Northwest Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure residents either had an advanced directive in place or failed to provide the residents and/or their representatives written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for two residents (Resident (R) 61 and R55) of nine reviewed for Advanced Directives. Findings include: Review of the facility's policy titled Advance Directive (Resident's Right to Choose, dated 03/27/24, revealed, Policy Explanation and Compliance Guidelines: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive. l. On admission, the facility will determine if the resident has executed an Advance Directive and if not, determine whether the resident would like to formulate an Advance Directive . 3. The facility will provide the resident or resident representative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview it was determined the facility staff failed to notify a resident representative of a resident-to-resident assault. This was evident for 1 (#20) of 50 residents reviewed. The findings include: Complaint #MD00173898 was reviewed on 8/20/24 at 3:45 PM. The complainant indicated Resident #20 informed him/her that on 11/3/21 he/she and a staff person were attacked by another resident however the facility never notified him/her of the incident. Review of Resident #20's medical record at that time failed to reveal documentation related to an incident involving resident #20. In an interview on 8/22/24 at 1:43 PM the complainant identified the staff person involved in the incident as the Activities Director (AD). The AD was interviewed on 8/22/24 at 3:23 PM and indicated she recalled the incident. When asked to describe the events she stated He/She struck us, I got in front, between the two residents, (Resident #912) was hitting (Resident #20) and kicking out at (Resident #20), I tried to stop him/her, and he/she kicked me in the stomach. I told the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, administrative record review, and staff interview, the facility failed to protect the resident's right to be free from verbal, mental, and physical abuse (R70, R48, R73 #914).These failures affected 4 of 61 residents reviewed for abuse. Findings include: 1. Review of the 5-Day Incident Report, provided by the facility, for R61 and R70 revealed, On 02/08/24, R70 was standing near the vending machine heard two other residents arguing tried to stop argument and one resident (R61) punched him/her in his/her nose R70 visibly upset after the incident, had complaint of bleeding from the nose and was transferred to the hospital for further investigation .Resident denied pain. Resident assessed by inhouse physician, followed by psychological services. No other injuries noted .Conclusion: The allegations were verified .Corrective actions taken: All three residents were separated and placed in a safe area. Police notified and responded to the situation. Skin assessment for all three…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to ensure an injury of unknown origin for 4 of 58 (R8, R35, #20 and #14) reviewed was reported to the state agency and in a timely manner. Specifically, the facility failed to ensure an initial incident report was submitted to the state survey agency within two hours as well as failed to submit the 5- day report following the investigation. This deficient practice had the potential to affect other residents at the facility that had unidentified pain, an injury of unknown origin, unwitnessed fall, or allegations of abuse. Findings include: 1. Review of R8's undated admission Record, located under the Profile tab in the EMR, revealed R8 was admitted to the facility on [DATE] with diagnoses that included dementia with psychotic disturbance, encephalopathy, and convulsions. Review of R8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/23, revealed a Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility staff failed to thoroughly investigate allegations of abuse. This was evident for 5 (R48, #901,#20, #14, and #913) of 75 residents reviewed during the survey. The findings include: 1) Review of a facility reported incident on 8/19/24 at 11:00 AM revealed Resident #901 was observed on 9/5/23 at 8:55 AM with a large cut above his/her right eye. The facility initiated an investigation. The facility investigation documentation revealed a Witness Statement from a Geriatric Nursing Assistant (GNA) who indicated she observed the injury upon entering the resident's room and notified the nurse. Another statement from the Nurse indicated she assessed the resident and followed facility precautions. 6 Witness statements asked, Did you see any resident fall or sustain a injury? all indicated no. 3 statements indicated they did not know anything about resident #901, and 1 statement indicated the staff member only worked with the residents they were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview it was determined the facility staff failed to provide written discharge/transfer notice to the resident and their representative. This was evident for 2 (#22 and #915) of 50 resident's reviewed during the survey. The findings include: 1) Review of Resident #22's medical record on 8/19/24 at 11:41 AM revealed a Social Services note dated 4/4/24 17:38 by the Social Services Director (SSD) indicating Resident #22 was sent to the hospital for evaluation after he/she was assaulted by another resident on 4/4/24. The note indicated the resident's guardian was notified by the Unit Manager of the incident. There was no evidence that the resident and their representative were provided with a written discharge notice. Licensed Practical Nurse (LPN3) who is the Unit Manager was interviewed on 8/19/24 at 2:29 PM. She was asked how the facility provides a written discharge notification to the resident and their representative when transferring to the hospital. She stated, we don't normally provide it in writing we call them, call their person of contact at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview it was determined the facility staff failed to ensure residents were prepared and oriented to ensure safe and orderly transfer from the facility.This was evident for 1 (#22) of 50 resident's reviewed during the survey. The findings include: Review of Resident #22's medical record on 8/19/24 at 11:41 AM revealed a Social Services note dated 4/4/24 17:38 by the Social Services Director (SSD) indicating Resident #22 was sent to the hospital for evaluation after he/she was assaulted by another resident on 4/4/24. There was no evidence that the facility provided and documented sufficient preparation and orientation of Resident #22 to ensure his/her safe and orderly transfer from the facility. Licensed Practical Nurse (LPN3) who is the Unit Manager was interviewed on 8/19/24 at 2:29 PM. When asked where nurses were expected to document that they prepared and oriented the resident for transfer, she was unable to explain and failed to find documentation indicating Resident #22 was prepared and oriented to the situation prior to transfer to the hospital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that the facility failed to provide a comprehensive care plan for a resident (resident #902) with a history of substance use disorder. This was found to be true for 1 of 50 residents reviewed during a annual survey. The findings include: Care Plan - This term refers to document which is the written plan of how a long-term care facility will provide care. This plan is based on resident health assessments, preferences and goals. Surveyor review of records on 8/22/24 at 8:15 AM revealed the resident #902 was admitted with records revealing a history of substance use disorder. Continued review of records on 8/22/24 at 8:30 AM revealed the resident's care plan failed to have interventions to prevent or assist with difficulties that can arise with a resident with a history of substance use disorder until the resident was in the facilities for over two weeks. During a surveyor interview with the Executive Director on 8/22/24 at 10:15 AM, the Executive Director admitted that the facility failed to fully develop a care plan that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff it was determined that the facility staff failed to review and revise resident care plans after each assessment or as resident care needs became apparent or changed over time. This was evident for 3 (#911, #51 and #14) of 50 residents reviewed during the survey. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1)Review of Resident #911's medical records on 8/19/24 at 1:30 PM revealed the facility administered Narcan, a medication that is used to reverse the effects of an opioid overdose, to the resident on 5/2/23. Review of the resident's care plan found no evidence of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview with staff it was determined the facility staff failed to develop and implement an effective discharge planning process which addressed each resident's discharge goals and needs and involved the resident and the interdisciplinary team in development, implementation and ongoing evaluation. This was evident for 1 (#51) of 50 residents reviewed during the survey. Maryland's Medicaid waiver program, also known as the Home and Community-Based Services (HCBS) Waivers, provides vouchers to help Maryland residents pay for long-term care services. These services can help people live in their homes, with loved ones, in adult foster care, or in assisted living facilities instead of nursing homes. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: Resident #51's medical record was reviewed on 8/22/24 at 11:13 AM. The record revealed the resident was admitted to the facility in 9/2022. A progress note dated 1/20/23 14:21 by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that the facility failed to place a provider discharge summary on a resident's (resident #911 and #913) medical record after discharge. This was evident for 2 of 50 residents reviewed in an annual survey. The findings include: 1) Review of resident #911's medical record on 8/20/24 at 1:30 PM revealed no evidence of a provider discharge summary after the resident discharged from the facility on 5/18/23. Interview with the Executive Director 8/20/24 at 2:00 PM revealed the resident discharged from the facility after the facility transferred the resident to a local hospital for psychiatric evaluation and he/she did not return to the facility after psychiatric treatment at the local hospital. The Executive Director also admitted that the facility failed to enter a provider discharge summary on the resident's medical record when the resident discharged . 2) Review of resident #913's medical record on 8/20/24 at 11:49 AM revealed no evidence of a provider discharge summary after the resident from the facility on 9/18/23. Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview it was determined the facility staff failed to maintain complete and accurate medical records by 1) failing to ensure X-Ray reports were filed in the medical record, 2) failing to document an assault by another resident in the resident's record. This was evident for 1 (#20) of 50 residents reviewed during the survey, and 3) failed to have a system in place to ensure investigative records were secured and free from being lost or misplaced. This was found to be evident for 1 facility investigation out of 30 facility reported incidents reviewed for investigative record documentation during an annual recertification survey. A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a complete manner, readily accessible, systematically organized, and accurately documented. All entries to the record should be legible and accurate The findings include: 1) Resident #20's medical record was reviewed on 8/20/24 at 1:20 PM. The record revealed Physicians orders dated 6/5/23 and 6/27/23 for Repeat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and resident interviews, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect all residents. The findings include: 1. On 6/23/2019 during an initial tour and resident interviews the following observations were made: At 8:42 AM room [ROOM NUMBER] bed C was observed to have opened, crumbled cookies and a soft drink cup lid on the floor. The sink in room [ROOM NUMBER] had multiple crumbs and dried brown liquid stains on it. Inspection of downstairs Shower room [ROOM NUMBER] revealed excessive mold buildup in the shower and grey cloth bins used to store wet towels. A hole was observed in the back wall of the shower and 2 drain flies were seen hovering in the shower. At 8:44 AM room [ROOM NUMBER] was observed with holes in the wall. The bathroom in this room had toilet paper and trash discarded on the floor. At 8:46 AM the two bathrooms adjacent to Shower room [ROOM NUMBER] were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview it was determined that the facility failed to ensure medication carts were kept secure, and medications thoroughly labeled with residents' name, and dated when the medication was open. This was evident during 1 of 2 medication administration reviews and for 2 of 4 medication carts observed during the annual survey process. The findings are: 1) Surveyor observed a medication administration on 6/24/19. After Staff #6 administered medication it was observed at 8:32 AM that the drawer containing controlled substances was partially out from the medication cart. The drawer was pulled and the staff member shown that even though the cart was locked, the drawer could still be pulled out. Staff #6 acknowledged that it should have been closed and pushed the drawer shut. The controlled substance drawer has a separate locked compartment that was still locked but such drawers are to be secured with two separate locks. The Administrator was interviewed on 6/24/19 and he said he understood the findings. 2) Observation of the medication carts and treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, interview and observation, it was determined the facility staff failed to promote care for residents in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality by labeling residents as feeders on posted staffing boards. This occurred on 1 of 3 nursing units' staffing boards. The findings included: On 6-23-19 at 8:40 AM it was observed on the Main floor nursing unit's staffing board the staff had written on the lower right hand corner the word Feeders. Underneath feeders was written [name of staff] 6B and [name of staff] 10A. The two residents were identified by their room number and the name of the staff who was to assist with their meal. Feeder is an undignified label meaning a resident is incapable of eating by themselves and is dependent on the nursing staff to feed them. Labeling residents in an undignified manner on staffing boards was confirmed by the Director of Nursing on 6-23-19 at 8:40 AM and the Administrator on 6-23-19 at 8:45 AM.

Based on a review of the facility's Beneficiary Protection Notifications and staff interview it was determined that the facility staff failed to ensure residents received a notification of an end to Medicare part A coverage (#50). This was evident for 1 out of the 3 residents reviewed for the survey's Beneficiary Protection Notification Review. The findings are: A review of Resident #50's beneficiary protection notification revealed that the resident's start date for Medicare Part A services was on August 16, 2018 and would end on October 1, 2018. The review also noted that no notification was provided to the resident or a representative party (RP). The Administrator was interviewed on 6/26/19 at 8:35 AM. He said they did not give the Notice of Non-Medicare Coverage (NOMNC) to the resident. The resident did not use up the 100 days of Medicare Part A coverage. The resident went to the hospital prior to this date and the 100 days reset and were available. Administrator said he would call the RP to inform him of this information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility investigation, medical record review, and facility staff and resident interviews, it was determined that the facility failed to prevent an incident of verbal abuse. This was evident for 1 of 1 residents (Resident #72) reviewed for verbal abuse during annual survey. The findings include: Resident #72 was admitted to the facility on [DATE]. Resident #72 had a history of using profanity and was care planned for verbally abusing the facility staff. On 6-5-19, Staff #3 requested Resident #72 move from another resident's doorway as the resident was sleeping. Resident #72, who was facetiming on his/her phone, was speaking loudly and had the phone's volume on high. The person on the phone with Resident #72 overheard Staff #3's request and began shouting at Staff #3 and then Resident #72 began shouting at Staff #3. Staff #3 then stated to the person on the phone we can meet out on the street and returned the verbal altercation yelling at both the person on the phone and Resident #72. The other facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of the clinical records and staff interview it was determined that the facility staff failed to document the administered of pain medication and monitor the effectiveness. This was true for 1 out of the 31 residents (Resident #52) reviewed for pain management during the annual recertification survey. The findings include: Medical record review of Resident #52's clinical record revealed on 06/24/19 the resident's primary physician ordered: Oxycodone IR 10 mg tablets 2 mg by mouth every 4 hours as needed for pain. Oxycodone is an opioid medication used to treat moderate to severe pain. Medical record review revealed the facility staff failed to document the administration of Oxycodone. Review of the Individual Narcotic Record revealed that Oxycodone was removed from the supply box on 06/11/19 and 06/20/19. Interview with the Director of Nursing on 6/24/19 at 11:00 AM confirmed the facility staff failed to thoroughly assess the need for pain medication for Resident #52 and document the administration of a strong narcotic.

Based on observation of the facility's kitchen, it was determined that food service employees failed to ensure that sanitary practices were followed, and equipment was maintained in order to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 6/23/19 at 8:26 AM, a tour of the facility's kitchen was conducted and revealed the following: In the room being used to store chemicals a cart containing uneaten, uncovered food was observed with drain flies circling around it. This room had plastic trash, drink lids and food wrappers discarded on the ground. The drywall under the shelving which housed cleaning chemicals was observed in disrepair. At 8:32 AM the facility's refrigerators were inspected and revealed a dead fly on the bottom metal tray of the Victory freezer. The bottom of the True refrigerator was found to have a large puddle of spilled milk. Inspection of the Traulsen refrigerator revealed unlabeled, undated containers of jelly, applesauce and sliced cheese. At 8:36 AM the kitchen ice machine was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.