Aspen Hill Rehabiliation & Healthcare Center

Based on record review and interview, the facility failed to implement their abuse policy by failing to investigate an allegation of abuse from one Resident (#95), which led to the abuse of another resident by the same certified nursing aide, out of a total sample of 28 residents. Specifically, Resident #95 alleged a certified nursing aide handled him/her roughly and refused to put the correct sized brief on Resident #95, which was filed as a grievance by the facility, ultimately leading to the same certified nursing aide physically abuse Resident #1. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised September 2022, indicates the following: -All reports of resident abuse (including injuries of uknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. -All allegations…

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, the facility failed to report an allegation of potential abuse for one Resident (#95) out of a total sample of 28 residents. Specifically, Resident #95 reported rough handling of a certified nursing aide to another staff member and the incident was not reported and filed as a grievance. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised September 2022, indicates the following: - All reports of resident abuse (including injuries of uknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. - If resident abuse, neglect, exploitation, misappropriation of resident property or injury of uknown source is suspected, the suspicion must be immediately reported to 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, record review, and interview, the facility failed to ensure that an individualized, comprehensive care plan was implemented for one Resident (#106), out of a total sample of 28 residents. Specifically for Resident #106, the facility failed to implement fall mats. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Center, dated as revised March 2022, indicated: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. Resident #106 was admitted 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 and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for one Resident (#111), out of a total sample of 28 residents. Specifically, the facility failed to follow physician orders to obtain daily weights for a resident with a diagnosis of congestive heart failure (condition when the heart muscle doesn't pump blood as well as it should causing a potential for fluid buildup/ weight gain), nursing did not obtain daily weights for 3 consecutive days and then Resident #111 was found to have a 5.2-pound weight gain. Findings Include: Review of the facility policy titled Heart Failure - Clinical Protocol, dated as revised November 2018, indicated: 1. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights) to monitor, when to report findings to the physician, etc. Resident #111 was admitted to the facility in December 2024 with diagnoses including pneumonia, chronic diastolic heart failure (CHF),…

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 observations, interviews and record review, the facility failed to provide care, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one Resident (#473) out of a total sample of 28 residents. Specifically for Resident #473, the facility failed to obtain a physician's order with appropriate settings for an air mattress that was in use. Findings include: Resident #473 was admitted to the facility in December 2024 with diagnoses that include heart failure and hypotension Review of Resident #473's most recent Minimum Data Set (MDS) Assessment, dated 1/2/25, indicated a Brief Interview for Mental Status exam score of 12 out of 15, indicating moderate cognitive impairment. On 1/14/25 at 7:57 A.M. and 1:36 P.M., the surveyor observed Resident #473 in bed on an air mattress. The air mattress was set at 175 pounds (lbs.). On 1/15/25 at 7:34 A.M., 8:08 A.M., and 9:31 A.M., the surveyor observed Resident #473 laying in bed on an air mattress. The air mattress was set at 175 lbs. Review of Resident #473's…

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 provide care and maintenance of a Peripherally Inserted Central Catheter (PICC: a flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV] ), consistent with professional standards of practice for one Resident (#106), out of a total sample of 28 residents. Specifically, for Resident #106, the facility failed to change the PICC line dressing as ordered by the physician and the facility failed to obtain weekly measurements for the external length of Resident #106's PICC line to ensure the PICC line had not migrated (moved from the heart to another area, which could have a significant impact on treatment, or cause serious harm). Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Edition, dated 2021, included the following for documentation related to PICC line migration and dressing changes: Use a sterile measuring tape or incremental markings on the catheter to measure the external length 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 observations and interviews, the facility failed to provide respiratory care service in accordance with professional standards of practice for one Resident (#88) out of a total sample of 28 residents. Specifically, the facility failed to maintain Resident #88 on the Oxygen (O2) level ordered by the physician, failed to change the O2 tubing as ordered by the physician, and failed to implement foam ear protectors on the nasal cannula. Findings include: The facility policy titled Oxygen Administration, dated as revised October 2010, indicated the following: -Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). -Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Resident #88 was admitted to the facility in September 2024 and has diagnoses that include Acute Respiratory Failure with Hypoxia and shortness of breath. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/7/24, indicated that on the Brief Interview for Mental Status exam…

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 the facility failed to ensure a care plan was developed for Trauma Informed Care, or Post Traumatic Stress Disorder (PTSD) with resident specific triggers and interventions, for two Residents (#7 and #85) out of a total sample of 28 residents. Findings include: By the end of the survey the facility failed to produce a policy for trauma informed care or PTSD. 1. Resident #7 was admitted to the facility in May 2023 with diagnoses including PTSD, depression and anxiety. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/5/24, indicated Resident #7 scored a 15 out of 15, indicating intact cognition. Review of the active diagnoses list indicated Resident #7 has a diagnosis of PTSD. Review of the facility document titled Social Services Assessment - V 4, dated 5/12/23, indicated that Resident #7 did not experience a past trauma. Review of the current active care plan indicated a focus for PTSD related to family discord/abuse. Further review indicated the following interventions: -Accept my current level of function. Be consistent,…

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, record review and interview for one Resident (#71) out of a total sample of 28, the facility failed to provide dental care. Findings include: Review of the facility policy titled Availability of Services, Dental, dated as revised August 2007 indicated that dental services are available to all residents requiring routine and emergency dental care. Resident #71 was admitted to the facility in May 2024 with diagnoses including Parkinson's Disease, malnutrition and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/31/24, indicated Resident #71 scored a 15 out of a possible 15 on the Brief Interview for Mental Status exam indicating intact cognition. The MDS further indicated Resident #71 did not have any obvious broken/carious teeth. During an interview on 1/15/25, at 2:05 P.M., Resident #71 said that he/she has not seen the dentist while a resident at the facility but that if it would help him/her to chew he/she would want to see the dentist. Resident #71 also said that he/she had not been asked if he/she wanted to see a dentist.…

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, record review and interview, the facility failed to have one Resident (#93), out of a total sample of 28 residents seen by the oral surgeon after the consulting dentist made the recommendation for tooth extractions and new dentures in May 2024. Findings include: Review of the facility policy titled Medication and Treatment Orders, Dental Services, dated February 2014, indicated the following: -Orders for the treatment of the resident's dental problems must be signed by the attending dentist. -All orders for the treatment of the resident's dental problems must be in writing and signed and dated by the dentist providing the service. -Medication orders and treatment will be administered by nursing service personnel as soon as the order has been received. -The residents attending physician must be informed of the treatment and medications ordered by the dentist. - Any conflict in treatment or medication must be brought to the attention of the dentist, attending physician, and director 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 record review and interview, the facility failed to develop a Quality Assurance Performance Improvement (QAPI) after two allegations of abuse for one certified nursing aide. Specifically, two Residents alleged abuse against the same certified nursing aide, and the facility failed to develop and implement a QAPI plan to prevent quality of care issues and ensure safety of residents. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, undated, indicated the following: -The objectives of the QAPI program are to 1. provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 4. establish systems through which to monitor and evaluate corrective actions. -The Administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements. -The QAPI committee reports directly…

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 observations, interviews and record review for two Residents (Resident #111 and #2i) out of a total sample of 30 residents, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, 1a. For Resident #111, the facility failed to implement contact precautions, for a Resident who was diagnosed with Clostridium difficile (C. difficile- an inflammation of the colon). 1b. For Resident #2i, the facility failed to implement contact precautions, for a Resident who was diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA- a bacteria that is resistant to several antibiotics). Findings include: Review of the facility policy titled Isolation-Categories of Transmission-Based Precautions, dated September 2022 indicated the following: - Transmission based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; 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 record review and interviews, the facility failed to offer the COVID 19 (Coronavirus disease) vaccine to two out of a sample of six employees. Specifically, the facility failed to offer COVID 19 vaccinations during new hire orientation. Findings include: A review of the facility policy titled, Employee Infection and Vaccination Status, dated as revised January 2024, indicated the following: -Prior to or upon an employee's duty assignment, the facility will assess the status of an employee's vaccination against infectious conditions. Vaccinations are documented in the employee health record. -Employees will be current with mandated vaccinations prior to performing direct resident care. -Employees are offered or provided with vaccinations per state or local agency policies/regulations. -Employees are provided with education materials to make informed decisions for non-mandated vaccinations. If declined, a declination form is completed and placed in the employee's health record. A review of 6 employee health records indicated 2 out of the 6 employees had not been vaccinated…

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 interview, the 1) facility failed to maintain a homelike environment on two of three resident units and 2) failed to ensure the appropriate water temperatures were maintained in three of three resident units. Findings include: Review of the facility policy titled Homelike Environment, revised and dated February 2021 indicated the following: *The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment. 1a) The following was observed on the B Unit on 1/25/24 at 9:15 A.M.: *In room [ROOM NUMBER] there was a gouge on the bathroom door resulting in scraped paint. * In room [ROOM NUMBER] a wooden panel above the heater which is below the window was falling off of the wall, there was missing paint on the wall next to the hand sanitizer pump by the room door and plaster was exposed. *In room [ROOM NUMBER] floor molding was 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 observations, record review, policy review and interviews, the facility 1) failed to provide incontinence care for three Residents (#49, #51 and #24), 2) failed to obtain physician's orders for the use and care of an indwelling urinary catheter for one Resident (#316) and 3) failed to ensure adequate infection control practices were implemented and the use of a privacy bag was used for one Resident (#75) with an indwelling urinary catheter out of a total sample of 34 residents. Findings include: 1a. Review of the facility policy titled, Urinary Continence and Incontinence - Assessment and Management, dated August 2022, indicated the following: *The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. *Management of incontinence will follow relevant clinical guidelines. *As indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. Resident #49 was admitted to 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 3.) For Resident #317 who required a bipap (bilevel positive airway pressure, ventilation machine used to help someone get oxygen at night), the facility failed to obtain physician's orders. Resident #317 was admitted to the facility in January 2024 with diagnoses including interstitial pulmonary disease, pulmonary fibrosis, centrilobular emphysema. Review of the Minimum Data Set (MDS) assessment, dated 1/20/24, indicated Resident #317 had a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. Review of the health status note, dated 1/22/24, indicated: -the patient admitted from hospital with history of severe chronic obstructive pulmonary disease (COPD) emphysema with hypoxia, pulmonary hypertension, pleural effusion. He/she is oxygen dependent. He/she uses the BiPAP. Review of the physician's orders, dated 1/24/24, failed to include orders for the bipap. Review of the active plan of care, dated 1/25/24, failed to include the use of bipap. On…

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 staffing level reviews and interviews, the facility failed to ensure that sufficient staffing levels were maintained to safely and adequately meet each resident's personal and cognitive care needs. Findings include: During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for Fiscal Year (FY) Quarter 4 2023 (July 1- September 30th) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. Review of the facility assessment indicated the following: *The average daily census of the facility is 106.6. *The daily number of Nurses and Certified Nursing Aids (CNAs) required to care for the residents is 30. *The daily number of Nurses required to care for the residents is 27. The Administrator provided the surveyor with the expected daily PPD (Per Patient Day) of the facility which was 3.19. Review of the daily schedules from July to September 2023 indicated that all weekend shifts during this time frame were below the facility's expected staffing levels, with no 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 observations, records reviewed, policy review and interviews, the facility failed to ensure it was free of a medication error rate of five percent or greater when 2 of 4 nurses, on 2 of 3 nursing units made 4 errors in 29 opportunities, totaling a medication error rate of 13.79%. These errors impacted 2 Residents (Resident #32 and #366) out of 6 residents observed. Findings include: Review of the facility policy titled, Administering Medications, not dated, indicated: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time, unless otherwise specified. 1a. For Resident #32, Nurse #5 did not administer Folic Acid 1 milligram (mg) as ordered. During an interview and observation on 1/24/24 at 8:54 A.M., Nurse #5 said he was unable to find Folic Acid 1 mg in the medication cart or in medication storage room so he is unable to administer the medication. The surveyor did not observe Nurse #5…

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 observations, policy review, and interviews the facility failed to 1.) ensure medication carts were locked when unattended on three out of three nursing units and 2.) medications carts were kept clean and orderly in two of four medication carts observed. Findings include: Review of the facility policy titled Medication Labeling and Storage, revised 2/23, indicated The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, sanitary manner. 1. On 1/23/24 at 6:58 A.M., the surveyor observed the high side medication cart in the hallway of the A unit unlocked and unattended. During an interview on 1/23/24 at 6:59 A.M., Nurse #6 said she should have locked her medication cart prior to walking away from it but did not. On 1/23/24 from 7:40 A.M. to 7:56 A.M., the surveyor observed the low side medication cart in the hallway of the C unit unlocked and unattended. On 1/23/24 at 9:58 A.M., the surveyor observed the low side medication cart in the hallway of the B unit unlocked and unattended. During an interview on 1/23/24 at 10:00…

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 4. For Resident #94 the facility failed to maintain an accurately documented medical record to reflect the refusal or non-use of Bi-level positive airway pressure (BiPAP), a non-invasive ventilation machine. Resident #94 was admitted to the facility in August of 2023 with diagnoses that include but are not limited to obstructive sleep apnea, chronic pulmonary disease, chronic respiratory failure, emphysema, shortness of breath, anxiety, and depression. Review of Resident #94's most recent Minimum Data Set (MDS), dated [DATE], indicated that the resident had a Brief Interview for Status Mental (BIMS) score of 10 out of a possible 15 indicating that he/she has moderate cognitive impairment. Further review of the MDS indicated that Resident #94 utilized non-invasive mechanical ventilation both on admission and while a resident at the facility. The following observations were made by the surveyor: *On 01/23/24 at 03:24 P.M., A BiPAP machine was on the windowsill, no mask or tubing attached, nor was there a power…

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 observations, interviews and policy review, the facility failed to ensure resident Protected Health Information (PHI) was secure on 1 of 3 units. Specifically, nurses on the C Unit failed to ensure PHI on the medication administration computers was not visible and accessible on the nursing unit. Findings include: Review of the facility policy titled, Confidentiality of Information and Personal Privacy, revised 10/17, indicated Our facility will protect and safeguard resident and personal privacy. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Access to resident personal and medical records will be limited to authorized staff and business associates. On 1/23/24 at 8:48 A.M., the surveyor observed the high side medication cart on the C Unit with the medication administration laptop screen open to resident information including the resident's picture, date of birth , and the resident medications. No nurse was present at the medication cart. On 1/23/24 from 10:57 A.M. to 11:25 A.M., the surveyor observed 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 record reviews and interviews the facility failed to send a copy of a facility initiated 30-day Notice of Intent to Discharge/Transfer to the Office of the State Long-Term Care Ombudsman. Specifically, for one resident (#67) out of a total sample of 34 residents, the Office of the State Long- Term Care Ombudsman was not notified when a facility initiated 30-day Notice of Intent to Discharge/Transfer was issued. Resident #67 was admitted in August of 2023 with diagnoses including, but not limited to, Chronic systolic (congestive) heart failure, muscle wasting and atrophy, morbid obesity, pain, Type 2 Diabetes, and major depressive disorder. Review of the most recent Minimum Data Set (MDS), dated [DATE], indicated Resident #67 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he/she is cognitively intact. Record review indicated the 30-Day Notice of Intent to Discharge/ Transfer was issued to Resident #67 on 1/16/24. Record review failed to indicate that the State Long- Term…

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 observations, interviews and record reviews, the facility failed to implement the plan of care for two Residents (#57 and #99) out of a total sample of 34 residents. Specifically: 1. For Resident #57, the facility failed to provide padded side rails. 2. For Resident #99, the facility failed to implement individualized fall care plan interventions. Findings include: 1. Resident #57 was admitted to the facility in 2/18 with diagnoses including dementia, major depressive disorder, adult failure to thrive and dysphagia. Review of Resident #57's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairments. The MDS further indicated that the Resident required assistance of a staff member for dressing and bathing. On 1/23/24 at 8:27 A.M. and 11:01 A.M., the surveyor observed Resident #57 in bed without pads on his/her side rails. On 1/24/24 at 7:51 A.M. and 10:13 A.M., the surveyor observed Resident #57 in bed without pads on his/her side rails.…

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 observations, record review and interview, the facility failed to provide care in accordance with professional standards of practice for one Resident (#76) out of a total sample of 34 Residents. Specifically, for Resident #76, the facility failed to implement the physician's orders for no paper products on meal trays. Findings include: Resident #76 was admitted to the facility in September 2020 with diagnoses that included Alzheimer's disease, dysphagia, and anxiety. Review of Resident #76's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairments. On 1/23/24 from 8:00 A.M. to 8:05 A.M., the surveyor observed Resident #76 eating their breakfast. The tray was observed to have a paper napkin and the Resident paper meal ticket. On 1/23/24 at 11:57 A.M., the surveyor observed Resident #76 eating their lunch tray, the tray was observed to have a paper napkin and a paper pepper packet. On 1/24/24 from 7:55 A.M. to 8:03 A.M., the surveyor…

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, record review and interview, the facility failed to provide assistance with meals as needed for two Residents (#57, #36) out of a total of 34 sampled residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), revised 3/18, indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: D. dining (meals and snacks) 1. Resident #57 was admitted to the facility in February 2018 with diagnoses including dementia, major depressive disorder, adult failure to thrive and dysphagia. Review of Resident #57's most recent Minimum Data Set (MDS) dated [DATE], indicated he/she was assessed by staff to have…

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 observations, record review and interviews the facility failed to ensure nursing provided treatment and services consistent with professional standards of practice to promote healing of a pressure ulcer for a one Resident (#316) out of a total sample of 34 Residents. Specifically for Resident #316, who was assessed by nursing to be at risk for skin breakdown and whose hospital paperwork indicated he/she had a stage two pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough), the facility failed to implement interventions to prevent a decline in the pressure ulcer. When on 1/13/24 during the evening shift, nursing observed a dressing on Resident #316's tail bone dated 1/9/24. On 1/15/24, Resident #316 was evaluated by the wound physician, the wound was documented as an unstageable (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed) deep tissue injury (purple or maroon localized area of discolored, intact skin or blood-filled…

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 observations, record review, policy review and interviews, the facility failed to address a significant weight loss for 1 Resident (#97) out of a total sample of 34 residents. Finding include: Review of the facility policy titled, Weight Assessment and Intervention, undated, indicated the following: *Residents are weighed upon admission and at intervals established by the interdisciplinary team. *Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. * The threshold for significant unplanned and undesired weight loss will be based on the following criteria a. One month - 5% weight loss is significant; greater than 5% is severe. b. Three months - 7.5% weight loss is significant; greater than 7.5% is severe. c. Six months - 10% weight loss is significant; greater than 10% is severe. Resident #97 was admitted to the facility in October 2023 with diagnoses including…

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, policy review, and record review, the facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC), consistent with professional standards of practice for one Resident (#318), out of a total sample of 34 residents. Specifically, for Resident #318 the facility failed to obtain PICC line measurements upon admission and weekly as ordered. Findings include: Review of the facility policy titled, Central Venous Catheter Care and Dressing Changes, dated as revised March 2022, indicated: 6. Measure the length of the external central venous access device with each dressing change. Compare with the length documented at insertion. 8. For PICCs, measure arm circumference and compare with baseline when clinically indicated to assess for edema and possible deep-vein thrombosis. Resident #318 was admitted to the facility in January 2024 with diagnoses including spinal osteomyelitis. Review of the Minimum Data Set (MDS) assessment, dated 1/17/24, indicated Resident #318 had a Brief Interview of Mental Status (BIMS) score of 15 out 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed, policy review and interviews, the facility failed to act upon recommendations made by the Consultant Pharmacist during monthly Medication Regimen Reviews (MRR) for three Residents (#99, #318, #67), out of a total sample of 34 residents. Specifically, the facility staff failed to ensure: 1.) For Resident #99, that the Consultant Pharmacist recommendations were reviewed by facility staff. 2.) For Resident #318, that the Consultant Pharmacist recommendations were reviewed by facility staff. 3.) For Resident #67, that the Consultant Pharmacist recommendations were reviewed by facility staff. Findings include: Review of the facility policy titled, consultant pharmacist reports, dated November 2021, indicated the consultant pharmacist performs a comprehensive review of each resident's medication regime and clinical record at least monthly. G. Recommendations are acted upon and documented by facility staff and/or the prescriber. 1) Prescriber accepts and acts upon suggestion or rejects 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 record review and interview, the facility failed to ensure that one Resident's (#316) medication regimen was free from unnecessary drugs out of a total sample of 34 Residents. Specifically, for Resident #316 the facility failed ensure he/she was free from an excessive dose (duplicate drug therapy) of medication when Resident #316 had two orders for latanoprost ophthalmic solution (medication used to treat certain types of glaucoma and other causes of high pressure inside the eye). Findings include: Resident #316 was admitted to the facility in January 2024 with diagnoses including urinary retention and irritable bowel syndrome. Review of the Minimum Data Set (MDS) assessment, dated 1/18/24, indicated Resident #316 had a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. Review of the physician's orders: - 1/12/24 Latanoprost Ophthalmic Solution 0.005 % (Latanoprost), instill 1 drop in both eyes at bedtime related to hypertension. - 1/17/24 Xalatan Ophthalmic Solution 0.005 % (Latanoprost), instill 1 drop…

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 observations, record review, policy review and interviews, the facility failed to provide a diet that met one Resident's (#111) preferences for both likes and dislikes and texture of diet out of a total sample of 34 residents. Findings include: Review of the facility policy titled, Therapeutic Diets, undated, indicated the following: *Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet. *The dietitian, nursing staff, and attending physician will regularly review the need for, and resident and acceptance of, prescribed therapeutic diets. *If the resident or the resident's representative declines the recommended therapeutic diet, the interdisciplinary team will collaborate with the resident or representative to identify possible alternatives. Resident #111 was admitted to the facility in January 2024 with diagnoses including dementia. Review of Resident…

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, the facility failed to ensure that trash, garbage, and refuse were disposed of properly in the dumpster. Findings include: Review of the 2022 Food Code (a model for safeguarding public health and ensuring food is unadulterated and honestly presented when offered to the consumer) by the U.S. Food and Drug Administration (FDA) indicated outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. Review of the facility's policy, entitled Food-Related Garbage and Refuse Disposal, not dated, indicted the following: Food-related garbage and refuse are disposed of in accordance with current state laws. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During the survey the following…

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, record review and interview the facility failed to ensure infection control practices were implemented to prevent the spread of infection, including Covid-19 on one unit out of three resident units. Specifically, staff failed to put on all required Personal Protection Equipment (PPE) and failed to perform hand hygiene when donning PPE prior to entering a resident room, identified by a sign as requiring isolation precautions. Findings include: Review of the sign posted on a resident's room indicated the following: Clean hands: when entering and exiting Gown-change between each resident. N95 respirator (facemask acceptable if N95 not available. Eye protection (goggles or face shield. Gloves-change between each resident. During the survey the following observations were made: On 1/23/24 at 7:53 A.M. Unit Manager #1 donned a gown, mask and gloves and entered a resident's room, identified by a posted sign as being on isolation precautions requiring PPE, including eye protection. Unit Manager #1 was not wearing eye protection. On 1/24/24 at 11:19 A.M. housekeeping…

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, policy review and interviews the facility failed to implement their antibiotic stewardship program for antibiotic use for one Resident #99 out of a total sample of 34 Residents. Specifically for Resident #99 the facility failed to implement a duration of treatment for cephalexin (an antibiotic). Findings include: Review of the facility policy titled, Antibiotic Stewardship, dated as revised December 2016, indicated antibiotics will be prescribed and administered to residents under the guidance of the facilities antibiotic stewardship program. 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: d. Duration of treatment: (1) Start and stop date; or (2) Number of days of therapy. f. Indications for use. 5. When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for antibiotic/ anti-infective orders. Resident #99…

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 records reviewed and interviews, for two of four sampled residents, (Resident #1 and Resident #3) the Facility failed to ensure they were treated in a dignified and respectful manner, when on 08/25/23 during the 11:00 P.M. to 7:00 A.M. shift, 1) Certified Nurse Aide (CNA) #1 yelled at Resident #1 due to the frequency of his/her need for assistance to use the commode, and 2) CNA #1 degraded Resident #3 after he/she had a bowel movement in an incontinent brief. Both of the interactions with CNA #1 and Resident #1 and Resident #3, were witnessed by their roommates. Findings include: Review of the Facility's Resident Rights Policy, not dated, indicated federal and state laws guarantee certain basic rights to all residents of this facility. The Policy indicated these rights include the resident's right to a dignified existence, and to be treated with respect, kindness, and dignity. 1) Resident #1's admission Minimum Data Set (MDS) assessment, dated 09/05/23, indicated during a Brief Interview for Mental Status conducted he/she had intact cognitive functioning. During an…

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.