Saylor Lane Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food safety when: 1. The ice machine was not clean per manufacturer's guidance, 2. The reach-in freezer was not clean, 3. The blade of the can opener was not well maintained, 4. The cutting boards had deep grooves, 5. Several metal pans were stacked wet and stored in the clean and ready-to-use storage areas, 6. Dietary Aide (DA) 1 and DA 2 were unable to verbalize the proper procedure of manual dishwashing with the 2-compartment sink, 7. DA 2 was unable to verbalize and demonstrate the proper testing and correct concentration of the sanitizer for the dishwashing with the dishwashing machine and 8. DA 3 was noted with long artificial nails with gem décor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean environment for the residents and visitors when one out of one garbage dumpster, located outside the facility, was not closed securely due to deformed dumpster lids. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were followed when nursing staff failed to label the flush bag (used to provide hydration) with the date and time attached to the Gastrostomy Tube (a tube inserted into the stomach through the abdomen to provide nutrition, fluids, and medication) for Resident 25, document pain assessment before and after administration of pain medication to Resident 19, verify or recheck vitals taken by Certified Nursing Assistants (CNAs) prior to withholding blood pressure medications, and wear appropriate personal protective equipment (PPE) while handling hazardous medication (medications that can cause serious effects including cancer, organ toxicity, fertility problems, genetic damage, and birth defects if not handled appropriately). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 14 sampled residents (Resident 3) when: 1. Resident 3's physician's order for oxygen therapy was not followed; and, 2. Resident 3's oxygen nasal cannula (NC- a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not changed every seven days. These failures had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 3 and to not achieve her highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR, an accountability record) for one of six randomly selected residents (Residents 288); 2. Controlled drug shift-to-shift count records (a record used to reconcile inventory of controlled medications in the medication cart by the off-going and on-coming nurse during a shift change) were routinely signed by the off-going and on-coming nursing shifts; 3. The narcotic emergency kit (e-kit; a kit/box containing medications and supplies for immediate use or during a medical emergency) was replaced according to facility policy and procedure (P&P) after use; 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 3) was free from unnecessary medication when Resident 3 received insulin glargine (a type of long-acting insulin to treat diabetes) without adequate monitoring. This failure had the potential to result in the worsening clinical conditions of Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility had a 5.56% error rate when two medication errors out of 36 opportunities were observed during a medication pass for two of nine Residents (Residents 1 and 12). This failure resulted in medications not given in accordance with the manufacturer's specifications and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation and interview, the facility failed to ensure refrigerated medications and biologicals were stored at temperatures in accordance with facility policy and procedure (P&P). This failure had the potential for residents to receive dangerous or inadequate treatment for their medical conditions, leading to further health complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Dietary Aide (DA) 1 and DA 2 had the appropriate skill set to safely perform the daily operations of the food and nutrition services department when: 1. DA 1 and DA 2 were unable to verbalize the proper procedure of manual dishwashing by the 2-Compartment sink (cross refer to F812, #6), and 2. DA 2 was unable to verbalize and demonstrate the proper testing and correct concentration of the sanitizer of dishwashing with the machine (cross refer to F812, #7). These failures had the potential to place 31 out of 33 highly susceptible residents who consumed food from the facility kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for the therapeutic diet during lunch on 5/6/25 when: 1. Five residents (Resident 1, 8, 10, 19 and 139) with mechanical soft (MS) texture diets (a diet consisting of soft, moist foods for people who have chewing and/or swallowing difficulties) received a smaller portion of mechanical soft meatballs. 2. Resident 16 with fortified diets (added calories and/or protein) did not get fortified foods with Resident 16's meal. These failures had the potential to result in compromising the medical and nutrition status of 6 out of 31 residents who received meals from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 33 residents when: 1. A staff handled resident's food with bare hands; 2. Clean linen touched the floor and touched employee's clothes; 3. Safe infection control practices were not followed for cleaning and disinfecting a shared glucometer (a device used to measure blood sugar) in-between resident care and aseptic technique was not followed during medication preparation; 4. Nursing staff did not perform hand hygiene when moving from one route of medication administration to another and after handling a contaminated medical device; 5. A facility staff held Resident 15's 5/5/25 lunch meal with bare hands; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 14 sampled residents (Resident 8) was provided with appropriate care and services with enteral feeding (also referred to as tube feeding/ feeding tube- the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 8's percutaneous endoscopic gastrostomy tube (PEG tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) placement was not checked before enteral feeding. This failure had the potential for Resident 8 to experience complications of enteral feeding such as regurgitation (digestive fluids and undigested contents in the stomach rise into the mouth) and/or accidental aspiration (accidental inhalation) of feeding formula into the lungs.

Inspectors wroteBased on interview and record review, the facility failed to document and maintain records of COVID -19 (mild to severe, viral, respiratory infections) vaccination status for seven of 80 facility staff, Licensed Nurse 4 (LN 4), LN 5, Laundry Aide 2 (LA 2), Certified Nursing Assistant 6 (CNA 6), [NAME] 2 (CK 2), CNA 4, and CNA 5. This deficient practice increased the risk for residents to acquire, transmit, or experience complications from COVID -19 infections, compromising the residents, and the visitor's safety.

Inspectors wroteBased on interview, and record review, the facility failed to protect one of four sampled residents (Resident 4) from physical abuse when Resident 1 hit Resident 4 with a walker on his left knee in the rehabilitation room. This failure had the potential to cause serious injury, fear and distress to Resident 4 and other facility residents that were present in the rehabilitation room during the incident.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse to the Department for 2 of 4 sampled residents (Resident 1 and Resident 4), when Resident 1 was witnessed throwing a walker at Resident 4 hitting his left knee in the facility's rehabilitation room. This failure decreased the facility ' s potential to protect vulnerable residents and provide a safe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety when food storage temperature logs and sanitization solution logs were not being consistently documented. This failure had the potential to lead to food borne illnesses for 38 residents eating facility prepared meals.

Inspectors wroteBased on interview and record review, the facility failed to assess and evaluate the Intake and Output (I&O, the measurement of fluids entering and leaving the body) weekly summaries for two of 15 sampled residents (Resident 20 and Resident 23) when the residents were on fluid restriction. This failure placed the residents at risk for unnoted fluid overloads and/or dehydration as well as difficulty to gauge fluid balance of the residents to determine the effects of the treatment and the progress of the disease.

Inspectors wroteBased on interview and record review, the facility failed to provide thorough drug regimen reviews (DRR) for one of 15 sampled residents (Resident 23) when the facility did not act on the facility pharmacist (FP) report on irregularities and the expired medications were mixed with other medications available for use in the medication storage room refrigerator. These failures resulted in unresolved irregularities of antipsychotic (to treat symptoms of psychosis) medication therapy for Resident 23 and increased the potential for medication errors.

Inspectors wroteBased on observation, interview and documentation review, the facility failed to discard expired medications for a census of 38 when the expired flu vaccines were mixed with non-expired flu vaccines in the medication refrigerator, available for use. This failure increased the potential for medication errors and placed the residents at risk for drug safety.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate, consistent, and complete medical records for three of 15 sampled residents (Resident 23, Resident 4 and Resident 20) and one randomly selected resident (Resident 3) for a census of 38. These failures resulted in the residents' health and care status to be inaccurately reflected in the medical records and placed the residents at risk for inadequate care due to the potential miscommunication among the healthcare providers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 38 residents when: 1. A facility staff did not wear required personal protective equipment (PPE) when assisting Resident 233 and Resident 234 with mobility exercises who were both on enhanced standard precaution (ESP- also known as enhanced barrier precaution/EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use); and, 2. Resident 14's nasal cannula (a medical device with two prongs connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was left uncovered and hanging on the resident's bedside rail when not in use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 15 sampled residents (Resident 232 and Resident 23) were assisted with nail care as part of their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 232 and Resident 23 had long fingernails with blackish substance underneath the fingernails. This failure had the potential for Resident 232 and Resident 23 to sustain injury and/or for the residents to acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 15 sampled residents (Resident 233 and Resident 234) received treatment and care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when: 1. Resident 233's physician's order for stage 3 pressure ulcer/injury (PU/PI- injury to skin and underlying tissue resulting from prolonged pressure which extends through the skin into deeper tissue and fat but do not reach muscle or bone) on the coccyx (area on the lower back where the bottom/base of the spine is) treatment was not followed; and, 2. Resident 233 and Resident 234's wound dressings was not labeled with the nurse initials, and time and date it was applied. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for one out of 15 sampled residents (Resident 14) when: 1. Resident 14 had no oxygen in use sign placed on the outside of the room entrance door; and, 2. Resident 14's physician's orders for oxygen therapy was not followed. These failures had the potential to result in unsafe delivery of oxygen to Resident 14 and potential harm to all the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 15 sampled residents (Resident 14) received dialysis care services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when: 1. Resident 14's post-dialysis weight was not consistently documented in the resident's chart; and, 2. Resident 14's the dialysis communication sheet was not consistently completed. These failures had the potential for Resident 14 to not achieve the highest practicable well-being and to not receive appropriate dialysis care treatment and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' rights to personal privacy and confidentiality of his or her personal medical information, when meal tray tickets were found thrown into the general trash. This had the potential to compromise resident privacy and confidentiality for the 38 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) coverage for eight consecutive hours a day, seven days per week for a census of 39 residents. This failure prevented the facility's ability to provide consistent RN services and supervision of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was procured, stored and served under sanitary conditions for 39 residents to prevent food borne illness when: 1. Opened food items were not labeled with an opened date; 2. Expired food was not discarded from the refrigerator; 3. Staff personal items were found in the food prep and ready-to-use areas; 4. Ready-to-use service items were dirty and kitchen surfaces were in poor condition; 5. An opened food item was uncovered, not properly labeled, and stored in the dry goods storage area; 6. Staff wore face masks improperly; and 7. Staff was unable to properly demonstrate the manual dishwashing process These failures decreased the facility's potential to prepare, store, and provide food under sanitary conditions for a census of 40 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain pharmacy services, when two opened refrigerated emergency kits (E-kit 15 and E-kit 66) out of three refrigerated E-kits were not replaced by the pharmacy for a census of 39 residents. This failure reduced the facility's potential to provide emergency pharmacy services to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly label and store medications and products for four residents (Resident 8, Resident 16, Resident 17, and Resident 20) out of a census of 39, when: 1. One expired kit of glucagon (an emergency drug used to treat low blood sugar) was stored in a medication cart; 2. One open bottle of blood glucose strips was stored in a medication cart without an opened date label; 3. Three expired vials of insulin glargine (long-acting insulin; drug used to control blood sugar levels) were stored in a medication cart; 4. Loose pills were stored in a medication cart; 5. One expired tube of diclofenac (a drug used to relieve pain, swelling, and joint stiffness) was stored in a treatment cart; and 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were performed for a census of 39 residents when: 1. Staff did not perform proper hand hygiene; 2. Laundry Staff (LS) did not wear a gown when handling soiled and clean linen; and 3. Staff placed urinary catheter bags on the floor. These failures had the potential to result in the spread of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper personal protective equipment (PPE) usage for unvaccinated staffs were performed for five out of 86 staffs when five unvaccinated staffs for COVID-19 (a virus attacking the respiratory system in people) were working in the facility. This failure decreased the facility's potential to protect the vulnerable population against COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' dignity when the urinary catheter (a tube that collects urine from the bladder and leads to a drainage bag) was not covered with a privacy bag for two residents (Resident 7 and Resident 17) of 14 sampled residents. This failure increased the potential to negatively impact the residents' self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure a written notice of transfer or discharge was provided to the long-term care Ombudsman (an advocate for residents in nursing homes) and to one resident (Resident 36) for a census of 39 residents. This failure resulted in the facility's reduced compliance to provide a written notice of transfer or discharge to the long-term care Ombudsman and to Resident 36.

Inspectors wroteBased on interview and record review the facility failed to issue a written bed hold notice for one resident (Resident 36) out of 12 sampled residents, when Resident 36 was transferred to the hospital. This failure had the potential for Resident 36 to be prohibited from returning to the facility leading to emotional and psychological stress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate assessments were documented for one resident (Resident 15) for a census of 39 residents. This failure decreased the facility's potential to identify current and future residents' care needs and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the physician was aware of a resident's wound for one resident (Resident 5) out of 14 sampled residents when, Resident 5 was admitted with purple discoloration on the sacrum and the physician was not notified. This failure had the potential to delay the physician's assessment and intervention.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a person-centered care plan for one resident (Resident 5) out of 14 sampled residents. This decreased the facility's potential to provide prompt and proper wound care to Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was within reach and a proper sized wheelchair was provided for one resident (Resident 16) of 14 sampled resident when Resident 16 stated she could not reach the call light because her feet were not able to touch the floor completely. This failure decreased the facility's potential to support Resident 16's independence to move freely within the facility and to call for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the pureed recipe for two residents (Resident 7 and Resident 26) out of 14 sampled residents when staff: 1. Did not follow the recipe for pureed BBQ chicken, pureed carrots, and pureed bread rolls; and 2. Did not hold food at the right temperature to maintain it's nutrient value. These failures placed Resident 7 and Resident 26 at risk for malnutrition and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record for two residents (Resident 15 and Resident 36) of 14 sampled residents when: 1. Resident 15's Minimum Data Sheet (MDS, a comprehensive assessment tool) was inaccurate; and, 2. Resident 36's medical record was incomplete. These failures decreased the facility's potential to maintain complete and accurate medical records and decreased the potential for Resident 15's and Resident 36's accurate clinical and functional representation.