Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 4
Date: Mar 21, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards related to medication administration, pharmaceutical services, medication regimen review, and food safety in the nursing home.
Findings
The facility was found to have multiple deficiencies including medication errors such as delayed administration of prescribed antibiotics, continued packaging of medications on hold, failure to timely address pharmacy recommendations, and failure to store food with proper expiration dates.
Deficiencies (4)
F0684: The facility failed to ensure residents received medications according to professional standards, evidenced by Resident #10 missing 11 doses of Cefdinir due to delayed administration.
F0755: Pharmacy continued to prepackage a medication for Resident #29 after it was placed on hold, contrary to proper pharmaceutical service standards.
F0756: The facility failed to address a pharmacy recommendation in a timely manner for Resident #20, resulting in unnecessary medications being continued until discontinued by the Medical Director.
F0812: The facility failed to store food in accordance with professional food safety standards, with several items in the kitchen missing expiration dates.
Report Facts
Missed medication doses: 11
Residents reviewed for medication errors: 17
Residents observed during medication pass: 4
Residents reviewed for unnecessary medications: 5
Pharmacist recommendation dates: 2
Food items missing expiration dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed medication error and findings in facility investigation; interviewed regarding medication packaging and regimen review. | |
| Medical Director #5 | Signed off on discontinuation of unnecessary medications following pharmacist recommendations. | |
| LPN Staff #11 | Observed medication pass where medication on hold was still prepackaged for Resident #29. | |
| Staff #3 (Interim DON) | Interviewed about communication regarding pharmacist recommendations. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 19, 2019
Visit Reason
The inspection was conducted as part of the annual survey process to review compliance with care and medication administration standards.
Findings
The facility failed to notify the responsible party and obtain consent for an increase in medication for Resident #34. Additionally, the facility staff failed to notify the physician of abnormal blood sugar levels and document the notification or treatment for Resident #24.
Deficiencies (2)
F 0580: Facility staff failed to notify the responsible party for Resident #34 of an increase in medication and obtain consent prior to initiation of the increase in Lexapro.
F 0684: Facility staff failed to notify the physician and document notification or treatment for abnormal blood sugar levels over 500 for Resident #24.
Report Facts
Residents selected for medication review: 5
Residents selected for review: 27
Blood sugar level: 534
Blood sugar level: 588
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding failure to notify family of medication increase for Resident #34 | |
| Director of Nursing | Confirmed failure to notify responsible party for Resident #34 of medication increase | |
| Assistant Director of Nursing | Confirmed failure to document physician notification and treatment for Resident #24's abnormal blood sugar levels |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 21, 2017
Visit Reason
The inspection was conducted as a complaint investigation to review the facility's compliance with regulatory requirements related to resident assessments, medication regimen reviews, medical record maintenance, and hospice service provision.
Complaint Details
The investigation was triggered by complaints regarding inaccurate resident assessments, failure to follow pharmacist recommendations, incomplete medical records, and failure to arrange requested hospice-related consultations. The deficiencies were substantiated based on medical record reviews and staff interviews.
Findings
The facility failed to accurately document resident assessments on the MDS for two residents, failed to obtain recommended laboratory blood tests for one resident, failed to maintain accurate medical records including missing physician orders for catheter care, and failed to ensure an ophthalmology consult was obtained for a resident requesting it.
Deficiencies (4)
F 0641: Facility staff failed to document accurate assessments for Resident #33 and Resident #39 on the MDS, resulting in inaccurate coding of medication and alarm use.
F 0756: Facility staff failed to obtain laboratory blood tests as recommended by the Consultant Pharmacist for Resident #34 until after surveyor intervention.
F 0842: Facility failed to maintain accurate medical records for Resident #39 and failed to obtain a physician's order for Foley catheter care for Resident #355.
F 0849: Facility staff failed to ensure an ophthalmology consult was obtained as requested by Resident #31.
Report Facts
Residents reviewed: 26
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Viewing
Loading inspection reports...
