Layhill Nursing and Rehabilitation Center

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to implement a physician's order to treat a resident's non-pressure-related skin issues. This was evident in one (Complaint #2743075) of five complaints investigated during the complaint survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided according to professional standards of practice that included non-pharmacological interventions (NPI) attempted/provided to a resident prior to administering as needed (PRN) pain medication and reordering routine pain medication in a timely manner. This was evident for 1 (Resident #101) of 12 residents reviewed during the survey.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to ensure food and equipment was prepared in a manner that maintains professional standards of food service safety and sanitation. This was found to be evident for 2 (Cook #1 and Dietary Aide #2) out of 4 kitchen staff and 1 commercial dishwasher observed during the recertification and complaint survey. This practice had the potential to affect all Residents who consumed food prepared by the facility's kitchen.

Inspectors wroteBased on interviews and record review it was determined that that facility failed to ensure Resident personal funds were fully accessible. This was found to be evident for 54 out of 54 Residents who have Resident Fund Accounts.

Inspectors wroteBased on observations, interviews and record review, it was determined that the facility failed to ensure 1) Residents were free of physical restraints and 2) a physician order was obtained for the use of a physical restraint. This was found to be evident for 1) 4 (Resident #16, #27, #4, & #11) out of 4 Residents reviewed for restraints and 2) 47 (Resident #90, #142, ##107, #146, #86, #137, #129, #81, #145, #70, #75, #68, #144, #91, #109, #99, #10, #147, #66, #119, #12, #84, #133, #124, #92, #56, #9, #47, #52, #37, #55, #41, #39, #59, #128, #105, #113, #11, #49, #13, #98, #102, #62, #25, #53, #104, & #34) out of 47 Residents reviewed for physician orders for physical restraints during the recertification and complaint survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure Residents had a comfortable chair in their room. This was found to be evident for 5 (Resident #40, #41, #12, #108, & #11) out of 5 Resident rooms observed during the recertification and complaint survey.

Inspectors wroteBased on record reviews, interviews and observations, it was determined that the facility (1) failed to provide access to services outside the facility and (2) failed to ensure Residents were provided a dignified existence. This was found to be evident for 2 (Resident #22 and #41) out of 2 Residents observed for resident rights.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide a homelike environment. This was found to be evident for 4 (Residents #53, #22, #62 and #119) out of 27 resident rooms observed for homelike environment during the course of the survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure the Resident/Resident Representative and Ombudsman received notification of a proposed transfer. This was found to be evident for 1 (Resident #27) out of 1 Resident reviewed for transfer during the recertification and complaint survey.

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure Resident care plans were developed. This was found to be evident for 2 (Resident #2 & #12) out of 27 Resident care plans reviewed during the recertification and complaint survey.

Inspectors wroteBased on record reviews, observations and interviews, it was determined the facility staff failed to revise care plans to meet the needs of the residents. This was evident for 2 (Residents # 15 and #13) of 2 residents reviewed for care plan revisions during the recertification survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure nursing standards of practice were met. This finding was evident for 1 (Resident #9) of 1 resident reviewed for standards of practice during the recertification survey.

Inspectors wroteBased on record reviews and interview it was determined that the facility failed to ensure Pharmacy Medication Regimen Review (MRR) recommendations were reviewed in a timely manner. This was found to be evident for 1 (Resident #4) out of 5 Residents reviewed for unnecessary medications during the recertification and complaint survey.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 3 out of 29 medications administered during the observation.

Inspectors wroteBased on medical record reviews and interviews it was determined that the facility failed to ensure medical records were complete and accurate. This was evident for 2 (Resident #22 and #9) of 2 residents reviewed for medical record documentation during the recertification survey.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to ensure staff practiced infection control. This was found to be evident for 2 (Residents #13 and #22) out of 2 Residents observed for infection control during the recertification survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure a Resident's smoke detector was in working condition. This was found to be evident for 1 (Resident #44) out of 9 Resident smoke detectors observed during the recertification and complaint survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to provide services that met professional standards of practice. This was found to be evident for 1 (Resident #5) out of 1 Resident reviewed for professional standards of practice during the complaint survey. This deficient practice was identified as past non-compliance.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure all medications were ordered as listed on the hospital discharge summary. This was evident for 1 (resident #5) out of 22 residents reviewed for physician services during the complaint survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure that an accurate pharmacy medication regimen review was conducted. This was found to be evident for 1 (Resident #5) out of 1 Resident reviewed for pharmacy medication regimen review during the complaint survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to notify a Resident's Representative of a change in condition. This was found to be evident for 2 (Resident #18 and #11) out of 2 Residents reviewed for notification during a complaint survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to ensure a Resident Fund Account was accurately managed. This was found to be evident for 1 (Resident #14) out of 1 Resident reviewed for resident funds during the complaint survey.

Inspectors wroteBased on review of the facility's investigative report and staff interview, it was determined the facility failed to report an allegation of abuse to the State Survey Agency, which was the Office of Health Care Quality (OHCQ) within 24 hours of the alleged incident. This was found to be evident for 2 (Resident #19 and #7) out of 7 Residents reviewed for abuse during the complaint survey.

Inspectors wroteBased on a complaint investigation, record reviews, and staff interviews, it was determined that the facility failed to ensure a complete and accurate written discharge summary was provided to a resident at the time of discharge. This was evident for 1 (Resident #2) of 1 resident reviewed for transfer and discharge process during the complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to review and revise the interdisciplinary care plans to reveal accurate interventions for a resident. This was evident for 1 (Resident #8) of 1 resident reviewed for care planning.

Inspectors wroteBased on record review, observation and interviews, it was determined that the facility failed to ensure that wound dressings were labeled to indicate when the dressing change occurred. This was evident for 2 (Resident #21and #22) of 3 wound dressing observations.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the facility failed to provide treatment and services necessary to prevent pressure ulcer. This was evident for 1 (Resident #16) out of 1 resident reviewed for facility acquired pressure ulcer during the complaint survey process.

Inspectors wroteBased on record review, interviews and review of facility investigation documents, it was determined that the facility failed to keep a resident free from accidents and hazards by failing to provide a qualified caregiver to assist the resident. This was evident in 1 (Resident #19) of 1 resident reviewed for accidents and hazards during the complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to have an effective system in place to correctly identify the appropriate decision maker regarding health care decisions and that the resident/health care decision maker's wishes regarding CPR were clearly documented in the medical record to ensure CPR was performed if needed. This was evident for 4 out 51 Residents, (Resident #328, #30, # 97 #55), reviewed for advanced directives during a survey. The facility's failure to ensure that each resident had only one active MOLST, led to the determination that immediate jeopardy existed. The facility was notified of this determination on [DATE] at 6:25 PM. Surveyors accepted the facility's plan to remove the immediacy on [DATE] at 11:00PM. The plan was validated, and the immediate jeopardy was removed on [DATE] at 5:05 PM.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to have an effective system in place to ensure interdisciplinary care plan meetings were occurring after assessments; and failed to ensure care plans were being reviewed and revised as needed. This was found to be evident for 8 (Resident #30; #23; #95; #78, #55. #84, #10, #100 ) out of 17 residents reviewed during the survey

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to post nursing staffing. This was evident during the staffing investigation portion of the recertification survey and had the potential to affect all residents, residents' representatives and visitors.

Inspectors wroteBased on pertinent document review and interview, it was determined that the facility failed to address identified issues with the facility MOLST forms to ensure that residents wishes regarding CPR treatments were correctly documented in the residents' medical record. This 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 establish a quality assurance committee that included a medical director at every quarterly meeting.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that staff had training in interpersonal communication. This was evident for 9 staff (NHA, DON, ADON, SW #11, SW #19, Staff #27, Staff #12, Staff #14, LPN #28, and Staff #29) of 10 staff training records reviewed during the extended survey portion of the recertification survey and had the potential to affect all residents.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to honor residents' right to self-determination. This was evident for 1 resident (Resident #37) of 17 residents reviewed for Medical Orders for Life Sustaining Treatments (MOLST) documentation related to the Immediate Jeopardy investigation during the recertification survey. This had the potential to affect all residents who could make their own decisions.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. This was found to be evident on both floors of the nursing facility.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to develop and implement a comprehensive, resident centered care plan for a resident receiving psychotropic medications. This was evident for 1 (#78) of 5 residents reviewed for unnecessary medications, and 1 #(78) of 5 residents reviewed for unnecessary medications. 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 residents care

Inspectors wroteBased on medical record review, observation and interviews, it was determined that the facility failed to ensure that activities were provided to meet the needs of the residents. This was found to be evident for 4 (Resident #30, #95, #13 and #109) out of 4 residents reviewed for activities during the survey.

Inspectors wroteBased on interview and observation, it was determined that the facility 1). failed to provide a Resident with a physician ordered pain medication. 2). failed to ensure that residents' pain was evaluated and managed. 3). failed to develop and implement non-pharmacological interventions prior to administering pain medication and failed to administer the pain medication on time. This was evident for 3 (Resident # 31, # 57 #50,) out of 4 residents reviewed for pain management during a survey.

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined that prior to the installation or use of bed rails, the facility failed to ensure, 1) appropriate alternatives were identified and used, 2) the resident's risk of injury or entrapment was assessed, 3) the risks and benefits of bed rails was discussed with the resident/representative, 4) informed consent for bed rails was obtained, and 5) failed to ensure that a care plan with measurable objectives and specific interventions was developed for a resident's use of a bed rail. 6) that monitoring and supervision were provided during the resident's use of the bed rails, This was evident for 4 (#78, #380, #13, #57) of 4 residents reviewed for side rails.

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 1) failing to follow physician ordered blood pressure parameters for administering medication, and 2) failing to ensure prescribed medications had adequate parameters in place to indicate when to administer as needed medications for pain. 3) failing to ensure that an attending provider's orders for a resident's topical anesthetic medication included a time to remove it This was evident for 3 (#78, # 25, # 50) of 5 residents reviewed for unnecessary medications, and 1 (#380) of 4 residents reviewed for pain management.

Inspectors wroteBased on observation, review of meal tickets and interview, it was determined the facility failed to ensure residents were served the correct portions and items as indicated on their meal tickets. This was found to be evident for one out of one test tray obtained during the survey.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility failed to conduct a regular inspection of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment and failed to ensure the equipment was inspected and maintained according to manufacturer's recommendations and requirements and timeframes. This was evident for 3 (#78, #380, #13) of 3 residents reviewed for bed side rails and had the potential to affect all residents.

Inspectors wroteBased on medical record review and interview, it was determined that the faciltiy failed to have an effective system in place to ensure code status was discussed with residents and or their responsible party when new MOLSTs were created. This was found to be evident for 3 (Resident #30, #23. #97) out of 17 residents reviewed for code status during the survey.

Inspectors wroteBased on interview, and observation, it was determined that the facility failed to ensure that a resident received services with dignity. This was evident for 1 (Resident #42), out of 132 residents observed during a survey.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to provide residents with information to formulate an advance directive. This was evident in 3 (Resident #24, #37, #55) of 17 residents reviewed for advance directives.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to notify a resident's representative of changes in the resident's treatment. This was found to be evident for 1 out of (Resident #23) one resident reviewed for notification of change.

Inspectors wroteBased on medical record review and interview, it was determined that the facility administered an intramuscular injection of an antipsychotic medication without adequate indication. This was found to be evident for one (Resident #30) out of five residents reviewed for unnecessary medication.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to prevent further potential abuse while an investigation was in progress as evidenced by an inaccurate immediate assessment of the alleged victim. This was evident in 1 (Resident #232) of 5 residents reviewed for abuse.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that essential information was provided to emergency department staff when a resident went to the hospital. This was evident for 1 resident (Resident #10) of 2 residents reviewed for hospitalization during the recertification survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide a resident with a notice of transfer when the resident transferred to the hospital. This was evident for 1 resident (Resident #10) of 2 residents reviewed for hospitalization.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide a resident a bed hold notice when the resident transferred to the hospital. This was evident for 1 resident (Resident #10) of 2 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review, observation, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 1 (#107) of 1 resident reviewed for behavior.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) form was completed for a newly admitted resident. This was evident for 1 (Resident #50) of 2 residents reviewed for PASRR.

Inspectors wroteBased on review of the medical record and interview with staff, it was determined that the facility staff 1) failed to provide residents/representatives with a copy of their baseline care plan that included a summary of the resident's medication. This was evident for 1 (#380) of 4 residents reviewed for pain management.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that nursing staff did not document administration of g-tube feedings that they had not actually provided. This was found to be evident for one (Resident #23) out of one resident reviewed for g-tube feeding.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that residents' communication needs were met. This was evident for 1 complaint (#MD00209021) of 5 complaints reviewed during the recertification survey. This had the potential to affect all deaf residents.

Inspectors wroteBased on medical record review, and staff interviews, it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by providing incontinent care in a timely manner. This was evident for 1 (Resident #16) out of 132 residents reviewed during the survey process.

Inspectors wroteBased on record review, observations and interviews, it was determined the facility failed to accurately assess the presence of pressure injuries and implement pressure prevention therapies. This was evident for 2 (Resident #328, #109) out of 5 residents reviewed for pressure injuries.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to develop a care plan to ensure that advances in mobility that were achieved during therapy were maintained. This was found to be evident for one (Resident #23) out of three residents reviewed for falls during the survey.

Inspectors wroteBased on medical record review, observations, and interviews, it was determined that the facility failed to have a system in place for monitoring residents who have been identified as high risk for elopement. This was evident for 1 (#59) of 6 residents reviewed for accidents.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to identify a resident with a critically low body mass index (BMI) and failed to have a policy and procedure in place to measure residents' height. This was evident for 1 resident (Resident #17) of 5 residents reviewed for nutrition during the recertification survey and had the potential to affect all residents.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that feedings via a g-tube were administered as ordered and failed to ensure a plan to try to restore oral eating was established. This was found to be evident for one (Resident #23) out of one resident reviewed for tube feeding.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to provide behavioral health monitoring to ensure a resident's highest practicable mental and psychosocial well being. This was found to be evident for 1 (Resident #30) out of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and interview with staff, it was determined that the facility failed to ensure that Irregularities identified by the pharmacist were reviewed by the attending physician, timely acted upon and documented in the resident's medical record. This was evident for 3 (#30, #78, 50 ) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure the resident was free from unnecessary psychotropic medications. This was found to be evident for 1 (Resident #30) out of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility failed to maintain a medication error rate of less than 5%. This was found to be evident based on 3 errors identified out of 25 opportunities for error.

Inspectors wroteBased on the interview and review of relevant documentation, it was determined that the facility failed to have a full time clinically qualified Food Service Director and failed to ensure scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This was evident for 1 (Staff #62) of 1 Food Service Director reviewed for required credentialing.

Inspectors wroteBased on observation, and interview, it was determined that the facility failed to ensure clean dishes were stored and maintained in a manner to prevent contamination. This practice had the potential to affect all the residents in the facility.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to document clinical assessments. This was evident for 1 resident (Resident #17) of 5 residents reviewed for nutrition during the recertification survey.

Inspectors wroteBased on record review, observation, and interview, it was determined the facility failed to maintain a resident's medical equipment in proper sanitary conditions and failed to process linens in a manner that prevents cross contamination. This was evident for 2 (Resident #88, #330) out of 2 residents, reviewed for urinary catheter or urinary tract infection during a survey and evident in 1 of 1 laundry room observations during the recertification survey and had the potential to affect all residents of the facility. .

Inspectors wroteBased on family and staff interview, and observation, it was determined the facility failed to maintain electrical equipment in safe operating condition and failed to maintain a bathroom safety rail in a safe operating condition. This was evident for 1 of 1 microwave observed during the survey and evident for 1 residents room. 1) On 9/20/24 at approximately 10:00 AM, Resident #380's family member asked if the surveyor had seen the microwave in the 1st floor pantry where residents could have food reheated. The family member then stated that the interior of the microwave was rusty and s/he was concerned the microwave was not safe to use. 9/20/24 at 10:05 AM, observation of microwave revealed the white coating on the walls and floor of the microwave was peeling with areas of coating missing, exposing areas of rust. [...]

Inspectors wroteBased on observation and staff interviews, it was determined that the Facility failed to have the call light within reach of a dependent resident. This was evident for 1 (#402) of 3 residents reviewed for Activity of Daily need (ADL) dependence during a revisit survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. This was found to be evident on both floors of the nursing facility.

Inspectors wroteBased on medical record review and staff interview, facility staff failed to provide privacy to a vulnerable resident (resident #26). This was evident for 1 of 8 residents reviewed during a complaint survey and resulted in psychosocial harm to resident #26.

Inspectors wroteBased on record review and staff interview it was determined that the facility failed to ensure that residents were free from abuse. This was evident for 2 (#3 and #29) of 27 residents reviewed for abuse. These identified concerns rose to the level of harm for both identified residents.

Inspectors wroteBased on review of facility documentation and interview with staff it was determined the facility staff failed to ensure that allegations involving abuse were reported to the Administrator of the facility and the State Agency no later than 2 hours after the allegation was made and results of all investigations were reported within 5 working days. This was evident in 5 of 27 abuse allegations reviewed for Residents (#1, #2, #7, #62, #3 ).

Inspectors wroteBased on review of facility documentation and interview with staff it was determined the facility staff failed to investigate, prevent, and correct alleged abuse violations. This was evident for 6 of 27 abuse allegations reviewed related to Residents (#1, #24, #29, #3, #61 and #17).

Inspectors wroteBased on medical record review and interview with staff it was determined the facility staff failed to accurately complete resident assessments reflective of the resident's status. This was evident for 5 of the last 5 assessments for 1 (Resident #1) of 65 resident's reviewed for during the survey.

Inspectors wroteBased on the review of a complaint, medical record review and interview with staff, it was determined that staff failed to provide all treatment and care to residents in accordance with professional standards of practice by failing to follow practitioner orders and established care plans. This was evident for 4 of 65 (#43, #1, #25 and #20) residents reviewed during a complaint 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 medical record review and interview, it was determined the facility staff failed to ensure Resident #35's responsible party (RP) was provided the opportunity to consent to the COVID-19 vaccine for Resident #35. This was evident for 1 of 81 residents selected for reviewed during the complaint survey.

Inspectors wroteBased on observations and interview with staff it was determined that the facility failed to assess a resident for capability to self-administer medications. This was identified during a resident interview where medications were randomly observed on the nightstand. (#43)

Inspectors wroteBased on random observations from tours and complaints that were placed with the Office of Health Care quality, it was determined that the facility failed to attend to and answer call bells timely for dependent residents. This was evident during tour of the first and second floor and the validated review of 1 of 49 complaints. (Resident #10)

Inspectors wroteBased on reviews of a closed electronic medical record and staff interview, it was determined that the facility medical staff failed to create a MOLST for a resident upon admission. This was evident for 1 (Resident #57) of 65 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of a closed medical record, and staff interviews, it was determined that the facility staff failed to 1. Immediately notify a resident's physician when a resident had fallen. 2. Notify the surgeon per discharge instructions or 3. Notify a residents' representatives of a change in condition and hospitalization. This was evident for 3 (Resident #8, #58, #59) of 65 residents reviewed during a complaint survey.

Inspectors wroteBased on the review of a complaint, staff and resident interview and medical record review, it was determined that the facility failed to adequately prepare a resident for discharge. This was evident during the review of 1 of 2 complaints regarding discharges. (Resident #5)

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to implement a care plan related to a resident's primary diagnosis and therefore implement a plan of care related to that diagnosis. This was evident for 1 of 65 residents (#43) reviewed during a complaint survey. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to ensure that residents had a discharge summary and it was complete and accurate (Resident #17, #25, #36 and #54). This was evident for 4 of 65 residents reviewed during a complaint survey.

Inspectors wroteBased on the review of a complaint, medical record review and interview with staff, it was determined that the facility failed to implement wound care orders for a resident with a stage 3 pressure ulcer. This was evident during the review of 2 of 5 residents (#40 and #37) reviewed for wounds during a complaint survey

Inspectors wroteBased on complaint, reviews of a closed medical record, and staff interviews, it was determined that the 1. facility staff failed to follow a resident's fall prevention care plan to ensure all nursing interventions were implemented. Resident #8 did not have the call light within reach and tried to walk to the restroom without assistance and fell. This was evident for 1 (Resident #8) of 65 residents reviewed during a complaint survey and 2. the facility failed to ensure that staff were using a mechanical lift to transfer residents based on the manufacturer's instructions to ensure resident's safety. This was evident for 1 of 1 observation of a resident transfer in a mechanical lift.

Inspectors wroteBased on complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to 1. discharge a resident home with all of their belongings. This was evident for 1 (Residents #53) of 65 and 2. failed to accurately monitor and assess a resident's weights on admission. This was evident for 1 of 3 residents during a complaint survey (#60)

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the physicians failed to have their notes in the medical record timely after seeing the resident. This was evident for 1 of 65 (#4) Residents reviewed during a complaint survey.

Inspectors wroteBased on the review of a facility reported incident (FRI) #MD00204392 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 5 employee files reviewed for competencies and skill sets.

Inspectors wroteBased on the review of a complaint, resident interview and interview with the facility staff, it was determined that the facility failed to timely provide a resident with an established psychiatric diagnosis with therapeutic treatment to maintain his/her highest practicable well-being. This was evident during the review of 1 of 65 residents (#33) reviewed during a complaint.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to administer medications according to the physician orders. This was evident for 1 out 1 resident (#51) in the complaint sample. Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication error and more prone to changes in condition that require review and adjustment of their medication regimen. [...]

Inspectors wroteBased on complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to discharge a resident home with all of their belongings. This was evident for 1 (Residents #53) of 65 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #25 and #51). This was evident for 2 of 65 residents reviewed during a complaint survey.

Inspectors wroteBased on a facility's Quality Assurance and Performance Improvement (QAPI) record review and interview, the facility failed to adequately monitor malfunctions in the facility's hot water heating system. QAPI Plan A written plan that contains the process that will guide a facility in their efforts to assure care and services are maintained at acceptable levels. QAPI Committee A group consisting of a facility's administration department and selected other facility staff that review the facility's process to ensure care and services are maintained at acceptable levels.

Inspectors wroteBased on surveyor observation, review of clinical records, facility policy and procedures and interview with facility staff, it was determined that the facility failed to ensure infection control practices to prevent development and transmission of communicable disease and infections for resident #221. This finding was evident for 1 of 3 residents reviewed for the respiratory care area. Additionally, based on surveyor observations and interview with facility staff, it was determined that the facility staff failed to ensure appropriate hand hygiene practices between residents' contacts during meal distribution. This finding was evident for 2 of the 2 floors within the facility of resident units.

Inspectors wroteBased on surveyor review of the clinical record, surveyor observation and interview with facility staff, it was determined that the facility failed to develop comprehensive plans of care for residents. This finding was evident for 4 of 34 residents selected during the survey (#30, #61, #64, #99).

Inspectors wroteBased on surveyor observations, review of the facility's policy and procedure, interview with residents, maintenance contractors and facility staff, it was determined that the facility failed to ensure that water temperatures were maintained in residents' rooms at a safe temperature below 120 degrees Fahrenheit (F).

Inspectors wroteBased on surveyor observations and interview with facility staff, it was determined that the facility failed to ensure the dignity of residents. This finding was evident for 3 of 4 residents selected for the Dignity review. (#26, #58, #219)

Inspectors wroteBased on surveyor review of the clinical records, and resident and facility staff interview, it was determined that the facility staff failed to prevent involuntary seclusion during the treatment of a resident's medical condition. This finding was identified in 1 of 5 residents with infections not UTI related during the survey. (#99).

Inspectors wroteBased on surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to report an incident of suspected elopement of a resident from the facility to the State Survey Agency. This finding was identified in 1 of 2 residents reviewed for accidents. (#222).

Inspectors wroteBased on surveyor review of clinical records and staff interviews, it was determined that the facility staff failed to ensure that services provided by the facility met professional standards of quality. This finding was evident in 2 of 34 residents selected for review (#68 and #99).