Lorien Bulle Rock

Based on observations and staff interviews it was determined the required staff posting information was not in prominent place readily accessible to residents and visitors. This was evident during the entire survey process. The finding includes: On 6/21/22, 6/22/22, 6/23/22, 6/24/22 and 6/27/22 the required nursing staffing information per this regulation the facility staffing posting was not posted visible upon entering the facility or readily accessible to residents, family members and legal representatives of residents. On 6/27/22 at 1:00 p.m. interview of Administrator and Director of Nursing verified the required staff posting was not available for resident or visitors during the survey process. The finding was discussed with the Administrator and Director of Nursing in detail of this concerns prior and during survey exit conference held on 6/28/22 at approximately 2:30 p.m.

Based on medical record review it was determined that the facility staff failed to ensure Residents #4 and #300 were free from un-necessary medications. This was evident for 2 of 5 residents selected for review of un-necessary medications and 2 of 27 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to ensure Resident #4 was free from un-necessary pain medication. Medical record review for Resident #4 on 6/22/22 at 11:30 AM revealed on 9/17/21 the physician ordered: Oxycodone 5 milligrams (mgs.) by mouth every 6 hours as needed for severe pain. Oxycodone belongs to a class of drugs known as opioid analgesics and is used to help relieve moderate to severe pain. It works in the brain to change how the body feels and responds to pain Medical record revealed the facility staff assessed and documented the resident's pain level as 0 on: 6/1/22 at 9:01 AM, 6/1/22 at 4:04 PM, 6/5/22 at 2:17 PM, 6/6/22 at 3:14 PM (1), 6/7/22 at 5:06 PM (1), 6/11/22 at 8:34 AM, 6/11/22 at 3:09 PM, 6/15/22 at 3:15 PM, 6/20/22 at 2:34 PM, 6/21/22 at 1:30…

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 interviews it was determined the facility staff failed to provide showers to Residents (#20, #23, #35 and #21). This was evident for 4 of 39 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to provide showers to Resident #20. Medical record review for Resident #20 revealed the resident was to have showers on 3-11 shift on Wednesday and Saturday. Review of staff documentation revealed the facility staff documented showers for Resident #20 on 8/29/18, 9/7/18, 9/15/18 and 9/22/18 (4 showers in 2 months). Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to provide Resident #20 showers at least 2 times a week. 2. The facility staff failed to provide showers to Resident #23. Interview with Resident #23 on 10/2/18 at 12:00 PM revealed Resident #23 revealed he/she did not get 2 showers a week. The resident also indicated she/he would like to have a shower on 10/2/18. Facility staff documentation revealed Resident #23 is to have showers…

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 the facility staff failed to provide Resident #35 with the most dignified existence. This was evident for 1 of 39 residents selected for review during the survey process. The findings include: During initial surveyor interview with Resident #35 on 10/2/18 at 10:00 AM facility staff nurse #1 and Geriatric Nursing Assistant (GNA) #1 entered the room without knocking and proceeded to attend to Resident #35's roommate. Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff nurse #1 and GNA #1 failed to knock on the door of Resident #35's room and wait for permission to enter prior to entering the room.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, it was determined that the facility staff failed to properly void an old MOLST form when a new one is created. This was evident for 1 (Residents #62) of 9 residents reviewed for advance directives during an annual recertification survey. The findings include: A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must be accurately and legibly complete the form and then sign and date it. Voiding the Form: to void this medical order form, a physician or nurse practitioner shall draw a line through the sheet, write VOID in large letters across the page, and…

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 complaint, reviews of a closed record, and staff interview, it was determined that the facility staff failed to notify residents and/or representative and the Ombudsman of transfer and reason for transfer to the hospital in writing. This was evident for 2 (Resident #216 and #66) of 2 residents reviewed for Hospitalization during an annual recertification survey. The findings include: 1. Review of complaint MD00126182 on 10/3/18 revealed an allegation that Resident #216 was not allowed to return to the facility after a brief hospitalization. Review of the medical record for Resident #216 revealed the resident was transferred to an acute care facility on 4/29/18. There was no documentation found in the medical record that the resident, the resident's responsible party, or the Ombudsman was given written notice of Resident #216 being transferred to the hospital and the reason for the transfer to the hospital. On 10/5/18 at 9:15 AM, the facility Administrator stated that Resident #216 and the Resident's responsible party did not receive written notice as to why Resident #216…

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 review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization. This was evident for 1 (Resident #66) of 5 residents reviewed for Hospitalization during an annual recertification survey. The findings include: Review of the medical record for Resident #66 revealed the resident was transferred to an acute care facility on 8/3/18 and returned to the facility on 8/6/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. On 10/5/18 at 11:06 AM, the Director of Nurses confirmed that Resident #66 and the Resident's responsible party did not receive the facility bed hold policy when Resident #66 was transferred to the hospital on 8/3/18.

Based on medical record review, observation and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for residents (#30 and #35). This was evident for 2 of 39 residents selected for investigation during the survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care…

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, observation and interview, it was determined the facility staff failed to apply ace wraps to Resident #35 according to the standard of practice. This was evident for 1 of 39 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #35 revealed on 5/12/18 the physician ordered: ace bandage to bilateral lower extremities, apply in morning and remove at bedtime. Typically, legs swell during the day because of dependent edema, meaning because a resident is up (even in a chair) fluid settles in feet, ankles and lower legs. This swelling should disappear at night when laying down. Typically, health care providers recommend wrapping legs or support stockings when the resident is up and then nothing during the night to give them a break and let the skin breath. It is the standard of practice to apply the ace bandage to the knee (unless thigh high is ordered). Surveyor observation of the resident on 10/4/18 at 12:30 PM revealed the facility staff applied an ace wrap; however, the ace wrap only…

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 interview, it was determined the facility staff failed to provide services that would allow residents the ability to achieve the greatest independence with performing Activities of Daily Living to Residents (# 116). This was evident for 1 of 39 residents selected for review during the survey process. The findings include: Activities of daily living are routine activities people do every day without assistance. There are six basic ADLs: eating, bathing, getting dressed, toileting, transferring and continence. It is the expectation the facility staff will provide dietary assistance to residents; cut food up, open milk and juice containers, butter breads and ensure the food is within reach to the resident 1. The facility staff failed to provide straws, plastic lid for liquids and to aid in opening of dietary packages for Resident #116. Surveyor observation of the resident's breakfast on 10/3/18 at 8:00 AM revealed the facility staff provided the resident with a carton of milk and coffee. The milk was unopened, and the facility staff failed to provide a straw…

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, observation and interview, it was determined the facility staff failed to obtain consultations as ordered for Resident #20; failed to ensure the validity of a fluid restriction for Resident #35 and it was determined the facility staff failed to follow a physician order and obtain daily weights for Resident #66. This was evident for 3 of 39 residents selected for review during the annual survey process. The findings include: 1 A. The facility staff failed to obtain a neurological consultation for Resident #20. Medical record review for Resident #20 revealed on 11/3/17 the physician ordered: Neurological consultation. Neurology consultation is an appointment with a neurologist for the diagnosis, management, or treatment of conditions that affect the nervous system. A neurologist is a doctor with specialized training in diagnosing and treating diseases of the brain, spinal cord, peripheral nerves, and muscles. Further record review revealed the facility staff failed to obtain 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.

Based on medical record review and interview, the facility failed to provide treatment/services to maintain vision (Resident #21). This is evident for 1 out of 39 residents selected for review during the investigation stage of the survey process. The findings include: During interview with Resident #21 on 10/2/18 at 11:55 AM, the resident stated he/she is waiting for a follow up appointment with the eye doctor. The resident stated I can't see out of my right eye. I have a cataract and was supposed to have surgery. Cataract surgery is a procedure to remove the lens of your eye and, in most cases, replace it with an artificial lens. Review of the resident's medical record revealed the resident did see the eye doctor on 4/26/18. The new orders for the resident at that time was a referral for Ophthalmology consult for low vision and cataract. Further review of the medical record revealed an Ophthalmology Consult was never scheduled. Interview with the Director of Nursing on 10/4/18 12:43 PM confirmed the surveyor's findings.

Based on medical record review and interview, the facility failed to obtain a podiatry consultation as ordered by the physician for Resident (#17) and the facility staff failed to assist in making the requested podiatry appointment for diabetic preventive care (Resident #25). This is evident for 2 out of 39 residents selected for review during the investigation stage of the survey process. The findings include: 1. The facility staff failed to obtain a podiatry consultation as ordered by the physician. Medical record review for Resident #17 revealed on 9/17/18 the physician ordered: podiatry consultation related to painful toes. Podiatry is the branch of medicine that treats the foot, ankle, and related structures of the leg. Interview with Resident #17 on 10/2/18 at 10:00 AM revealed the resident resting in bed; however, complained to toe nail pain; however, the facility staff failed to obtain the podiatry consultation as ordered. Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to obtain podiatry consultation for Resident #17 as…

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, observation and interview, it was determined the facility staff provided care to Resident #30 to prevent a potential accident. This was evident for 1 of 39 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #30 revealed on 8/21/18 the physician in collaboration with Speech Language Pathologist (SLP) ordered: nectar thick liquids by spoon only and monitor for swallow completion. Liquids to be given by teaspoon only. SLPs specialize in the evaluation, diagnosis, and treatment of communication disorders (speech disorders and language disorders), cognitive-communication disorders, voice disorders, and swallowing disorders. Nectar-thick liquids are easily pourable and comparable to apricot nectar or thicker cream soups. Surveyor observation of lunch on 10/3/18 at 1:00 PM revealed the resident being fed by Geriatric Nursing Assistant (GNA) #2. It was further noted at that time, GNA #2 failed to provide liquids to the resident via teaspoon. The GNA #2 poured the liquids into a cup and put…

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, observation and interview, it was determined the facility staff failed to obtain weights as ordered for Resident #20 and the facility staff failed to offer Resident #30 alternative foods. This was evident for 2 of 39 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to obtain weekly weights as ordered by the physician for Resident #20. Medical record review for Resident #20 revealed on 7/30/18, the physician ordered: weekly weights- on Mondays. Further record review revealed the facility staff documented the weights on the following days: 8/6/18, 8/13/18, 8/21/18---Tuesday, 8/27/18, 9/7/17-Friday, 9/10/18, 9/18/18-Tuesday and 9/27/18- Thursday. Further record reviews the facility staff failed to obtain a weight for Resident #20 on 10/1/18. Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to obtain weekly weights on Mondays for Resident #20 as ordered by the physician. 2. The facility staff failed to offer an alternative food choice to…

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, observation and interview, it was determined the facility staff failed to administer DuoNeb treatment to Resident #118 in accordance with the standard of practice. This was evident for 1 of 39 residents selected for review during the annual survey process. The findings include: Surveyor observation of Resident #118 on 10/2/18 at 1:00 PM revealed the resident sitting in his/her room next to the nebulizer. A nebulizer changes medication from a liquid to a mist so that it can be more easily inhaled into the lungs. An interview of the resident at that time revealed that the resident had a change of condition on 10/1/18 that included coughing and fever and the physician ordered that he/she receive nebulizer treatments. The resident stated that he/she did not receive the first treatment until today. Review of the medical record revealed an order written on 10/1/18 at 10:30 AM for DuoNeb treatments every 8 hours for 2 days. Review of the Medication Administration Record (MAR) revealed documentation for the first DuoNeb was on 10/2/18 at 6 AM. Interview of the Nurse…

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 act upon the consultant pharmacist recommendation in a timely manner for Resident #35. This was evident for 1 of 39 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #35 revealed on 5/5/18 the consultant pharmacist was in the facility and noted: Resident on Lorazepam .5 milligrams by mouth every 4 hours as needed. The consultant pharmacist also noted the medication should be limited to 14 days and with the following information: indication for use (the medical record must show documentation of adequate indications for the medications' use and the diagnosed condition for which the medication was prescribed. The consultant pharmacist also indicated the attending physician believed the medication was to be extended beyond 14 days should: document the rationale and indicate the duration of the as needed order. Further medical record review revealed the facility staff failed to address those recommendations in a timely manner.…

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 document the heart rate and blood pressure for Resident #44 when the physician ordered parameters. This was evident for 1 of 39 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #44 revealed on 6/23/18 the physician ordered: Hydralazine 25 milligrams by mouth 3 times a day for blood pressure and Metoprolol extended release, 200 milligrams by mouth every day, hold for heart rate less than 50, hold for systolic blood pressure (top number) less than 110. Hydralazine is a medication used to treat high blood pressure and heart failure. Metoprolol is prescribed to treat high blood pressure and prevent angina (chest pain) and it works by relaxing blood vessels and slowing heart rate, which improves blood flow and lowers blood pressure. Review of the Medication Administration Record for the above medications revealed the facility staff failed to obtain/document the blood pressure and heart rate as ordered by the physician for…

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 identify specific targeted behaviors to monitor and assess for the continued use of psycho-active medication for Residents (#20 and #35). This was evident for 2 of 39 residents selected for review during the survey process. 1. The facility staff failed to identify specific targeted behaviors to monitor and assess for the continued use of psycho-active medication for Resident #20. Medical record review for Resident # 20 revealed on 11/3/17 the physician ordered: Abilify 2.5 milligrams by mouth 2 times a day for psychosis. Abilify is an antipsychotic medication. It works by changing the actions of chemicals in the brain. Abilify is used to treat the symptoms of psychotic conditions such as schizophrenia and bipolar I disorder (manic depression). Further record review revealed the facility staff failed to identify specific target behaviors monitor and to justify the continued use of the medication. Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed…

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 and staff interview, it was determined that the facility staff failed to provide treatment to maintain dental health for Resident #21. This is evident for 1 out of 39 residents selected for review during the investigation stage of the survey process. The findings include: During interview with Resident #21 on 10/2/18 at 11:55 AM, the resident stated he/she is waiting for treatment after a follow up appointment with the dentist. Review of the resident's medical record revealed the resident did see the dentist on 6/12/18. The new orders for the resident at that time was for Biotene to treat resident's Dry Mouth Syndrome. Biotene is an oral rinse to managing Dry Mouth symptoms. Dry Mouth Syndrome is a condition in which the salivary glands in the mouth don't make enough saliva to keep your mouth wet. Dry Mouth Syndrome is often due to the side effect of certain medications or aging issues. Dry Mouth Syndrome can cause problems speaking, tasting, chewing, and swallowing. Further review of the medical record revealed that the Biotene was never ordered to treat…

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 interview, it was determined facility staff failed to label with an expiration date individual serving containers of fruit juice. The findings included: On 10/3/18 at 9:00 AM during a tour of the kitchen refrigerator and all unit nourishment refrigerators it was determined the individual packaged fruit juices were not labeled with an expiration date. The shipping box containing the fruit juices in the kitchen refrigerator was not labeled with an expiration date. Further review with the dietitian confirmed on 10/4/18 at 12:00 PM that the individual fruit juice containers had not been labeled with an expiration date nor had the shipping box.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to maintain the medical records for Residents ( #23, #35 and #25) in the most complete and accurate form. This was evident for 3 of 39 residents selected for review during the survey process. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. An advance directive is a written document, electronic document, or oral directive that indicates a patient's wishes about medical treatment and/or appoints a health care agent to make medical decisions. In the event, the resident does not have an advance directive, and no one is appointed a health care agent, a surrogate decision maker is appointed for the resident in accordance with the Health Care Decision Act. A…

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 observation and staff interview the facility staff failed to post an isolation sign on room [ROOM NUMBER] door to alert visitors, residents, and staff to see the nurse before entering the room. This was true for 1 out of 39 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to post a sign on a resident door indicating isolation. On 10/2/18 and 10/3/18, an observation outside resident's room [ROOM NUMBER] was a box. When opened contained items necessary for respiratory isolation, gowns, masks, and gloves. The box had no signage indicating the items needed to be worn before entering the room or to see the nurse before entering. The resident has an infection requiring isolation. No one entering without previous knowledge would be alerted that the box meant isolation was expected. On 10/3/18 at the Director of Nursing confirmed there was not signage to indicate to stop and see a nurse before entering room [ROOM NUMBER].