Middle River Health and Rehabilitation Center

Inspectors wroteBased on record review, observation, and interview, the facility did not ensure the resident's environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R) reviewed. (R1)R1's motion sensor alarm was not turned on when R1 was in bed, as indicated in R1's care plan to prevent falls.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 of 4 residents reviewed (R1) received adequate supervision and assistance devices to prevent accidents. Certified Nursing Assistant (CNA) C did not use stand aid correctly causing a fall resulting in R1 sustaining a fracture.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide evidence that all alleged violations are thoroughly investigated for an injury of unknown cause.-Facility did not conduct interviews for other staff and residents.-Facility did not complete education in relation to the incident-Facility did not ensure a Registered Nurse (RN) completed an assessment after a Licensed Practical Nurse (LPN) completed the initial assessment.-Facility did not investigate further after becoming aware of fracture.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 4 residents reviewed (R1) received person-centered care according to the comprehensive care plan.-A facility staff member did not follow R1's care plan for toileting resulting in a fall.

Inspectors wroteBased on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicate and Medicaid [NAME] (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system. This has the potential to affect all 45 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility did not ensure each resident (R), or their representative had the right to participate in the care planning process for 7 of 13 residents (R3, R5, R25, R42, R1, R4, R11) reviewed for care conferences. This is evidenced by: Facility policy titled Resident Care Conference, revised 5/25, states in part: Policy: To have a multi-disciplinary approach to evaluate and make assessments of a resident's needs and goals and to implement the assessment into a resident's total plan of care. Procedure. All residents shall have a care conference every quarter or more if necessary. a reminder will be sent to the resident and/or their responsible party when the care conference is scheduled. Each department gives a brief report of how the resident is doing. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure drugs and biologicals were stored under proper temperature controls. This practice had the potential to affect 5 of 5 residents. Staff were not monitoring the refrigerator temperatures for both first and third floor medication rooms.

Inspectors wroteBased on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed in the bed hold notice. This has the potential to affect 1 of 2 residents (R), R51. R51 received a bed hold notice with no daily rate documented.

Inspectors wroteBased on interview and record review, the facility did not ensure development and implementation of a comprehensive person-centered care plan to address the resident's history of recurring urinary tract infections (UTI), for 1 of 13 residents (R) R27 whose care plans were reviewed, This is evidenced by:The facility's policy titled: Care Plans - Comprehensive, states in part: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Section 3 states, each resident's comprehensive care plan is designed to: (a) Incorporate identified problem areas.(e) Reflect treatment goals, timetables, and objectives in measurable outcomes, and (i) Reflect currently recognized standards of practice for problem areas and conditions. [...]

Inspectors wroteBased on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (R42 and R11) reviewed. R42's record review noted an unwitnessed fall when staff did not implement interventions of a fall mat per plan of care resulting in an emergency room (ER) visit. R42 was observed being transferred with a mechanical lift with an assist of 1 staff member. R42 requires assistance of 2 per plan of care. R11 had a fall where staff did not follow the facility protocols to do a complete assessment post fall. This is evidenced by: The facility policy titled Falls and Fall Risk, managing, states: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents (R27) reviewed. The facility failed to follow up on recommendation for urology consult due to history of frequent UTIs. This is evidenced by:R27 was admitted to the facility on [DATE] and has diagnoses of acute renal failure, morbid obesity, type II diabetes and urinary tract infections. R27's Minimum Data Set (MDS) assessment, dated 06/26/25, indicated that R27 is frequently incontinent and has no urinary toileting program. R27 has a BIMS score of 15/15, meaning cognitively intact. R27's care plan, dated 06/05/25, states that R27 has functional bladder incontinence related to activity intolerance. The identified Intervention/Tasks states in part. [...]

Inspectors wroteBased on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 48 residents (R). Physical Therapy Assistant (PTA) C and Registered Nurse (RN) O entered R5's room without proper Personal Protective Equipment (PPE) who is on airborne precautions for parainfluenza infection.

Inspectors wroteBased on interviews and record reviews, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being by not assessing and/or treating a post-medication error for 1 out of 3 residents (R) reviewed for medication errors, R8. -R8 was given the wrong medications of Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. R8 was not assessed every 4 hours for 24 hours as per physician order.

Inspectors wroteBased on interview and record review, the facility did not ensure medications were administered under professional standards of clinical practices for 3 of 3 residents (R) reviewed for medication errors, R6, R8 and R7. -R6 received ciprofloxacin 500 mg twice a day for 3 days and should have received 250 mg twice a day for 3 days, and ciprofloxacin did not have an expiration label on it. -R8 received the wrong medications, including Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. -R7's self-administration assessment stated R7 required assistance and nurse left Eliquis, melatonin, omeprazole, and metoprolol in a medicine cup at R7's bedside, left the room, and did not ensure R7 took the medications. Example 1 Surveyor reviewed medication error, dated 06/16/25, which stated, in part, R6 received the wrong dose of ciprofloxacin 500mg twice a day on 06/14/25, 06/15/25, and 06/16/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to reconcile accurately. This affected 12 out of 49 residents (R) in the facility. (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) The facility did not ensure medications were administered under professional standards of clinical practices for residents. This had the potential to affect all residents on 1 of 2 floors in the facility.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure they were monitoring the effectiveness of psychotropic drugs. Behavioral monitoring was not completed as outlined in the comprehensive care plan to determine effectiveness of the medication for 1 of 3 residents (R) reviewed (R2).

Inspectors wroteBased on observation, interview and record review, the facility did not prepare, store, or distribute foods in a safe and sanitary manner. The facility practices have the potential to affect all 43 residents. Facility staff do not cover beverages that are poured by staff on the wings and delivered to residents in their rooms. Cook Q did not allow the thermometer to air dry after wiping with alcohol and before inserting into resident foods. Dietary Aide (DA) T used alcohol-based hand rub (ABHR) as a means to sanitize her hands in the kitchen. ABHR is not an approved means to sanitize hands when food handling in the kitchen. The refrigerators and freezers where resident foods are brought into the facility do not have complete logs of monitoring for safe storage temperatures. The freezer on the first floor showed evidence of melted ice cream in the freezer. [...]

Inspectors wroteBased on record review and interviews, the facility did not implement their abuse policy in regard to screening for 7 of 8 employees. Caregiver and criminal background checks were not completed for Certified Nursing Assistant (CNA) (CNA H, I, J, and K), Licensed Practical Nurse (LPN) L, Dietary Manager (DM) M, and Laundry Aide (LA) N. Out of state background checks were not completed for DM M and LA N.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure nutritional values are maintained when altering food consistencies to minced and moist and pureed consistencies. This has the potential to affect 12 of 43 sampled and supplemental residents who eat this food consistency (R5, R8, R2, R4, R35, R24, R18, R20, R41, R15, R25 and R292). Cook Q was observed pureeing scrambled eggs and bacon using hot water as a thinning agent. [NAME] Q expressed there are no recipes, no policy or any directions that tell her what she is to use to modify food to ensure nutritional value. This is evidence by: On 06/06/23 at 7:10 AM, Surveyor observed [NAME] Q pureeing scrambled eggs and bacon. [NAME] added the eggs to the robocoup to puree then proceeded to the hot water thermos to pour water to pitcher. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure each resident received care consistent to prevent Pressure Injuries (PIs) from developing for 1 of 2 sampled residents (R)2. R2 is at moderate risk for PI development. R2 was observed in bed with both heels on the mattress. This is evidenced by: R2 was admitted to facility on 01/22/21. Diagnoses include dementia with behavioral disturbance, Type 2 Diabetes Mellitus, repeated falls, depression, weakness, and need for assistance with personal cares. R2's Power of Attorney (POA) is activated. Minimum Data Set (MDS), dated [DATE], indicated R2's cognition is severely impaired. R2 is at risk for development of pressure related injuries. R2 requires a Hoyer (mechanical lift) for transfers and has recently been using a Broda chair (positional wheelchair) for mobility. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident environment is free from accidents for safe smoking, affecting 2 of 2 residents reviewed for smoking (R12 and R37). R12 indicated she maintains her smoking materials in her coat pocket or dresser drawer in her room and goes out to smoke on her own without any devices worn for smoking. R12's smoking assessment was not complete, to ensure safety interventions were in place on R12's smoking care plan. R37 indicated she maintains her smoking materials in her room and does not wear any apron or other devices while smoking. R37's smoking assessment was not complete, to ensure safety interventions were in place on R37's smoking care plan to prevent injury while smoking. This is evidenced by: Surveyor reviewed the facility policy titled Accident Prevention-Smoking Policy dated as last reviewed on 10/2022. [...]

Inspectors wroteBased on record review and interview, the facility did not provide written notice of the facility bed-hold policy for 2 of 3 residents (R) reviewed for hospital transfer (R19 and R40). R19 was transferred to hospital on [DATE] and 05/07/23. A bed-hold notice was not provided to R19 or his representative. R40 was transferred to hospital on [DATE]. A bed-hold notice was not provided to R40. This is evidenced by: Surveyor reviewed Bed Hold Policy Acknowledgement, as part of facility admission packet. Policy reads in part .At the time of transfer to the hospital you or your legal representative will be asked to make a decision whether or not you would like your bed held here at the facility. This will be done with every transfer to the hospital. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility did not post the daily required information related to nurse staffing levels. This practice could potentially affect all 43 residents. On 06/05/23 the daily nurse staff posting that was displayed was dated 05/22/23. The faciity did not ensure the daily nurse staff posting was posted daily and updated each shift. This is evidenced by: On 06/05/23 at 11:41 AM Surveyor observed the staff listing titled Aspen Health and Rehab posting for daily care staffing dated 05/22/23. The posting read: [...]