Willowbrooke Ct Skilled Care Buckingham's Choice

Inspectors wroteBased on medical record review and staff interview, it was determined that facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 8 (#21, #1, #19, #7, #22, #5, #16, #30) of 19 residents reviewed during the recertification/complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to ensure that the attending physician visit residents at the required intervals . This was evident for 3 (Resident #14, #16, #9) of 19 residents reviewed during an recertification/complaint survey.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility failed to provide respiratory services in accordance with professional standards of practice. This was evident for 1 (Resident #9) of 2 residents reviewed for respiratory care during the recertification/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 2 (Resident #5 and #6) of 19 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on record reviews, interviews and a review of the facility's investigation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS) assessments for: 1) the use of residents' 1/8 grab bars and 2) the resident's status after a fall. This was evident for 5 residents (Resident #5, #15, #23, #2 and #231) of 18 residents reviewed during the annual survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to develop and implement comprehensive person-centered care plans for residents residing in the facility for: 1) the use of Hearing Aids 2) Pain 3) Chronic Constipation and 4) the use of bilateral Grab Bars. This was evident for 4 (Resident #233, #230, #5 and #23) of 18 residents reviewed for care planning during the annual survey.

Inspectors wroteBased on interview and observation, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures. This practice has the potential to affect all residents who eat food prepared by the facility.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to store and label food items to maintain the integrity of the specific item. This was evident during the initial tour of the Skilled Nursing Unit kitchen. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on interviews, record reviews and observations, it was determined that the facility failed to: 1) have quarterly care plan meetings 2) review and revise interdisciplinary care plans to reveal accurate interventions for residents residing in the facility. This was found to be evident for 2 (Resident #5 and #230) of 18 residents reviewed during the survey.

Inspectors wroteBased on review of the facility investigation, record review, observation and interview. It was determined that the facility failed to provide a safe environment to prevent an elopement incident from occurring. This was evident for 1 (Resident # 231) of 2 residents reviewed for elopement during the survey.

Inspectors wroteBased on surveyor observation and staff interview, it was determined that the facility staff failed to properly label, and date food items stored in the main kitchen. This was evident during the initial tour of the kitchen and on a subsequent visit to the kitchen.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed ensure that a resident's current wishes related to life-sustaining treatment were up to date by failing to void previous MOLST (Maryland Medical Order for Life Sustaining Treatment) forms when a new MOLST was created. This was evident for 1 (#23) of 1 residents reviewed for advanced directives.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to immediately notify the physician of multiple resident refusal of a prescribed treatment. This was evident for 1 (#1) of 5 residents reviewed for unnecessary medication.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to provide residents with a clean, homelike environment. This was evident for 2 (#8 and #230) of 28 residents reviewed during the initial process.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to conduct an accurate, assessment by failing to assess a resident's cognition and mood on a quarterly MDS assessment and failing to timely complete a resident's quarterly assessment. This was evident for 1 (#11) of 1 residents reviewed for activities. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident.

Inspectors wroteBased on medical record and staff interview, it was determined that the facility staff failed to develop baseline care plans that included instructions needed to provide effective and person-centered care and failed to provide residents/representatives with a copy of their baseline care plan and medication list. This was evident for 2 (#22 and #230) of 14 residents in the final sample.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed develop resident centered, comprehensive care plans. This was evident for 7 (#20, #1,#10, #26, #28, #23, #11) of 16 residents reviewed during the survey.

Inspectors wrote3) A record review on 8/16/19 at 9:25 PM, revealed a progress note, dated 3/24/2019 at 7:53AM, that documented Resident #6 was found beside the bed with his/her upper body in the bed and the lower body on floor. Another progress note dated 4/8/19 at 5:27 AM, documented that resident was found beside the bed upper half in the bed and lower half on floor. Both notes were signed by Register Nurse (RN) Staff #3. Further review of the medical record revealed a current care plan with a focus on falls related to Resident #6's history of falling with cognitive impairment weakness, gait abnormality, and poor safety awareness. The goal had a target date of 9/12/19, and multiple interventions were dated 2/12/18, which was prior to his/her last admission on [DATE]. [...]

Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to provide care and treatment to a resident that met professional standards of quality by failing to provide\complete assessments for residents who had unwitnessed falls. This was evident for 2 (#230 and #6) of 5 residents reviewed for accidents.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that a pertinent medical discharge summary was completed within 30 days of the resident's discharge. This was evident for 1 (#28) of 2 closed resident records reviewed.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff, 1) failed to ensure a physician provide documented clinical rational for residents receiving psychotropic drugs and 2) failed to ensure that a psychotropic medication prescribed as needed was limited to 14 day. This was evident for 2 (#1, #10) of 5 resident's reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to document in the medical record when a resident refused neurological checks after an unwitnessed fall. This was evident for 1 (#230) of 5 residents reviewed for accidents.

Inspectors wroteBased on facility documentation and staff interview, it was determined that the facility failed to have all infection control policies and procedures updated on an annual basis. This was evident for the 4 of 4 Policies and Procedures reviewed for infection control.