Saylor Lane Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 33 residents when: 1. A staff handled resident's food with bare hands; 2. Clean linen touched the floor and touched employee's clothes; 3. Safe infection control practices were not followed for cleaning and disinfecting a shared glucometer (a device used to measure blood sugar) in-between resident care and aseptic technique was not followed during medication preparation; 4. Nursing staff did not perform hand hygiene when moving from one route of medication administration to another and after handling a contaminated medical device; 5. A facility staff held Resident 15's 5/5/25 lunch meal with bare hands; 6. Resident 3's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) face mask was not changed every seven days; These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful…

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, interview, and record review, the facility failed to ensure one out of 14 sampled residents (Resident 8) was provided with appropriate care and services with enteral feeding (also referred to as tube feeding/ feeding tube- the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 8's percutaneous endoscopic gastrostomy tube (PEG tube- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) placement was not checked before enteral feeding. This failure had the potential for Resident 8 to experience complications of enteral feeding such as regurgitation (digestive fluids and undigested contents in the stomach rise into the mouth) and/or accidental aspiration (accidental inhalation) of feeding formula into the lungs. Findings: A review of Resident 8's clinical record indicated Resident 8 was admitted January of 2025 and had diagnoses that included diabetes mellitus (a chronic condition causing too much sugar in 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 interview and record review, the facility failed to document and maintain records of COVID -19 (mild to severe, viral, respiratory infections) vaccination status for seven of 80 facility staff, Licensed Nurse 4 (LN 4), LN 5, Laundry Aide 2 (LA 2), Certified Nursing Assistant 6 (CNA 6), [NAME] 2 (CK 2), CNA 4, and CNA 5. This deficient practice increased the risk for residents to acquire, transmit, or experience complications from COVID -19 infections, compromising the residents, and the visitor's safety. Findings: During a concurrent interview and record review with the Director of Staff Development (DSD) and Infection Control Nurse (IC) on 5/8/25/ at 12:11 p.m., the DSD and IC confirmed they did not find vaccination records for COVID -19 for 7 facility staff in their Employee Records. The DSD stated they offered immunizations such as COVID -19 to the newly hired employees during their first day of orientation in the facility. The DSD searched the Employee Records and did not find documentation of COVID -19 vaccination status for the following facility staff: 1. LN 4, date…

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 interview, and record review, the facility failed to protect one of four sampled residents (Resident 4) from physical abuse when Resident 1 hit Resident 4 with a walker on his left knee in the rehabilitation room. This failure had the potential to cause serious injury, fear and distress to Resident 4 and other facility residents that were present in the rehabilitation room during the incident. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility in early 2025 with multiple diagnoses including Huntington ' s Disease (a progressive brain disorder that worsens over time causing gradual decline in movement, thinking, and mood). A review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/24/25, reflected a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 out of 15 indicating Resident 1 had…

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 interview and record review, the facility failed to report allegations of abuse to the Department for 2 of 4 sampled residents (Resident 1 and Resident 4), when Resident 1 was witnessed throwing a walker at Resident 4 hitting his left knee in the facility's rehabilitation room. This failure decreased the facility ' s potential to protect vulnerable residents and provide a safe environment. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility in early 2025 with multiple diagnoses including Huntington ' s Disease (a progressive brain disorder that worsens over time causing gradual decline in movement, thinking, and mood). A review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/24/25, reflected a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 out of 15 indicating Resident 1 had intact…

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, interview, and record review, the facility failed to ensure food safety when food storage temperature logs and sanitization solution logs were not being consistently documented. This failure had the potential to lead to food borne illnesses for 38 residents eating facility prepared meals. Findings: During a concurrent observation and interview on 5/13/24, at 8:21 a.m., with [NAME] (CK1), the Dry Food Storage Temperature Control Log was reviewed. CK1 stated the temperature for the dry foods' storage room was taken and documented twice daily, once on morning shift and once on evening shift. CK1 confirmed 4 entries were missing for the month of May 2024. CK1 stated it was not acceptable for entries to be missing and not monitoring the temperature could lead to food safety concerns. During a concurrent observation and interview on 5/13/24, at 8:24 a.m., with Kitchen Aid (KA) 2, the red bucket sanitizing solution was observed near the dishwashing sink. KA 2 tested the solution and stated the sanitizing solution is tested twice daily and results are written on a log.…

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 interview and record review, the facility failed to assess and evaluate the Intake and Output (I&O, the measurement of fluids entering and leaving the body) weekly summaries for two of 15 sampled residents (Resident 20 and Resident 23) when the residents were on fluid restriction. This failure placed the residents at risk for unnoted fluid overloads and/or dehydration as well as difficulty to gauge fluid balance of the residents to determine the effects of the treatment and the progress of the disease. Findings: Review of Resident 20's admission Record indicated the resident was a long-term resident in the facility with diagnoses that included hemodialysis (a treatment to filter wastes and fluid from the blood using a dialysis machine, an artificial kidney), heart disease, lung problem with localized swelling issues. Review of Resident 20's medical record, Order Summary, indicated the resident was on fluid restriction of a total of 2000 ml (milliliter, 2 Liters) per 24 hours with the specification for, Dietary Allotment 1200 ML; Nursing allotment 800 ML/24 Hrs, AM-350 ML,…

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 interview and record review, the facility failed to provide thorough drug regimen reviews (DRR) for one of 15 sampled residents (Resident 23) when the facility did not act on the facility pharmacist (FP) report on irregularities and the expired medications were mixed with other medications available for use in the medication storage room refrigerator. These failures resulted in unresolved irregularities of antipsychotic (to treat symptoms of psychosis) medication therapy for Resident 23 and increased the potential for medication errors. Findings: Review of Resident 23's medical record, admission Record, indicated the resident was a long term resident in the facility with diagnoses that included unspecified memory problems with behavioral disturbance. Review of Resident 23's medication administration record (MAR) for March, April, and May 2024 indicated the resident was on antipsychotic medication monitoring every shift as follows: 1. Monitor side effect of Antispychotic medication (Risperidone) episodes of facial/tongue movement, decreased mental status, inability to sit…

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, interview and documentation review, the facility failed to discard expired medications for a census of 38 when the expired flu vaccines were mixed with non-expired flu vaccines in the medication refrigerator, available for use. This failure increased the potential for medication errors and placed the residents at risk for drug safety. Findings: During the medication storage room observation on 5/13/24 starting at 2:45 p.m. with Licensed Nurse (LN 3), there were multiple identical boxes of flu vaccines stored in the medication refrigerator drawer in the room. There were 5 milliliter pre-filled Influenza Vaccine afuria® Quadrivalent for 2022-2023 mixed with 2023-2024 flu vaccines; two boxes of 2022-2023 vaccines were open and each contained six and three pre-filled syringes apiece, a total of nine syringes, with the expiration date of 6/30/23. Review of the facility's March 2018 policy and procedure, Medication Storage in the Facility, stipulated, Outdated .are immediately removed from stock, disposed of according to procedures for medication disposal . In 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.

Based on interview and record review, the facility failed to maintain accurate, consistent, and complete medical records for three of 15 sampled residents (Resident 23, Resident 4 and Resident 20) and one randomly selected resident (Resident 3) for a census of 38. These failures resulted in the residents' health and care status to be inaccurately reflected in the medical records and placed the residents at risk for inadequate care due to the potential miscommunication among the healthcare providers. Findings: 1. a) Review of Resident 23's medical record, admission Record, indicated the resident was a long-term resident in the facility with diagnoses that included unspecified memory problem with behavioral disturbance. Resident 23 was on fluid restriction due to a heart problem. Review of Resident 23's medication administration record (MAR) for March, April, and May 2024 indicated the resident was on antipsychotic medication monitoring every shift for Risperidone (to treat symptoms of psychosis). The antipsychotic monitoring included the side effect of Risperidone and for 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 observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 38 residents when: 1. A facility staff did not wear required personal protective equipment (PPE) when assisting Resident 233 and Resident 234 with mobility exercises who were both on enhanced standard precaution (ESP- also known as enhanced barrier precaution/EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use); and, 2. Resident 14's nasal cannula (a medical device with two prongs connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was left uncovered and hanging on the resident's bedside rail when not in use. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure of Resident 233, Resident 234, 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 observation, interview, and record review, the facility failed to ensure two out of 15 sampled residents (Resident 232 and Resident 23) were assisted with nail care as part of their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 232 and Resident 23 had long fingernails with blackish substance underneath the fingernails. This failure had the potential for Resident 232 and Resident 23 to sustain injury and/or for the residents to acquire an infection. Findings: 1. A review of Resident 232's clinical record indicated Resident 232 was admitted April of 2024 and had diagnoses that included chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and need for assistance with personal care. A review of Resident 232's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 4/29/24, indicated Resident 232 had a Brief Interview for Mental…

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, interview, and record review, the facility failed to ensure two out of 15 sampled residents (Resident 233 and Resident 234) received treatment and care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when: 1. Resident 233's physician's order for stage 3 pressure ulcer/injury (PU/PI- injury to skin and underlying tissue resulting from prolonged pressure which extends through the skin into deeper tissue and fat but do not reach muscle or bone) on the coccyx (area on the lower back where the bottom/base of the spine is) treatment was not followed; and, 2. Resident 233 and Resident 234's wound dressings was not labeled with the nurse initials, and time and date it was applied. These failures had the potential for Resident 's 233's coccyx wound to get worse, and Resident 233 and Resident 234 to not achieve their highest practicable well-being and to not receive appropriate wound care treatment. Findings: 1. A review of Resident 233's clinical record indicated Resident 233 was admitted April of 2024 and had diagnoses…

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, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for one out of 15 sampled residents (Resident 14) when: 1. Resident 14 had no oxygen in use sign placed on the outside of the room entrance door; and, 2. Resident 14's physician's orders for oxygen therapy was not followed. These failures had the potential to result in unsafe delivery of oxygen to Resident 14 and potential harm to all the residents in the facility. Findings: 1. A review of Resident 14's clinical record indicated Resident 14 was admitted April of 2024 and had diagnoses that included respiratory failure (is a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems, heart failure (a condition in which the heart cannot pump…

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 interview and record review, the facility failed to ensure one out of 15 sampled residents (Resident 14) received dialysis care services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when: 1. Resident 14's post-dialysis weight was not consistently documented in the resident's chart; and, 2. Resident 14's the dialysis communication sheet was not consistently completed. These failures had the potential for Resident 14 to not achieve the highest practicable well-being and to not receive appropriate dialysis care treatment and services. Findings: 1. A review of Resident 14's clinical record indicated Resident 14 was admitted April of 2024 and had diagnoses that included diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect kidney function and breathing), stage 5 chronic kidney disease (a condition in which the kidneys are severely damaged and have stopped doing their job to filter waste from the blood), and dependence on renal dialysis (the process of removing excess water,…

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 interview and record review, the facility failed to ensure Registered Nurse (RN) coverage for eight consecutive hours a day, seven days per week for a census of 39 residents. This failure prevented the facility's ability to provide consistent RN services and supervision of care. Findings: During a concurrent interview and record review on 5/17/22 at 3:15 p.m., the Human Resources/Payroll (HRP) stated the Director of Nursing (DON) was on leave on 4/14/22, 4/15/22, and 5/13/22. A review of the Employee Timesheet (ET) indicated, the DON was on vacation on 4/14/22, 4/15/22, and 5/13/22. The HRP also stated Licensed Nurse 2 (LN) 2 worked on 4/14/22 and 4/15/22 for 4 hours each day. The ET indicated, the LN 2 worked on 4/14/22, 4/15/22 from 11:19 a.m. to 3:19 p.m., and 11 a.m., to 3 p.m., respectively. The HRP confirmed there was no documented evidence there was a RN at the facility for 8 consecutive hours on 4/14/22, 4/15/22, 5/13/22, 5/14/22, and 5/15/22. During an interview on 5/17/22 at 2:45 p.m., the Clinical Consultant (CC) stated there was no RN coverage on the weekend.…

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, interview, and record review, the facility failed to ensure food was procured, stored and served under sanitary conditions for 39 residents to prevent food borne illness when: 1. Opened food items were not labeled with an opened date; 2. Expired food was not discarded from the refrigerator; 3. Staff personal items were found in the food prep and ready-to-use areas; 4. Ready-to-use service items were dirty and kitchen surfaces were in poor condition; 5. An opened food item was uncovered, not properly labeled, and stored in the dry goods storage area; 6. Staff wore face masks improperly; and 7. Staff was unable to properly demonstrate the manual dishwashing process These failures decreased the facility's potential to prepare, store, and provide food under sanitary conditions for a census of 40 residents. Findings: 1. In an observation of a walk-in refrigerator with the Dietary Supervisor (DS) and the [NAME] 1 on 5/16/22 at 8:35 a.m., the following items were found open and not labeled with an opened date: a half container of coleslaw dressing; one carton of soy…

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, interview, and record review the facility failed to maintain pharmacy services, when two opened refrigerated emergency kits (E-kit 15 and E-kit 66) out of three refrigerated E-kits were not replaced by the pharmacy for a census of 39 residents. This failure reduced the facility's potential to provide emergency pharmacy services to residents. Findings: A concurrent observation and interview was conducted on 5/16/22 at 2:35 p.m., with the Licensed Nurse 3 (LN 3) in the medication storage room. A medication order slip inside E-kit 15 indicated 25 units of Regular Human Insulin (Humulin R; a drug used to control high blood sugar) was withdrawn from a 100 u/ml (units per milliliters; a unit of measure) vial on 3/15/22. The LN 3 confirmed the E-kit 15 was opened and 25 units of Humulin R was withdrawn from the vial on 3/15/22. A concurrent observation and interview was conducted with the LN 3 in the medication storage room on 5/16/22 at 2:37 p.m. A 100 u/ml vial of Humulin R and a medication order slip were missing from E-kit 66. The LN 3 confirmed the missing…

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, interview, and record review the facility failed to properly label and store medications and products for four residents (Resident 8, Resident 16, Resident 17, and Resident 20) out of a census of 39, when: 1. One expired kit of glucagon (an emergency drug used to treat low blood sugar) was stored in a medication cart; 2. One open bottle of blood glucose strips was stored in a medication cart without an opened date label; 3. Three expired vials of insulin glargine (long-acting insulin; drug used to control blood sugar levels) were stored in a medication cart; 4. Loose pills were stored in a medication cart; 5. One expired tube of diclofenac (a drug used to relieve pain, swelling, and joint stiffness) was stored in a treatment cart; and 6. One expired cream of triamcinolone (a drug used to treat the itching, redness, dryness, crusting, and discomfort of various skin conditions) was stored in a treatment cart. This failure increased the potential for drug diversion and unsafe administration 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were performed for a census of 39 residents when: 1. Staff did not perform proper hand hygiene; 2. Laundry Staff (LS) did not wear a gown when handling soiled and clean linen; and 3. Staff placed urinary catheter bags on the floor. These failures had the potential to result in the spread of infections. Findings: 1. During a concurrent observation and interview on 5/16/22 at 9:20 a.m., the Certified Occupational Therapy Assistant (COTA) entered room [ROOM NUMBER]. The COTA did not wash or sanitize her hands prior to entering the room. The COTA was then observed to push down the contents of the garbage bin, immediately put on gloves, and assisted the resident in room [ROOM NUMBER]B onto the wheelchair. Hand hygiene was not observed after the COTA touched the garbage bin. The COTA stated she was not aware she had not performed hand hygiene and confirmed she should have performed hand hygiene before…

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, interview, and record review, the facility failed to ensure proper personal protective equipment (PPE) usage for unvaccinated staffs were performed for five out of 86 staffs when five unvaccinated staffs for COVID-19 (a virus attacking the respiratory system in people) were working in the facility. This failure decreased the facility's potential to protect the vulnerable population against COVID-19. Findings: During an observation on 5/17/22 at 12:10 p.m., Certified Nursing Assistant 2 (CNA 2) was in the hall wearing surgical mask and face shield. During an interview on 5/18/22 at 12:10 p.m., the Infection Preventionist (IP) confirmed unvaccinated staffs were provided with N95 mask, the facility did not enforce unvaccinated staff to use N95 mask while on the floor. The IP confirmed CNA 2 was not vaccinated and had a religion exemption. The IP confirmed there were 5 unvaccinated staffs with exemptions. During a review of an undated facility's policy and procedure titled, Facility COVID-19 Mitigation Plan Manual, indicated, All staff will wear recommended PPE…

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, interview, and record review, the facility failed to maintain residents' dignity when the urinary catheter (a tube that collects urine from the bladder and leads to a drainage bag) was not covered with a privacy bag for two residents (Resident 7 and Resident 17) of 14 sampled residents. This failure increased the potential to negatively impact the residents' self-esteem. Findings: A review of an admission record indicated Resident 17 was admitted to the facility in March 2022 with multiple diagnoses which included aphasia (loss of ability to understand or express speech) and obstructive and reflux uropathy (a condition in which the flow of urine is blocked). In an observation on 5/16/22 at 9:26 a.m., Resident 17 was lying in bed. A urinary catheter tubing with a drainage bag attached to it was observed on the floor without a privacy bag. In a concurrent observation and interview on 5/16/22 at 9:43 a.m., the Director of Nursing (DON) acknowledged Resident 17's urinary catheter bag should be covered with a privacy bag. In an interview on 5/17/22 at 12 p.m.,…

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 interview and record review the facility failed to ensure a written notice of transfer or discharge was provided to the long-term care Ombudsman (an advocate for residents in nursing homes) and to one resident (Resident 36) for a census of 39 residents. This failure resulted in the facility's reduced compliance to provide a written notice of transfer or discharge to the long-term care Ombudsman and to Resident 36. Findings: A review of the face sheet and admission record indicated, Resident 36 was admitted to this facility in early 2022 with multiple diagnoses which included recurrent major depressive disorder and urinary tract infection (UTI). During an interview on 5/17/2022 at 12:50 p.m., the Clinical Consultant (CC) stated the notice of transfer was done using an electronic documentation system and the Responsible Party (RP) was notified verbally only and the Ombudsman was not notified of transfers. The CC also stated, It [was] not in our policy and procedure. A review of the facility's policy and procedure titled Transfer or Discharge, Emergency, revised 8/18,…

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 interview and record review the facility failed to issue a written bed hold notice for one resident (Resident 36) out of 12 sampled residents, when Resident 36 was transferred to the hospital. This failure had the potential for Resident 36 to be prohibited from returning to the facility leading to emotional and psychological stress. Findings: A review of the face sheet and admission record indicated Resident 36 was admitted to the facility in early 2022 with diagnoses which included recurrent major depressive disorder and urinary tract infection (UTI). A review of a nurse's note dated 3/20/22 at 10:54 a.m. indicated, [Resident 36] endorsed to staff that he wants to kill himself and die .Notified MD [Medical Director], DON [Director of Nursing] and Administrator. Ordered to send to ER [Emergency Room] for psych evaluation .RP [Responsible Party] notified . During a concurrent interview and record review on 5/17/2022 at 11:30 a.m., the Medical Records person stated, There is no documentation of bed hold for this patient. During an interview on 5/17/2022 at 3 p.m., 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 observation, interview, and record review, the facility failed to ensure accurate assessments were documented for one resident (Resident 15) for a census of 39 residents. This failure decreased the facility's potential to identify current and future residents' care needs and well-being. Findings: A review of an admission record indicated Resident 15 was re-admitted to the facility early 2021 with multiple diagnoses which included contracture (a permanent tightening of the muscles, tendons, skin, and tissues which causes joints to shorten and become very stiff) of the left hand and muscle weakness. A review of an annual and quarterly Minimum Data Set (MDS, an assessment tool), dated 12/8/21 and 3/9/22 respectively, indicated Resident 15 had no functional impairment to the range of motion of the upper extremities. A review of a MDS, dated [DATE], indicated Resident 15 had moderate memory problems. A review of a care plan, dated 3/18/22, indicated Resident 15 had a left hand contracture. A review of 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.

Based on interview, and record review, the facility failed to ensure the physician was aware of a resident's wound for one resident (Resident 5) out of 14 sampled residents when, Resident 5 was admitted with purple discoloration on the sacrum and the physician was not notified. This failure had the potential to delay the physician's assessment and intervention. Findings: A review of an admission record indicated Resident 5 was admitted to the facility in mid-2022 with diagnoses including chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing). A MDS (Minimum Data Set, an assessment tool), dated 2/23/22, indicated Resident 5 had moderate memory problems. A review of facility document titled, Admission- Nursing Assessment, dated 5/11/22, indicated, .purple discoloration on sacrum [the bottom of the spine] measuring 8 cm [centimeters, a unit of measurement] in length, 6 cm in width. During an interview on 5/16/22 at 9:20 a.m., Resident 5 stated staff told her she had a wound on her sacrum. A review of an order…

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, interview and record review, the facility failed to develop a person-centered care plan for one resident (Resident 5) out of 14 sampled residents. This decreased the facility's potential to provide prompt and proper wound care to Resident 5. Findings: A review of an admission record indicated Resident 5 was admitted to the facility in mid-2022 with diagnoses including chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of a Minimum Data Set (MDS, an assessment tool), dated 2/23/22, indicated Resident 5 had moderate memory problems. A review of a facility document titled, Admission- Nursing Assessment, dated 5/11/22 indicated, .purple discoloration on sacrum [the bottom of the spine] measuring 8 cm [centimeters, a unit of measure] in length, 6 cm in width. A review of an order summary report indicated, Purplish discoloration to sacrum: cleanse with normal saline, pat dry and apply [skin protectant] to prevent skin breakdown every shift. During an interview on 5/16/22 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 observation, interview, and record review, the facility failed to ensure a call light was within reach and a proper sized wheelchair was provided for one resident (Resident 16) of 14 sampled resident when Resident 16 stated she could not reach the call light because her feet were not able to touch the floor completely. This failure decreased the facility's potential to support Resident 16's independence to move freely within the facility and to call for assistance when needed. Findings: Resident 16 was admitted to the facility late 2021 with multiple diagnoses which included diabetes, heart disease, respiratory disease, and muscle weakness. A review of a Minimum Data Sheet (MDS, a comprehensive assessment tool), dated 3/14/22, indicated Resident 16 had no memory problems and used a wheelchair for mobility. During a concurrent observation and interview on 5/16/22 at 9:57 a.m., Resident 16 was in her wheelchair; her feet were unable to reach the floor completely, and her call light button was on her bed. Resident 16 tried to move her wheelchair, but was unable to easily turn…

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, interview, and record review, the facility failed to follow the pureed recipe for two residents (Resident 7 and Resident 26) out of 14 sampled residents when staff: 1. Did not follow the recipe for pureed BBQ chicken, pureed carrots, and pureed bread rolls; and 2. Did not hold food at the right temperature to maintain it's nutrient value. These failures placed Resident 7 and Resident 26 at risk for malnutrition and weight loss. Findings: 1. In an observation on 5/17/22 at 11:39 a.m., the [NAME] 2 placed an unmeasured amount of chicken broth from a bag and placed five pieces of chicken in the food processor to make pureed BBQ chicken for lunch. In a subsequent interview, the [NAME] 2 acknowledged she did not follow any recipe. The [NAME] 2 stated that was how she always did it. In an observation on 5/17/22 at 11:49 p.m., the [NAME] 2 placed 3/4 quarter of a cup water and three scoops (which measured 4 ounces per scoop) of cooked carrots in the food processor to make pureed carrots. In a subsequent interview, the [NAME] 2 acknowledged she did not follow any…

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, interview, and record review, the facility failed to maintain a complete and accurate medical record for two residents (Resident 15 and Resident 36) of 14 sampled residents when: 1. Resident 15's Minimum Data Sheet (MDS, a comprehensive assessment tool) was inaccurate; and, 2. Resident 36's medical record was incomplete. These failures decreased the facility's potential to maintain complete and accurate medical records and decreased the potential for Resident 15's and Resident 36's accurate clinical and functional representation. Findings: 1. A review of an admission record indicated Resident 15 was re-admitted to the facility early 2021 with multiple diagnoses which included contracture (a permanent tightening of the muscles, tendons, skin, and tissues which causes joints to shorten and become very stiff) of the left hand and muscle weakness. A review of an annual and quarterly MDS, dated [DATE] and 3/9/22 respectively, indicated Resident 15 had no functional impairment to the range 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.