Liberty Heights

Inspectors wroteBased on record review and interviews the facility failed to ensure residents were treated with dignity and respect for one (#4) of three residents out of six sample residents. Specifically, the facility failed to ensure Resident #4 was treated with dignity and respect by certified nurse aide (CNA) #1.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#1) of three out of six sample residents who required respiratory care were provided such care consistent with professional standards of practice. Specifically, the facility failed to ensure Resident #1 received oxygen according to the physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents out of three sample residents received food prepared in a form designed to meet individual needs. The facility failed to ensure Resident #1 was served the correct diet texture as ordered by the physician. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare and distribute food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure employees performed hand hygiene appropriately during meal service and avoided cross contamination.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections. Specifically, the facility failed to:-Ensure resident rooms were cleaned in hygienic manner;-Ensure housekeeping staff performed hand hygiene appropriately during room cleaning;-Ensure linen and resident clothing were transported in hygienic manner;-Ensure dirty linen was transported appropriately; and, Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who should be on enhanced barrier precautions (EBP).

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents had the right to a dignified existence. Specifically, the facility failed to provide an environment of engagement and promote quality of life for residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure accurate assessments and informed risks were in place for three (#18, #3 and #7) of five residents with bed rails out of 27 sample residents. Specifically, the facility failed to:-Ensure Resident #18, Resident #3 and Resident #7 were assessed for the use of bed rails and less restrictive alternatives were attempted prior to use; and,-Ensure the risks of bed rails were explained to and informed consent for use was obtained from Resident #18, Resident #3 and Resident #7.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate allegations related to an injury of unknown origin and incidents of resident-to-resident physical and verbal altercations for two (#35 and #18) of eight residents reviewed out of 27 sample residents. Specifically, the facility failed to:-Ensure an investigation was conducted for incidents of physical and verbal altercations involving Resident #35; and,-Ensure a complete and thorough investigation was completed for injuries of unknown origin on the wrist for Resident #18.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#6 and #2) of five residents who required assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities out of 27 sample residents. Specifically, the facility failed to:-Conduct a safe transfer, develop a communication plan to ensure the resident was provided interaction in her native language and ensure timely incontinence care and repositioning was provided for Resident #6;-Ensure timely incontinence care, repositioning and eating assistance was provided for Resident #2; and,-Ensure Resident #2's comprehensive care plan was revised to accurately depict the resident's current level of care with ADLs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental and psychosocial well-being were provided for two (#6 and #30) of three residents out of 27 sample residents. Specifically, the facility failed to provide a program of meaningful activities for Resident #6 and Resident #30.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#3 and #33) of two out of 27 sample residents with limited range of motion (ROM) received appropriate treatment and services. Specifically the facility failed to:-Ensure parameters were clearly identified to indicate the length of time, how often and by whom the brace should be donned (put on) and doffed (taken off) by Resident #3;-Ensure staff were monitoring the skin condition under the brace for Resident #3;-Follow physician's orders for Resident 33's contracture management; and,-Ensure Resident #33's carrot split was included on the care plan, monitored and reviewed for effectiveness.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#18) residents of six residents was free from significant medication errors out of 27 sample residents. Specifically, the facility failed to ensure Resident #18 was administered Keppra oral solution (for seizure prevention) per physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#6 and #2) of two residents received a sufficient amount of drinks to maintain hydration out of 27 sample residents. Specifically, the facility failed to ensure Resident #6 and Resident #2 were offered and provided hydration.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#7) of one reviewed out of 24 sample residents. Specifically, the facility failed to timely assess, investigate, notify the physician and implement interventions to prevent reoccurance when Resident #7 had a bruise of unknown origin to her right arm.

Inspectors wroteBased on record review and interviews, the facility failed to prevent accidents for two of six residents (#23 and #27) reviewed out of 24 sample residents. Specifically, the facility failed to develop and implement a person-centered care plan that identified the resident's fall risk and put effective interventions in place to reduce falls for Resident #23 and Resident #27.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#2) of two residents reviewed for falls, out of 23 sample residents, received adequate supervision and assistance to prevent accidents. Specifically, the facility failed to ensure Resident #2 received adequate supervision to prevent an avoidable fall with minor injury.