Westminster Rehabilitation and Wellness Center

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that the facility environment maintained a homelike, safe, and sanitary environment. This was evident during the initial and subsequent observations and tours during the recertification and change of ownership survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to provide a transfer notice to residents. This was evident for 2 (Resident #2 and Resident #105) of 2 residents reviewed for hospitalizations.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure medications were available for administration and failed to administer medications as ordered for 3 (Resident #103, Resident #49, and Resident #32) of 4 Residents observed during a medication pass. This observation of medication administration revealed 3 errors out of 26 opportunities, for an error rate of 12%.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) program identified, implemented, and sustained corrective actions for a known, ongoing systemic issue involving the unavailability of ordered medications from the pharmacy provider. This failure allowed a previously identified performance deficiency to continue without the required systematic analysis or monitoring to ensure residents received medications as ordered. This was evident for 1 (Resident #11) of 2 residents reviewed for pain management and for one QAPI plan reviewed during the recertification and change of ownership survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to complete and submit Minimum Data Set (MDS) assessments for residents admitted to the facility. This was evident for one (Resident #110) of one Resident reviewed for Resident assessments.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that a resident had a personalized, resident-specific care plan. This was evident for 1 (Resident #78) of 1 resident reviewed during a communication and sensory investigation.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to hold care plan meetings. This was evident for 1 (Resident #37) of 3 residents reviewed for care planning.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide necessary care and services in accordance with professional standards of practice by failing to administer medications as ordered for 3 (Resident #103, Resident #49, and Resident #32) of 4 residents observed for medication administration during the annual recertification survey.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers. This was evident for one (Resident #23) of five residents reviewed for ADL.

Inspectors wroteBased on interviews and medical record reviews, it was determined that the facility failed to ensure that residents received medications and treatments as ordered. This was evident for one (Resident #11) out of two residents reviewed for pain management and for 1 (Resident #37) of 1 resident reviewed for dialysis.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure implementation of physician-ordered pressure-relieving interventions and proper functioning of a pressure-reducing device for 1(Resident #47) of 1 residents reviewed for pressure ulcer care.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to ensure that ordered medications were available for dispensing to residents. This was evident for 1 (Resident #11) of 2 residents reviewed for pain management.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that physicians provide a clinical rationale for not implementing pharmacist recommendations. This was evident for 1 (Resident #113) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to serve residents meals that reflected their preferences. This was evident in one out of two kitchen observations during the survey.

Inspectors wroteBased on resident interviews, observation, and staff interviews, it was determined that the facility failed to serve residents meals that were appetizing in appearance and at the appropriate temperature. This was evident for 1 of 2 kitchen observations.

Inspectors wroteBased on observations and record review, it was determined that the facility failed to store food in accordance with professional standards. This was evident in 1 of 2 observations of the facility's kitchen during the recertification survey.

Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure staff maintained physician ordered enhanced barrier precautions when providing care. This was found to be evident for one (Resident #7) out of one resident reviewed for tube feeding.

Inspectors wroteBased on observation and interview, the facility failed to ensure that a resident call system was within reach and readily accessible to meet resident needs for 1 (Resident #47) of 1 resident reviewed for call bell accessibility.

Inspectors wroteBased on administrative record review and staff interview it was determined that the facility staff failed to ensure that a resident was free of abuse while in the care of a Geriatric Nursing Assistant (GNA). This was evident for 1 (#2) of 1 residents reviewed for abuse.

Inspectors wroteBased on administrative record review and staff interviews, it was determined that the facility staff failed to immediately report allegations of abuse to the facility administration and the state agency and failed to report the results of their investigation of an alleged incident to the State Survey Agency within 5 working days of the incident. This was evident for 1 (#2) of 1 resident reviewed for abuse.

Inspectors wroteBased on observation, medical record review, facility documentation review and interview, it was determined the facility staff failed to prevent intimidation of a resident after the resident alleged sexual abuse resulting in psychosocial harm (Resident #5). This was evident for 1 of 4 residents reviewed for abuse during a complaint survey.

Inspectors wroteBased on medical record review, facility documentation review and interview it was determined the facility failed to maintain an effective grievance system as evidenced by the failure to resolve a complaint regarding missing clothing belonging to a resident (Resident #6). This was evident for 1 of 3 residents reviewed for grievances during this complaint survey.

Inspectors wroteBased on review of facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of misappropriation of property were thoroughly investigated. This was evident for 1 (#2) of 3 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on record review and staff interview it was determined that the facility failed to meet professional standards of practice as evidenced by licensed nursing staff signing off that a medication was administered when the medication had not yet been delivered to the facility. This was evident for 1 (#1) of 3 residents reviewed for pharmacy services.

Inspectors wroteBased on medical record review and interviews, it was determined that the medical provider failed to review the pain medication orders for a resident (Resident #4). This was evident for 1 out of 3 residents selected for review during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to provide physician ordered medications timely to meet the needs of the residents. This was evident for 1 (#1) of 3 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (#1) of 3 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to follow the physician's orders for 1 (Resident #1) of 3 residents reviewed for medications. Specifically, the facility failed to discontinue Resident #1's tramadol, (pain medication) as ordered by the physician, on 12/13/2024 when oxycodone (opioid pain medication) arrived at the facility. The facility administered both medications to Resident #1 on the morning of 12/14/2024.

Inspectors wroteBased on review of facility-reported investigation records and interview with staff, it was determined the facility staff failed to report an allegation of suspected resident abuse to the state agency in a timely manner. This was evident for 1 resident (Resident #102) out of 3 reported incidents by the facility reviewed during the survey.

Inspectors wroteBased on record review and interview it was determined that the facility staff failed to complete a thorough investigation of an allegation of misappropriation of property and failed to investigation an allegation of verbal abuse. This deficient practice was evident in 2 (Resident #31 & #49) of 9 facility reported incidents reviewed during the survey.

Inspectors wroteBased on interviews with residents, review of medical records, and interview with facility staff, it was determined that the facility failed to provide a baseline care plan summary to residents. This was evident for 1 (#45) of 7 residents reviewed for baseline care plans during the survey.

Inspectors wroteBased on record review and interview it was determined that the facility staff failed to initiate person centered care plan for mobility and wound care. This deficient practice was evidenced in 1 (#67) of 4 resident records reviewed for care plans.

Inspectors wroteBased on medical record reviews and interviews it was determined that the facility failed to ensure that a dependent resident's personal hygiene needs were adequately met. This was evident for 1 (Resident #2) of 23 residents reviewed during the survey process.

Inspectors wroteBased on record review and interview it was determined that the facility staff failed to notify the family of a deceased resident that money was still in their account. This deficient practice was evidenced in 1 (#113) of 2 resident accounts reviewed during the survey.

Inspectors wroteBased on surveyor observation and interview with staff, it was determined that the facility staff failed to protect the privacy of residents' medical information. This was found to be evident for 1 (#70) of 45 residents reviewed during the survey.

Inspectors wroteBased on interviews, observations, and medical records reviews, it was determined that the facility failed to: 1.) perform and/or document that appropriate revisions to care plan goals and interventions as resident care needs changed over time. This was evident for 1 (Resident #2) of 45 resident care plans reviewed during the facility's survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to adhere to professional standards of practice by failing to: 1.) ensure that controlled medications (Narcotics) were signed off by the Licensed Practical Nurse upon removing the medication from the narcotic drawer for 3 residents (Residents # 41, #45, and #107) during a random narcotic reconciliation observation; and 2.) ensure the safety and integrity of narcotic medications blister packs for Resident Resident # 67 and Resident # 78; and 3.) ensure that two nurses sign the narcotic sheet during change of shift to verify the narcotic count was complete. This was found to be evident during the facility's survey.

Inspectors wroteBased on surveyor observation and interview with staff, it was determined the facility staff failed to ensure medications were secured as evidenced by an unlocked and unattended medication cart. This was found to be evident for 1 of 7 medication carts reviewed during the survey.

Inspectors wroteBased on observation and interviews it was determined that the facility staff failed to maintain infection control practices as evidenced by an uncapped foley catheter drainage bag in a resident bathroom, two unlabeled urinals without lids were in a shared bathroom along with a brown matter on the commode of a shared bathroom. This deficient practice was discovered during the survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to: 1) revise and update a comprehensive care plan within 7 days after completing the comprehensive assessments, and 2) have care plan meetings with residents and/or their representatives. This was evident for 5 (Resident #61, #75, #87, #88, and #110) of 41 residents reviewed during the recertification survey.

Inspectors wroteBased on medical record review, staff interviews and a complaint, it was determined that the facility failed to: 1) have a process in place to address and review medical orders pending provider signature; 2) provide timely care for residents who experienced a change in condition; and 3) timely arrange for a resident to go for their 2-weeks follow up (F/u) post op visit. This was evident for 4 of 41 residents (Resident #46, #109 and #110, #107) reviewed during recertification survey

Inspectors wroteBased on medical record review and staff interview it was determined that the physician/Certified Registered Nurse Practitioner (CRNP) progress notes were not written, signed and timely present in the resident medical records. This was evident for 2 (Residents #46, and #106) of 41 residents reviewed during the survey.

Inspectors wroteBased on record review and interview it was determined that the facility failed to treat residents with respect and dignity. This was evident for 1 facility reported incident (MD00204591) of 7 facility reported incidents reviewed during the recertification survey.

Inspectors wroteBased on a complaint, reviews of medical records, and staff interview, it was determined that facility staff failed to notify a resident's representative party and physician when a resident had a change in diet order and a new prescribed medication. This was evident for 1 (Resident #110) of 41 residents reviewed during the survey.

Inspectors wroteBased on review of facility records and interview with facility staff, it was determined that facility staff failed to ensure that all allegations of abuse were thoroughly investigated. This was evident for 1 (Resident #108) of 5 residents reviewed for Abuse during the survey.

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to provide dental services to meet residents' needs. This was evident for 1 of 2 (Resident #17) reviewed for dental during the survey.

Inspectors wroteBased on record review and interviews, it was determined the facility failed to: 1) adequately document certifications of incapacity and ensure accuracy of the Maryland Medical orders for life sustaining treatment (MOLST) form (Resident #15), and 2) ensure pertinent information regarding surrogacy/guardianship disputes were documented in the medical records (Resident #101). This was evident for 2 of 41 residents reviewed during the recertification survey. The findings Include 1. On 4/2/24 at 10:00AM the surveyor reviewed Resident #15's advanced directives document in which they had identified their selection of a primary health care agent. On 4/2/24 at 10:00AM the surveyor reviewed Resident #15's MOLST form dated 2/19/24 which indicated the patient had a guardian. No documentation could be found in the medical record regarding a guardian for the resident. [...]

Inspectors wroteBased on observations and interview with staff it was determined the facility staff failed to ensure the results from the last annual survey were posted in a place readily accessible to residents and visitors and failed to post accurate notice of the availability of the reports in areas of the facility that are prominent and accessible to the public. This was evident on 2 of 2 floors of the facility.

Inspectors wroteBased on interviews, observation, and record review, it was determined that the facility administration failed to provide adequate oversight activities for the facility to ensure that resources were used effectively to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards. This was evidenced by failing to: 1) ensure that the facility had sufficient staff to care residents' needs, 2) ensure that the facility's nursing staff was competent and had the necessary skill sets and training to provide nursing and related services; and 3) ensure that the facility conducted thorough investigations of self-reported incidents. This was evident during the recertification survey and had the potential to affect all residents.

Inspectors wroteBased on interview and record review it was determined the facility failed to report allegations of abuse or injuries of unknown origin within required timelines or to all required agencies. This was evident for 7 (#22, #69, #74, #99, #109, #151, and #154) of 19 residents reviewed for abuse during the annual survey.

Inspectors wroteBased on review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, neglect, misappropriation of resident property, and injuries of an unknown source. This was evident for 7 (#17, #34, #46, #62, #66, #69, and #149) of 19 residents reviewed for abuse, neglect, misappropriation of resident property, and injuries of an unknown source during this recertification survey.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#34 and #78) of 5 residents reviewed for Respiratory Care, 1 (#121) of 4 residents reviewed for communication, and 1 (#101) of 2 residents reviewed for dementia care.

Inspectors wroteBased on review of the medical record and interview with staff it was determined the facility staff 1) failed to ensure resident care plans were reviewed and revised by the interdisciplinary team after each assessment and revised as changes in treatment occur; and 2) failed to have care plan meetings with a resident and/or resident representative. This was evident for 4 (#34, #78, and #85, #66) of 5 residents reviewed for Respiratory Care, 3 (#62, #9, #77) of 4 residents reviewed for care planning; and 1 (#74) of 9 residents reviewed for accidents during this survey.

Inspectors wroteBased on a complaint, medical record review, and interview, it was determined that the facility failed to ensure staff followed physician orders. This was evident for 6 (#2, #3, #34, #92, #137, and #142) of 15 residents reviewed for quality of care during the recertification/complaint survey.

Inspectors wroteBased on resident, family and staff interview, documentation review, observation, and review of Resident Council meeting minutes, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 9 (#30, #34, #42, #46, #78, #85, #92, #96, and #120) of 22 Residents' and Residents' Representative interview and 6 (GNA #43, #53, #63, and Staff #35, #52, #54) of 13 Staff's interviews.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to assure that all nursing staff had competency evaluations. This was evident for 5 (RN #42, GNA #43, GNA #57, GNA #58, and GNA #59) of 5 randomly selected nursing staff reviewed for competencies.

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) employee records and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months. This was evident for 3 (GNA # 44, #57, and #59) out of 3 GNAs records reviewed during this survey.

Inspectors wroteBased on medical record review, interviews and observations it was determined the facility staff failed to: 1) maintain complete and accurate medical records in accordance with accepted professional standards, and 2) maintain a psychological consult on the medical record. This was evident in 7 (Resident #78, #91, #126, #128, #133, #153 and #128) of 18 residents reviewed for their care during this survey.

Inspectors wroteBased on interview and documentation review, it was determined the facility failed to ensure that staff received training regarding abuse, neglect, exploitation, misappropriation of resident property. This was evident for 6 staff of 11 staff (Registered Nurse (RN) #42, Geriatric Nursing Assistant (GNA) #43, GNA #58, GNA #60, Licensed Practical Nurse (LPN) #61, and LPN #62) reviewed for training records.

Inspectors wroteBased on medical record review and interview of facility staff it was determined the facility failed to identify the responsible party of a resident. This was evident for one (Resident #144) out of three residents reviewed for resident rights during the facility's recertification survey.

Inspectors wroteBased on medical record review, interview and review of pertinent facility policies and documentation, it was determined that the facility failed to: 1.) prevent incidents of abuse related to using a residents image on social media, and 2.) failed to ensure that their residents were free of neglect. This was evident for 2 (Resident #62 and #93) of 19 abuse investigations, including complaints and facility reported incidents.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to protect a resident's right to be free from misappropriation and/or exploitation. This was evident for 1 (#78) of 6 residents reviewed for personal property during an annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (#74, #111, #96) of 7 residents reviewed for hospitalization.

Inspectors wroteBased on observations, record review, and interviews it was determined that the facility failed to develop and implement a comprehensive care plan. This was evident for 3 (#121, #128, and #153) of 6 residents reviewed for care planning during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to meet professional standards of practice as evidenced by: 1) failing to ensure nursing staff documented on Medication Administration Record (MAR) and Controlled Drug Administration Record (known as control sheet), 2) taking a narcotic medication from one resident to medicate another. This was evident for 3 (#3, #77, and #148) out of 11 residents reviewed for narcotic medication administration.

Inspectors wroteBased on medical record review and interview it was determined the facility failed to ensure residents' bathing preference for showers. This was evident for 1 (Resident #142) out of 2 residents reviewed for activities of daily living during the facility's recertification survey.

Inspectors wroteBased on medical record review and interview of facility staff it was determined the facility failed to: 1) ensure a resident received a timely wound consult, 2) consistently and timely implement recommendations made by the wound care provider, 3) ensure treatment recommendations made by the wound care provider were provided timely for a resident. This was evident for 3 ( #131, #137, and #144) out of 7 residents reviewed for wounds during the facility's recertification survey.

Inspectors wroteBased on observations, record review, and interview of facility staff it was determined the facility failed to implement the resident's care plan for a resident at risk for falls. This was evident for 1 (#91) out of 5 residents reviewed for falls during the facility's recertification survey.

Inspectors wroteBased on medical record review and staff interview it was determined the physician progress notes were not placed timely in the resident medical records. This was evident for 3 (#13, #93, and #131) of 12 residents reviewed during the annual survey.

Inspectors wroteBased on review of medical records, policies and other pertinent documentation, and interviews it was determined that the facility failed to ensure narcotics removed from the resident's supply were administered to the resident. This was found to be evident for 4 (#19, #29, #78, and #148) out of 11 residents reviewed for narcotic usage during the survey.

Inspectors wroteBased on review of the medical record and interview with staff it was determined the facility staff failed to ensure that the attending physician documented in the medical record that drug irregularities identified by the consultant pharmacist were reviewed. This was evident for 1 (#46) of 2 residents reviewed for Antibiotic Use.

Inspectors wroteBased on review of the medical record and interview with staff it was determined the facility staff failed to: 1) ensure that the residents drug regimen was free from unnecessary drugs and 2) administer medication in accordance with the standards of practice. This was evident for 1 (#46) of 2 residents reviewed for Antibiotic Use, and 1 of (#34) of 11 Controlled drug administration records reviewed and a review of a self-report during the recertification survey.

Inspectors wroteBased on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 2 (#92, #62) of 5 residents reviewed for dental services during the survey.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident for 1 (Resident #159) out of 3 residents' antibiotic use reviewed during the recertification survey.