collection bag below the level of their bladder to prevent backflow of urine and failed to obtain a physician's order for a catheter.

Inspectors wroteBased on staff interview, clinical record review and review of facility documentation the facility staff failed to ensure the medication regimen for two of 49 sampled residents (Resident #114, and Resident #27) was free of unnecessary medications. 1. The facility staff administered the narcotic pain medication Hydrocodone-Acetaminophen to Resident #114, for pain scale ratings below the physician ordered parameters of severe pain (8-10) and failed to attempt non-pharmacological interventions prior to administering the medication. 2. Resident #27 received Diclofenac Sodium Gel 1% (topical analgesic) medication ordered for moderate pain, when pain level was zero.

Inspectors wroteBased on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure residents were free of unnecessary psychotropic medications for two of 49 residents in the survey sample, Residents #62 and #114. 1. The facility staff failed to monitor Resident #62 for targeted behaviors and side effects for the use of Seroquel (1). 2. The facility staff failed to offer non-pharmacological interventions prior to the administration of the as needed (PRN) Ativan an anti-anxiety medication, failed to document the reason for the administration of Ativan anti-anxiety medication, failed to have a stop date for the as needed Ativan anti-anxiety medication and the physician/nurse practitioner failed to document the monitoring for the use of an anti-anxiety medication for Resident #114.

Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, it was determined that the facility staff failed to serve food at temperatures and flavor that was palatable for meal enjoyment.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner. In the freezer an unsealed box of fish fillets was observed fish fillets in the box were exposed to the environment in the freezer and a bottle of opened thickened orange juice, half used, was not dated with an opened date or placed in the refrigerator after opening.

Inspectors wroteBased on staff interview, clinical record review and facility document review, it was determined the facility staff failed to maintain a complete and accurate medical record for two of 49 residents in the survey sample, Resident #59 and Resident #101.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to post nurse staffing information. The facility staff failed to post nurse staffing information on 7/27/21 and on 7/28/21, during the morning.

Inspectors wroteBased on observation, staff interview, and facility document review, it was determined that the facility staff failed to maintain the dumpster area in a sanitary manner.