Adelphi Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Upon record review and facility staff interviews it was determined that the facility failed to code resident medication accurately on the Minimum Data Set (MDS) assessment. This was true for 1(Resident #61) of 32 residents reviewed during the annual survey. The findings include: Surveyors conducted a review of Resident #61's medical record on 1/30/25 at 10:43 AM. Review of the quarterly MDS dated [DATE] revealed that the resident received 1 injection of an insulin for 1 day. Further record review revealed the Medication Administration Record (MAR) for the month of November 2024 showed that Trulicity was administered on 11/25/24 at 12:00 PM by injection. On 1/30/2025 at 12:30 PM surveyors held an interview with the MDS Coordinator, Staff # 6. Staff #6 reviewed the MDS data and the November MAR with surveyors and determined that Trulicity was coded as an insulin in error. It should have been coded as a hypoglycemic.

Based on record review and interviews it was determined that the facility failed to develop a comprehensive person-centered care plan. This was found evident of 2 (Resident #5 & #160) of 5 residents reviewed for care planning. The findings include: 1a) On 2/4/25 at 10:23 AM, the surveyor reviewed Resident #5's medical record. The review revealed that Resident #5 was readmitted to the facility in November of 2024. Further review of the hospital transfer records revealed that Resident #5 had a past surgical history that consisted of an ileostomy (a surgical procedure in which the ileum (small intestine) is diverted to an artificial opening in the abdominal wall). It also revealed that Resident #5 reported no longer producing any urine and was on hemodialysis (a treatment to filter wastes and water from your blood). Next the surveyor reviewed Resident #5's care plan. A care plan was created on 10/30/24 that stated Resident #5 is incontinent of bladder and/or bowels related to medication use and impaired mobility. On 2/5/25 at 7:01 AM, the surveyor conducted an interview with 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 review, and interview it was determined that the facility failed to invite a resident to participate in their care plan meeting and conduct care plan meetings after each resident's Minimum Data Set (MDS) assessment. This was found evident in 2 (Resident #134 & #90) out of 5 residents reviewed for care planning. The findings include: 1) On 1/30/25 at 10:42 AM, the surveyor interviewed Resident #134. During the interview Resident #134 stated he/she had never been to a care plan meeting. On 1/31/25 at 12:48 PM, the surveyor reviewed Resident #134's medical record. The review revealed that Resident #134 was admitted to the facility in late December of 2024 and had a Minimum Data Set (MDS) assessment dated [DATE]. In section C Cognitive Patterns the resident scored a 15 on his/her Brief Interview for Mental Status (BIMS), which indicated that Resident #134 was cognitively intact. On further review the surveyor noted two care plan meeting logs. One dated 1/2/25 and another dated 1/9/25. Neither care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent residents. This was found evident in 1 (Resident #134) out of 2 residents reviewed for Activity of Daily Living (ADL) cares. The findings include: On 1/30/25 at 10:44 AM, the surveyor interviewed Resident #134. During the interview Resident 134 stated that he/she only received bed baths and was not offered the chance to take a shower. On 1/31/25 at 12:48 PM, the surveyor reviewed Resident #134's medical record. The review revealed that Resident #134 was admitted to the facility in late December of 2024 and had a Minimum Data Set (MDS) assessment dated [DATE]. In section C Cognitive Patterns Resident scored a 15 on his/her Brief Interview for Mental Status (BIMS) which indicated that Resident #134 was cognitively intact. On further review it was noted that Resident #134 had an order, written on 1/24/24, that stated, validate shower schedule twice a week 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 interviews, and record review, and facility policy, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 2 (Resident #108 & #5) out of 4 residents reviewed for respiratory care during the survey. The findings include: Pulse oximeter - a device that uses a light source to analyze the light that passes through a finger and can determine the percentage of oxygen saturation in the red blood cells, referred to as a pulse ox. Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels. 1a) On 1/30/25 at 10:38 AM, the surveyor observed Resident #108 being pushed in a recliner chair by Geriatric Nursing Assistant (GNA) #22 through the Terrace level hallway. Resident #22 had a nasal cannula (NC) in his/her nose but the NC was not hooked up to any supplemental oxygen. The surveyor observed Unit Manager (UM) #24 assist GNA #22 push Resident #108 to the elevator. On 1/30/25 at 10:47 AM, the surveyor observed GNA #22 return…

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

Based on record review and interviews, it was determined that facility staff failed to appropriately document pro re nata (PRN) narcotic medication in the facility's medication administration record (MAR). This was found to be evident in 3 (Residents #4, #11, #53) of 3 residents reviewed for PRN medication administration during the recertification survey. The findings include: PRN medication stands for pro re nata, which is a Latin term meaning as needed or as the situation arises. It refers to medication that is taken only when necessary, rather than on a regular schedule. A MAR is a document used in healthcare settings to track and record the medications given to patients, including details like dosage, time, and the person administering the medication. It is important because it ensures accurate medication administration, helps prevent errors, and provides a legal record of treatment. It also supports continuity of care by informing healthcare providers of a patient's medication history. A Controlled Substance Log Book is a record used in healthcare settings to track the use,…

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 interviews and record review it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices. This was found evident in 2 records of (Resident #5 & #165) out of 70 residents reviewed during the survey. The findings include: 1a) On 2/4/25 at 10:23 AM, the surveyor reviewed Resident #5's medical record. The review revealed that Resident #5 was readmitted to the facility in November of 2024. Further review of the hospital transfer records revealed that Resident #5 had a past surgical history that consisted of an ileostomy (a surgical procedure in which the ileum (small intestine) is diverted to an artificial opening in the abdominal wall). It also, revealed that Resident #5 reported no longer producing any urine and was on hemodialysis (a treatment to filter wastes and water from your blood). Next the surveyor reviewed Resident #5's care plan. A care plan was created on 10/30/24 that stated Resident #5 was incontinent of bladder…

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, it was determined that the facility staff failed to maintain an infection prevention/control program i.e. standard of care of an enteral feeding tube. This was evident for 1 (Resident #17) out of 2 residents reviewed for feeding tubes during the annual survey. The findings include: Observation, on 1/30/25 at 7:59 AM, found that Resident # 17's tube feeding water flash bag was dated 1/29/25 still hanging on a pole. 2 Jevity unopened bottles were sitting on a draw table unlabeled. Record review, on 2/03/25 at 11:54 AM, indicated that tube feed order was through a tube feed pump for Jevity 1.5 via the Percutaneous Endoscopic Gastrostomy (PEG) tube five times a day and cleanse PEG tube site with soap and water, cover with split gauze dry dressing and dated every day shift. A Percutaneous Endoscopic Gastrostomy (PEG) tube is inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient. Giving food through 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 observations and interviews it was determined that the facility failed to maintain all patient care equipment in safe operating condition. This was found evident on 2 random observations on the Terrace level. The findings include: On 1/30/25 at 10:38 AM, the surveyor observed Resident #108 being pushed in a recliner chair by Geriatric Nursing Assistant (GNA) #22 through the Terrace level hallway. The surveyor observed the chair was not steering straight and the reclining setting was not able to be maintained. It was noted that the head of the chair would lose the reclining position abruptly and the foot of the recliner would fall synchronously. The surveyor observed Unit Manager (UM) #24 assist GNA #22 to push Resident #108 to the elevator. UM #24 asked GNA #22 why she wasn't using the other chair and GNA #22 stated, they are all like this. On 2/6/25 at 11:03 AM, the surveyor again observed Resident #108 in a reclining chair being transported down the hallway. When the GNA stopped at the nursing station, the surveyor observed the head of the chair come up and the feet 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.

Based on observations and interviews it was determined that the facility failed to ensure that a resident's bed mattress properly fit the bed frame and that annual inspections were performed. This was found evident of 1 Resident (Resident #108) out of 160 beds. The findings include: On 2/5/25 at 1:30 PM, the surveyor observed that Resident #108's call light was on. Next the surveyor conducted an interview with Resident #108. During the interview Resident #108 stated he/she was calling to follow-up from his/her earlier call where he/she reported the bed was not working. The surveyor observed that the mattress on Resident #108's bed was hanging over the bed frame on both sides of the bed. It appeared that the mattress was too big for the bed frame. The sheets were noted to be pulling the corners of the mattress up and the mattress was not able to lay flat. On 2/5/25 at 1:31 AM, a Geriatric Nursing Assistant (GNA) came to the room and asked what Resident # 108 needed. After Resident #108 explained his/her request the GNA stated she would follow-up with Resident #108's nurse who was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews it was determined that the facility failed to keep a sanitary environment in the common hallway. This was found in one random observation on the East Wing. The findings include: On 2/5/25 at 6:42 AM, the surveyor observed three garbage bags full of garbage placed in the hallway of the East wing. No staff were present. On 2/5/25 at 6:45 AM, the surveyor observed Geriatric Nursing Assistant (GNA) #56 walk out of room [ROOM NUMBER] with a garbage bag in her hand. The surveyor asked GNA #56 why there were garbage bags left outside of resident rooms in the hallway. GNA #56 stated after she was done completing her rounds she had placed the garbage outside the door. At this time the surveyor observed two staff members come to the hallway and pick up the garbage and state they were taking the garbage to the dirty utility room. On 2/5/25 at 7:01 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON confirmed that garbage should not be left outside 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 record review and interviews it was determined that the facility failed to have an effective pest control program. This was found evident on 2 observations (Resident 121's room and the elevator) and during one of three observations during kitchen tours on the annual survey. The findings include: 1a) On 1/31/25 at 8:26 AM, the surveyor interviewed Resident #121 in his/her room on the Terrace level. During the interview Resident #121 stated he/she could not see very well but could feel things crawling on him/her at times. During the interview the surveyor observed a bug crawling on the floor and another bug crawling on the wall next to Resident #121's bed. Next the surveyor notified Unit Manager (UM) #24 of the observations. UM #24 stated she would address the issue. On 2/4/25 at 11:41 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the meeting the surveyor confirmed that the NHA was aware of the observation of bugs in Resident #121's room. She stated that a pest…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined facility staff failed to ensure a resident assessed to need a mobility device had access to the device. This was evident for 1 (Resident #69) of 5 residents reviewed for accidents during the survey. The findings include: On 1/30/25 at 9:44 AM, the surveyor observed Resident #69 resting in bed and noted a triangle shaped wedge sitting alongside Resident #69's right upper body. The wedge was not under the Resident. Resident #69 stated he/she used the wedge under his/her head sometimes. On 2/10/25 at 8:16 PM, the surveyor reviewed Resident #69's medical record. The review revealed that on 1/14/25 a care plan was initiated that stated Resident #69's daughter and guardian prefer to have side rails. No order was written, however Resident #69 was transferred out on 1/15/25 and readmitted on [DATE]. On further review a bed side rail tool was completed on 1/21/25 that documented Resident 69's family and Resident Representative (RP) consent to bed side rails 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, resident medical record reviews, interviews with staff, and a review of the facility's policies and procedures, it was determined that the facility failed to immediately permit 1 (Resident #165) of 3 residents investigated for discharge, to return to the facility after a therapeutic service and a visit to the emergency room. This resulted in the resident returning to the hospital's emergency department for an additional 8 days. The findings include: On 2/3/25 at 9 AM, the surveyor reviewed a complaint, MD00198820, that alleged the facility did not allow Resident #165 to return to the facility after an emergency room visit. The complaint also revealed that Resident #165 was taken to the hospital by ambulance on 9/27/23, then discharged from the hospital's emergency department on 9/28/2023 and attempted to return to the facility on 9/28/23 by transport ambulance. A review of Resident #165's record was reviewed on 2/4/25 at 11:30 AM. The record review revealed that the resident's MDS Discharge…

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 resident clinical record review and facility staff interview, it was determined that the facility failed to develop and implement a discharge plan focused on the discharge goals for Resident # 166. This was evident for 1 (Resident #166) of 3 residents investigated for discharge during the annual survey. The findings include: On 2/7/25 at 10 AM the surveyor reviewed a complaint, MD00198854 that alleged Resident #166 was held at the facility against their will. The complainant also alleged that facility staff were not working with them to plan their discharge goals. Review of Resident #166's medical record on 2/7/25 at 11:45 AM revealed that Resident #166 was admitted to the facility on [DATE] for rehabilitation following acute cellulitis of the genital area with additional diagnosis including dementia and bipolar disorder. Further review of the medical record revealed a care plan initiated on 8/24/23 that stated, the resident's discharge plans are uncertain at this time and are yet to be determined.…

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, observations, and interviews, it was determined that the facility failed to ensure a resident received dialysis treatment as ordered by the provider. This was found to be evident for 1 (#183) of 2 residents reviewed for dialysis care during the annual survey. The findings include: According to Centers for Medicare/Medicaid Services (CMS), dialysis is a treatment that removes waste from the body when the kidneys aren't working. During a review of complaint #MD00213507 on 2/11/25 at 7:30 AM, it was noted that Resident #183 had missed dialysis treatments during his/her stay at the facility. Review of the record revealed an order for Dialysis on Tuesday, Thursday, and Saturdays however, review of the record did not reveal treatment notes for 1/4/25. During an interview on 2/11/25 at 07:55 AM, the Dialysis Clinical Manager (DCM) informed the surveyors that Resident #183 missed her dialysis treatment on 1/4/25 and when she was notified on 1/5/25 around 07:00 PM, it was too late to do a dialysis treatment. Dialysis was closed on 1/6/25 due to weather. She further…

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 of facility staff, and documentation review, it was determined that food service employees failed to ensure that sanitary practices were followed such as keeping equipment in the kitchen maintained, keeping a sanitary environment, and reporting when dishwasher final rinse temperatures were out of range. This was evident during the initial and follow-up tours of the facility kitchen during a complaint survey. The findings include: 1) On 10/10/23 at 10:21 AM an environmental tour was taken of the kitchen. Observation was made of the dishwasher machine in the kitchen washing dishes following breakfast service. The temperature of the dishwasher was fluctuating between 177 and 178 degrees Fahrenheit during the final rinse cycle. The water temperature during the rinse cycle should be at a minimum 180 degrees Fahrenheit. There also was water spewing out of the dishwasher pipe on the side of the dishwasher where the water should have been going in the drain. The water was draining across the floor and under the ice machine. There also was water on the floor…

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 complaint # MD00189766, observation, and interviews, the facility failed to keep the facility in good repair. This was evident in all rooms and hallways in the facility. Findings include: Observation of the 2nd floor outside the conference room revealed all the pictures were taken down off the wall. The area was painted by an outside vendor according to the maintenance director staff # 16. There were holes in the dry wall and nails all over the walls. On the first floor room [ROOM NUMBER], Beds 1 and 2 room were very cluttered and would hinder egress in an emergency. room [ROOM NUMBER]; The bathroom revealed a leak above the toilet. The leak had been fixed and patched but due to rain over the weekend, the ceiling leaked again. On the left side of the floor by the doorway in the bathroom, molding was coming away from the wall. There was a black substance seen between the wall and molding and spackle on the wall, it had not been painted. There was a rough area that had not been painted above the paper…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#82, #79, #89, #76) of 96 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 10/11/23 at 1:57 PM Resident #82's medical record was reviewed and revealed a 5/18/23 wound care note that documented, patient is seen today for a Sacral pressure ulcer, Left great toe Diabetic foot ulcer. Review of Resident #82's MDS with an assessment reference date (ARD) of 5/19/23, Section M1040B, failed to capture the diabetic foot ulcer. On 10/17/23 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) Review of the medical record for Resident #21 on 10/19/23 revealed multiple comorbidities including hypertension, stroke with hemiplegia on his/her dominant side and seizures. Resident #21's hospital discharge record from 11/2020 included recommendations for a follow up with a cardiologist secondary to the finding of a cardiac aneurysm and follow up with a neurologist. Resident #21 was interviewed on 10/23/23 at 9:54 AM. Surveyor inquired about his/her discharge process and any follow up appointments that s/he was given or told to make. S/he stated that they were unaware of any. Surveyor reviewed the discharge summary completed on 3/2/21, under section M. scheduled appointments and tests it stated, follow up with your primary doctor in 2 weeks. A comprehensive review of Resident #21's medical record on 10/24/23 at 11:03 AM noted that Resident #21 on 1/8/21 saw the facility Nurse Practitioner (NP) for complaints of right sided numbness. The NP documented that this was not the first time she saw him/her for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, it was determined that the facility failed to ensure that resident's medications were administered as ordered. This was evident for 4 (# 63, #72, #70, #33) of 96 resident reviewed during a complaint survey. The findings include: Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication error and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles. Late documentation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and observation, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 8 (#69 #42, #55, #22, #46, #4, #17, #47) of 96 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 10/16/23 at 8:41 AM a review of complaint MD00187110 alleged that Resident #69 did not receive care on 12/25/22 and 12/26/22. On 10/16/23 at 8:41 AM a review of Resident #69's medical record revealed a December 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) that documented the medications and treatments Resident #69 received as evidenced by nurse'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations during an environmental tour and interviews, it was determined that the facility failed to maintain a safe, sanitary, comfortable, and functional environment for the residents, staff, and visitors. The findings include: On 10/12/23 at 10:30 AM, a tour and observation of the facility revealed that there was evidence of unattended maintenance needs: 1. room [ROOM NUMBER] has a hand washing sink with a large hole under the sink exposing the pipes. 2. The first-floor activities room door was missing the handle and was propped open by a trash can. 3. The shower door on the second floor was peeling at the bottom and had missing pieces of wood. The bottom of the door was discolored with brown and blackened areas. 4. The second-floor shower room [ROOM NUMBER] had a missing shower head and was used for storage of housekeeping supplies. 5. Other concerns included the storage of excess miscellaneous equipment inside the shower rooms in such a manner as to obstruct the entry of staff and residents. All…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews, it was determined the facility staff failed to include a resident's Power of Attorney representative in the care of a resident (Resident #50). This was evident for 1 of 19 residents reviewed during a complaint survey. The findings include: On 10/12/23 at 10:30 AM a review of complaint MD00175715 and electronic medical record revealed Resident #50 was admitted to the facility on [DATE] from the hospital with a diagnosis to include Amyotrophic lateral sclerosis (ALS). ALS is a fatal type of motor neuron disease. It is characterized by progressive degeneration of nerve cells in the spinal cord and brain. Further medical record review revealed a Durable Power of Attorney that becomes effective immediately granting Resident #50's Agent the ability to make decisions and act with respect to Resident #50's property, prepare applications, provide information, and perform any other act requested by any government or its agencies in connection with governmental benefits…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility failed to ensure call bells are within reach and failed to ensure a bariatric bed was available for a resident. This was evident for 2 (#12, #35) of 96 residents reviewed during a complaint survey. The findings include: 1) Review of Resident #12's medical record on 10/11/23 revealed the Resident was admitted to the facility from the hospital on 7/3/19 with a diagnosis to include legal blindness. During an interview with Resident #12's representative on 10/12/23 at 11:45 AM, he/she stated the Resident is blind and cannot always reach his/her call bell to alert staff when he/she needs assistance. The representative also stated often when he/she visits the call bell is under the Resident's bed. Observation of the Resident on 10/12/23 at 11:55 AM revealed the Resident was in bed and his/her call bell was on the floor under the bed and out of reach. The Surveyor asked the Resident if he/she knew where his/her call bell was and the Resident stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to notify a resident's representative (RP) in a timely manner of a resident's death (Resident #5). This was evident for 1 of 3 residents reviewed for notification of death during a complaint survey. The findings include: Review of Resident #5's medical record on [DATE] revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include heart failure. Further review of Resident #5's medical record revealed a nurse's note (Staff #28) on [DATE] at 2:32 AM that stated, on shift change this writer was making rounds with off duty nurse checking on all patients, when we got to the residents room he/she was laying quietly and unresponsive. Patient is a No CPR (cardiopulmonary resuscitation). Physician #1 times 3 could not be reached, call made to Medical Director could not be reached awaiting call back. Further review of Resident #5's medical record revealed Staff #7's (nurse supervisor) note on [DATE] at 3:07 AM…

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

Based on review of complaints and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) for Resident #89 and failed to report abuse for Resident #94. This was evident for 2 of 21 residents reviewed for abuse during a complaint survey. The findings include: 1) On 10/12/23 at 3:16 PM a review of complaint MD00197454 revealed the family member alleged that Resident #89 was being handled roughly by the CNA (certified nursing assistant) on duty. On 10/13/23 at 9:01 AM an interview was conducted with the Nursing Home Administrator (NHA) who stated she came to the facility that Sunday night around 8 PM and spoke to the daughter. The NHA stated the daughter did complain to her about Resident #89 being handled roughly by staff. The surveyor asked the NHA if that was reported to OHCQ and if she did an investigation. The NHA stated she did not do an investigation and it was not reported.2) On 10/11/23 at 12:42 PM a review of complaint MD00180154 was conducted. 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 review of facility administrative records, facility investigations, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse. This was evident for 1 (#85, #39, #94) of 21 residents reviewed for abuse during a complaint survey. The findings include: 1) On 10/11/23 at 8:43 AM a review of facility reported incident MD00194555 revealed on 7/14/23 Resident #85 was transferred to the hospital for a medical condition. The facility received a report from the hospital on 7/19/23 that Resident #85 alleged that he/she had been sexually assaulted while in the nursing facility. The facility reported incident documented that the facility was not aware of the alleged allegation and that they immediately did an investigation. Review of the facility's investigative packet that was given to the surveyor documented that the police were notified, 6 staff and 6 residents were interviewed, skin checks were done for non-interviewable residents, and 73 staff members were given abuse training. Review of the staff schedule for 72 hours prior 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 complaint review, medical record review, and interview, it was determined that the facility staff failed to create and implement care plans related to resident's specific needs. This was evident for 4 (#79, #55, #76, #61) of 96 residents reviewed during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 10/12/23 at 8:50 AM a review of complaint MD00192801 documented since February 2023 Resident #79 had requested to be discharged home from the facility to be with family and a therapist who…

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

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan and failed to evaluate and update a resident's care plan. This was evident for 4 (#83, #86, #65, #22) of 96 residents reviewed during a complaint survey. The findings include: 1) On 10/16/23 at 12:10 PM Resident #83's medical record was reviewed and revealed that care plan meetings were held on 7/7/22, 11/16/22, and 5/16/23. There was no other evidence of care plan meetings. On 10/19/23 at 12:57 PM the social work assistant, Staff #10 stated that she was the only one doing care plan meetings for 3 floors since the other social worker left. 2) On 10/17/23 at 12:17 PM Resident #86's medical record was reviewed and revealed that care plan meetings were held on 6/4/21, 12/14/21, 6/7/22, and 6/8/23 as evidenced by care plan meeting sign-in sheets. On 10/19/23 at 12:57 PM an interview was conducted with Staff #10 who stated, I am the only…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint # MD00169194, Medical Record Review of MDS, and GNA [NAME], the facility failed to toilet residents on a regular basis. This was evident for 1 (Resident #4) of 1 resident reviewed for toileting. Findings include: On 10/10/23 at 8:35 AM a medical record review was conducted and revealed Resident # 4 is dependent for most ADLs (activities of daily living) according to the MDS sec. G. Resident also requires 2 people to transfer in and out of bed and in and out of the wheelchair. (MDS, The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid-certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.) Resident gets up in the morning and is placed in his electric chair and he is off and around in the building. When he returns and wants to be changed the staff of 2 people is not always available to transfer back…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility failed to assess, document, and treat a surgical site and failed to ensure that the facility staff were able to administer a medication before admitting a resident to the facility. This was evident for 2 (#46, #60) of 96 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to a) assess and document Resident #46's surgical site and b) failed to provide treatment to that site timely. Review of Resident #46's medical record on 10/18/23 revealed the Resident was admitted to the facility on [DATE] with diagnosis to include benign prostatic hyperplasia. Benign prostatic hyperplasia (BPH) is a condition in which the prostate gland is enlarged. Further review of the Resident's medical record revealed the Resident was transferred to the hospital on 1/11/22 and returned to the facility on 1/17/22 after undergoing a partial penectomy. a) Review of the Resident's Admission/readmission skin check 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint review, medical record review, and interview, it was determined the facility failed to ensure a resident continued to have access to a retinal specialist and/or ophthalmologist for follow-up for a retinal problem. This was evident for 1 (#55) of 96 residents reviewed during a complaint survey. The findings include: On 10/13/23 at 11:42 AM a review of complaint MD00178316 alleged that the facility cancelled all appointments that Resident #55 had at a facility with a retinal specialist/ophthalmologist. Review of Resident #55's medical record revealed a hospital Discharge summary dated [DATE] that documented the resident had diabetes mellitus with hyperglycemia (high blood sugar) and the blood sugars were uncontrolled. Continued review of Resident #55's medical record revealed a follow-up consultation report dated 12/7/20 that documented Resident #55 had diabetic macular edema in the left eye. A 5/3/21 consultation report documented the resident had a follow-up for diabetic macular edema in both…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews it was determined the facility staff failed to provide appropriate treatment and services to promote healing of pressure ulcers. This was evident for 3 (#82,#76, #58) of 96 residents reviewed during a complaint survey. The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). 1) On 10/11/23 at 1:57 PM Resident #82's medical record was…

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

Based on medical record review, interview with facility staff and the review of a complaint, it was determined that the facility failed to adequately investigate the cause of an alleged fall and thereby prevent further occurrences. This was evident during the review of 1 of (3) falls reviewed during a complaint survey. The findings include. 1. a. Review of the medical record for Resident #22 on 10/20/23 at 1:00 PM revealed diagnosis including left ankle and foot gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints) affecting his/her mobility and intervertebral disc degeneration (Osteoarthritis of the spine, usually in the neck or lower back) again affecting his/her mobility. On admission, Resident #22 was assessed as a 35 on the 'Morse Fall scale.' The scored levels are low, medium, and high and Resident #22 ranged in the medium 25-44 range. Additionally on the admission 'Morse Fall scale' noted that Resident #22 had a history of falls just prior to admission. An activity of daily living care plan was initiated on admission that documented s/he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility failed to provide adequate management of a resident's pain medication (resident #36) resulting in the resident being denied pain medication when they requested it. The findings include: A Medication Administration Record (MAR) - a document that records when and how much medication a resident is administered. For as-needed pain medication, it also documents what pain score a resident is reporting and whether the pain medication was effective at easing that pain. Failure to maintain an accurate MARs prevents members of the healthcare team from knowing when and why medication has been given. This can result in medication mistakes, overdose, or denying practitioners information on how much medication a resident receives. On 10/10/23 at 12:30 pm, the surveyor reviewed a facility investigation dated 11/14/21 regarding the facility's failure to provide resident #36 with his/her Hydromorphone medication leading to the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility staff failed to obtain post dialysis treatment records for Resident #18. This is evident for 1 out of 3 residents reviewed for dialysis services during a complaint survey. The findings include: Review of Resident #18's medical record on 10/18/23 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include dependence on renal dialysis. Dialysis is a treatment that filters and purifies the blood using a machine. This helps keep your fluids and electrolytes in balance when the kidneys can't do their job. Further review of Resident #18's medical record revealed the Resident was ordered to receive dialysis treatments three times a week or 8 times from the Resident admission to discharge on [DATE]. Further review of the Resident's medical record revealed only 2 of 8 dialysis communication forms on 12/5 and 12/7/20. The facility's dialysis communication form contains pre and post dialysis vital signs 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 review of complaint MD00187110, facility documentation, medical record review and interview, it was determined that the facility failed to have sufficient nursing staff to provide care in a manner to provide nursing care needs to residents. This was evident for 2 of 2 days reviewed for sufficient staff during a complaint survey. The findings include: 1) On 10/16/23 at 8:41 AM a review of complaint MD00187110 alleged that on Christmas Day 2022 and the day after the staff did not report to work leaving residents without food, medication, and left to sit in their own soil. Review of the actual worked nursing schedule for 12/25/22 and the staffing assignment sheets did not match. Employee time clock punches were reviewed and did not entirely match the staffing schedule or assignment sheets. The PPD sheet provided to the surveyor revealed on 12/25/22 the PPD was 1.97 for a census of 165 residents and on 12/26/22 the PPD was 2.66. PPD is the nursing care hours per resident per day. Review of Resident #69's December 2022 Medication Administration Record (MAR) and Treatment…

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

Based on review of complaint, interview, and documentation review, it was determined the facility failed to have a process in place to assure resident transportation arrangements were made timely. This was evident for 1 (#68) of 19 residents reviewed during a complaint survey that were currently residing in the facility. The findings include: On 10/10/23 at 12:30 PM a review of complaint MD0019012 and MD00186749 alleged that Resident #68 missed outside provider appointments due to transportation issues. On 10/10/23 at 12:49 PM an interview was conducted with Resident #68 who stated he/she has missed appointments. Resident #68 stated, I tell them when I'm going to an appointment. They said the transportation people had it wrong. Stated my insurance doesn't cover. They did not write it up right. On 10/10/23 at 1:08 PM an interview was conducted with the Director of Nursing (DON). When asked about transportation issues she stated that the transportation company did not bring the right stretcher or wheelchair. She said she would have expected the person making the transportation…

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

Based on review of complaint MD00197454, medical record review, and interview with facility staff, it was determined that the facility failed to ensure a resident received their prescribed diet with the prescribed consistency. This was evident for 1 (#89) of 96 residents reviewed during a complaint survey. The findings include: On 10/12/23 at 3:16 PM a review of complaint MD00197454 was conducted and revealed an allegation from the complainant that she observed the food on Resident #89's meal tray. The complainant alleged that the food was solid and not pureed as Resident #89 required. The complainant stated that she explained to the nurse that Resident #89 was at risk of aspirating. Review of Resident #89's medical record revealed a physician's order, Regular diet, Dysphagia Pureed texture, Thin Liquids consistency. Review of a health status note dated 8/25/23 documented, Regular diet, Dysphagia Pureed texture, Thin Liquids consistency. On 10/13/23 at 9:01 AM an interview was conducted with the Nursing Home Administator (NHA) as she came to the facility that evening that 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 during tour of the facility's dumpster area, it was determined the facility staff failed to dispose of garbage and refuse properly. This deficient practice has the potential to affect all residents. The findings include: On 10/11/23 at 1:30PM 2 of the facility's dumpsters were observed with open side doors and lids. All doors and lids on dumpsters should remain closed to maintain cleanliness and reduce the risk of pests. Multiple pieces of trash and debris were present on the ground including a clear plastic bag filled with trash, and grocery cart and furniture such as a shelving unit. The findings were reviewed with the Administrator on 10/24/23 at 12 PM.

Based on medical record review and staff interviews, it was determined that the consultant pharmacist failed to identify and/or ensure that the facility staff established perimeters for the continued use of anti-depression medication for Resident (#10). This was evident for 1 (R#10) out of 5 sampled residents reviewed for medication regimen review during the investigative portion of the survey process. The findings include: 1) Wellbutrin is anti-depressant medication used to treat depression, which is a serious disorder of the brain. There are a variety of causes, including genetic, biological, environmental and psychological factors. Depression can happen at any age. On 3/11/20 at 9:30 A.M. a record review was conducted for Resident (#10) who was admitted with a medical diagnosis of depression. The medical record review revealed that in November 2019 a Pharmacist completed the required monthly medication review. On that same date and time the record revealed a physician's order for Wellbutrin (anti-depressant) XL 150MG tablet give 1 tab by mouth every day for Depression with…

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 staff observations of the facility's kitchen/ food services and staff interview, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations. This was identified during an initial inspection of the facility's dish washing machine and dishwasher temperature logs. The proper dishwashing temperature was not maintained for 3 of 3 months of temperature logs reviewed. The findings include: An initial Tour of the kitchen was conducted on 3/9/20 at 9:35 AM. Review of the current dishwasher temperature log for March 2020 revealed multiple occasions when the wash temperature was below 160 degrees Fahrenheit. Inspection of the dishwashing machine did not have a data plate containing manufacturers specification. The Food Service Director (staff #5) was asked to provide the specifications for the dish washing machine. Review of the manufacture's specifications on 3/11/20 revealed that the dishwashing machine was a Holbert CL44e single tank model. The minimum temperatures for using high-temperature sanitizing was…

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

Based on the review of the facilities infection control program, it was determined that the facility staff failed to ensure that a surveillance plan was established/ implemented in place. This was evident during the investigation of the facilities infection control program review during the survey process. The findings include: Long-term care facilities are required by federal and state agencies to have in place an infection control program following the Centers for Disease Control and Prevention (CDC) infection control guidance. The gap analysis for the prevention of healthcare-acquired infections in long-tern care facilities is an assessment tool used by facilities to guide them through the evaluation for the presence of best practice recommendations in the prevention of healthcare-acquired respiratory illnesses. On 3/12/20 at 9:29 A.M. during review of the facilities gap analysis for the prevention of healthcare-acquired Infection in long-term Care assessment tool revealed under the category's: Standard and transmission-based precautions: Question: 6). Do staff receive…

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

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident to an acute care facility along with the reason for the transfer. This was evident for 3 (#15, #90, #81) of 5 residents reviewed for transfer to an acute care facility. The findings include: 1) Review of the medical record for Resident #15 on 3/16/20 revealed documentation that the resident was sent out to an acute care facility on 5/28/19 due to having a seizure. There was no documentation found in the medical record that indicated the resident's responsible party was notified in writing of the transfer. Interview of the Director of Nursing on 3/18/19 confirmed the findings that the facility did not notify the resident or family in writing when the facility had initiated the discharge to the hospital. 2) Review of the medical record on 3/10/20 at 11:47AM for Resident #90 revealed documentation, that Resident # 90 was sent out to an acute care facility on 1/29/20 for abnormal labs. There was no…

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 resident and staff interview and medical record review it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident/exemplified for 6 (#127, #181, #52, #60, #90, #105) of 41 residents reviewed. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Resident #127 was interviewed on 3/10/20. When asked, the resident acknowledged that Resident #127 was incontinent of bowel and bladder and briefs were utilized. Resident #127's medical record was reviewed on 3/16/20. The resident was sent out to an acute care facility on 1/17/20 and returned to the facility on 1/24/20. A 5-day comprehensive admission MDS (minimum data set) assessment was dated 1/30/20 and another MDS assessment was dated 2/25/20. Review of the resident's current care plans revealed that all the plans of care had an initiation date of 1/27/20 or 1/28/20.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and staff interview it was determined that the facility failed to have an effective system in place to ensure that a care plan meeting was held after each resident assessment, failed to ensure that care plans were thoroughly evaluated and revised by the interdisciplinary team after each assessment, and failed to ensure the documentation of why the resident or responsible party was unable to attend a care plan meeting. This is exemplified for 7 residents (#46, #127, #15, #52, #7, #16 and #10). The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) An interview was conducted with Resident #46 on 3/10/20 at 2:28 PM. The resident was asked; if s/he attends care plan meetings? The resident responded that s/he has not been to any care plan meetings. Review of Resident #46's medical record on 3/16/20, revealed that the resident was admitted to the facility in June…

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, resident and staff interview it was determined that facility staff failed to ensure that all residents were treated with respect and dignity by receiving permission from residents before entering resident's rooms. This was evident for 1 out of 10 residents who were interviewed involving (R#8) observed during the survey process. The findings include: On 03/11/20 at 11:37 A.M. during a bedside interview with Resident #8 the Surveyor observed and witnessed staff member #2 Geriatric Nursing Assistant (GNA) knock on room [ROOM NUMBER]'s door and just walk into the room without time for the resident's response or giving permission to enter the room. Staff member #2 apologized and stated to Resident #8, I didn't know the surveyor was in the room with you. Resident #8 replied, I'm in my interview with the State, I don't need anything right now. After the staff member left the room Resident #8 replied to this writer, the staff always just walk into your room and you can be unpresentable. On 3/11/20…

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, interviews and medical record review it was determined that the facility staff failed to: 1) bathe a resident according to his/her preference, 2) to have a process in place to make meal choices available to those residents who ate in their room and wanted a different meal, and 3) to provide an escort for those individuals who need extensive assistance when out on an appointment. This was evident for 3 (#46, #35, #16) of 5 residents reviewed for Choices during the facility's annual Medicare/Medicaid Survey. The findings include: 1) On 3/10/20 at 2:28 PM, during an interview with Resident #46 when asked, do you choose how many times a week you take a bath or a shower? Resident #46 indicated that he/she has only had four showers the whole time he/she has been living at the facility. Resident #46 indicated that he/she would prefer to get showers routinely. When asked if he/she has discussed that concern at care plan meetings, Resident #46 responded that he/she has not been to any care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined that the facility failed to obtain incapacity certifications and medical condition certifications prior to allowing a surrogate decision maker to withhold life sustaining treatments. This was evident for 1 (#124) of 1 resident reviewed for advanced directives. The findings include: Resident #124 was admitted to the facility on [DATE]. Resident #124's medical record was reviewed on [DATE]. Review of the Maryland Medical Orders for Life Sustaining Treatment (MOLST) form revealed that a no CPR order was written by the Certified Registered Nurse Practitioner on [DATE]. The MOLST form revealed that the decision to withhold CPR (Cardiac Pulmonary Resuscitation) was based on the informed consent of Resident #124's surrogate decision maker. Review of the admission comprehensive assessment (dated [DATE]) revealed that Resident #124 had severely impaired cognition. There were not any physician certifications of incapacity and there were not any physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interview it was determined the facility staff failed to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair. This was evident throughout the survey and on multi-levels of the facility. The findings include: The following environmental concerns were observed during the survey and a tour was conducted with the Maintenance Director on 3/18/20 at 12:30 PM: room [ROOM NUMBER] there was a large section of missing wallpaper on the left-hand side of the window and heating unit. room [ROOM NUMBER] noticeable from the hallway door entrance were multiple areas with wallpaper seam separations. room [ROOM NUMBER] was discussed as another surveyor had previously informed him the wallpaper was peeling off the wall. On the 1B Unit one of the shower rooms was utilized as storage for a mechanical lift. The handle to the shower was broken and there was not a shower head on the handheld water line. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2(#132) and (# 90) of 2 residents reviewed for MDS accuracy. The findings include: The MDS (minimum data set) is part of the Resident Assessment Instrument (RAI) that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1. On 03/18/20 09:58 AM a review of resident medical records was conducted. Resident # 132 was admitted to this facility in December of 2019. 0n 12/29/19 nursing note states resident scheduled to discharge to his/her friend home today 12/29/19, alert and verbally responsive with no…

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, the facility failed to develop a baseline care plan for Resident #90 who had C-diff and went to dialysis 3 times per week. This was evident for 1 out of 1 residents that did not have a baseline care plan. The findings include: On 3/12/20 a medical record review was conducted for Resident # 90. Resident # 90 was admitted to this facility on 1/9/2020. He/she has a history of , C- Diff. On 1/10/20 the resident was placed on Imodium 2 mg 1 now for loose stools with an order to collect stool for C-diff. On 1/11/20 the culture came back positive for C-diff. Resident # 90 was placed on contact isolation. There was no baseline care plan for the C-Diff diagnosis on file in the medical record for Resident #90. On 3/12/20 at 2:14 PM a medical record review was conducted for Resident # 90. Resident # 90 was admitted to this facility on 1/9/2020. He/she has a history of Renal dialysis and end stage renal disease. Resident #90 goes to dialysis 3 times per week. All dialysis communication paperwork had been filled out. There is no baseline care plan for dialysis.

Based on medical record and staff interview, it was determined that the facility staff failed, 1) to perform a routine 2 hour turning and 2) failed to apply splint to left lower extremity for resident who had a contracture of left ankle. This was evident for 2 (#9, #7) out of 3 residents investigated for activities of daily living. The findings include: 1) On 3/16/20 a complaint regarding the daily care of Resident # 9 was being investigated. The complaint alleged that on the morning of 11/23/19, the resident's daughter went to the facility to visit her mother and found the resident in her bed covered in urine and feces. The daughter alleged that the resident had been left lying in her stool for a long period of time. On 3/18/20 at 10:30 AM Geriatric Nursing Assistant, GNA #10, who was assigned to the resident the morning of 11/23/19 was interviewed. The GNA stated that on that morning in question the GNA was doing morning rounds and observed the resident in bed, covered up. The GNA stated that there was no odor in the room to suggest the resident needed cleaning. The GNA stated…

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 resident and staff interview, the facility staff failed to follow up and treat Resident #60 for a change in bowel status. This was evident for 1 out of 41 residents investigated during the survey process. The findings include: On 3/12/20 when interviewing Resident #60 about any concerns, the resident stated that the resident was having a problem with constipation. When the writer asked if anything was being done about it, Resident #60 stated, no. The GNA's (geriatric nursing assistants) are responsible for documenting the residents bowel and bladder functioning on a daily basis. On 03/13/20 08:39 AM a review of the resident's continence records (whether the resident voluntarily controlled emptying the bladder and bowels) revealed that since 3/4/20 through 3/12/20 the resident had been having loose diarrhea. The writer interviewed the resident to clarify what was going on. When interviewed the same morning, the resident stated that he was confused. He was not constipated; he was having loose stools. Interview with the resident's nurse after speaking to Resident #60 revealed…

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 review of medical records and staff interviews, it was determined the facility staff failed to provide adequate supervision to ensure the safety of Residents #20 ,#71 and #117 , who smoke. This was evident for 3 out of 4 residents investigated while smoking during the survey process. The findings include: A) On 3/11/20 during the 8:00 A.M. smoke time, Resident #20 and Resident #71 lit their own cigarettes with lighters in their own possession. At the 10:00 A.Mm smoke time, Resident #71 again, had his own lighter. Per the facility's smoking policy, retention, storage and distribution of smoking accessories are to be kept under the control of the facility staff when not in use . Staff #12, from the business office, informed the writer that staff number 12 is the one who takes the residents out for their smoke breaks. Staff stated the staff is trying to encourage the resident to turn in their cigarettes and lighter after each smoke break. From smoke break at 8:00 A.M. to smoke break at 10:00 A.M. it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the nursing department failed to review orders and administer the correct liters of oxygen according to Doctors orders provided for Resident # 105 who receives oxygen. This was evident for 1 out of 41 residents. The findings include: On 3/9/2020, this surveyor went to room [ROOM NUMBER]-1 to interview the resident. Resident # 105 was sitting in the hallway outside her room because her/his room was being deep cleaned. Resident #105 was sitting in a geri chair reclined and appeared comfortable. There was an oxygen concentrator next to his/her chair with a humidifier attached and a nasal canula placed on the resident. The oxygen tank was set on 5 liters on O2. The resident was unable to speak and all activities of daily living must be done for him/her. A chart review was conducted on 3/11/20 at 1:20 PM. Resident # 105 has a history of Alzheimer's Disease, Peripheral Vascular Disease, Hyperlipidemia, Hypertension, Antiphospholipid Syndrome, Acidosis, Chronic Pulmonary…

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 the medical record review, it was determined that the facility staff failed to document an assessment of Resident #9 in a timely manner. This was evident for 1 out of 41 residents investigated during the survey process. The findings include: On 3/17/20 while investigating a complaint regarding Resident #9, this writer was reviewing the progress notes in the resident's chart surrounding the dates of concern related to the complaint. The chart revealed a Medical Professional's note from MD #11 that was written as a Late Entry. The effective date of the note read 11/21/19 at 10:58. Further review of the progress note revealed that the initiation of the note for 11/21/19 was written on 1/14/20, fifty-four (54) days after the assessment was completed on the resident, during that 21st day in November 2019.

Based on observation and staff interviews it was determined that the facility staff failed to develop a care plan that is specific enough for Resident #55, with a diagnosis of dementia. This was evident for 1 out of 5 Residents reviewed for unnecessary medications. The findings include: On 03/11/20 around 011:19 AM, this surveyor was reviewing Resident #55's medical record. It was noted that the resident has a diagnosis of dementia. Further review of the record revealed that there was no care plan that was specific for this resident with cognitive difficulties. A Care Plan is a formal process that includes correctly identifying existing needs, as well as recognizing potential needs or risks. This allows nursing to identify interventions to assist the resident with any barriers that interferes with the resident's optimal level of health. On 03/13/20 at 11:24 AM, staff #14, Licensed Practical Nurse (LPN) was interviewed about the resident's plan of care. Staff #14 was asked how staff provided dementia care for this particular resident. Staff #14 explained that the nurses have the same…

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 resident interview, observations, medical record review and staff interview it was determined that the facility failed to provide meals and food items that were high in fiber. This was evident for 1 (#181) of 2 residents reviewed for nutrition. The findings include. Resident # 181 was admitted to the facility on [DATE]. On 3/10/20 at 9:35 AM Resident #181 indicated that there was a communication issue with the kitchen. Resident #181 explained that s/he had gotten constipated while in the hospital and s/he received salads, and prune juice with no starch, rice, or potatoes. The resident stated; The facility here knew s/he was to be on a special diet, and they did not provide it. Resident #181 further indicated that the facility is giving her/him eggs and sausage and not oatmeal. The resident shared that she/he had an issue with bad hemorrhoids and was constipated and was recently given a laxative. Resident #181's lunch meal tray was observed on 3/11/20 at 12:25 PM. The meal/tray ticket indicated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews it was determined that the facility failed to have medical records readily available. This was evident with all medical records reviewed for multiple days of the survey. Additionally, the facility failed to carry over physician orders (4) for Resident # 26, Resident # 105, Resident 127 and Resident 181. This is evident for 2 out of 41 residents reviewed during the survey. The findings include. 1) Upon initiation of the survey on 3/9/20, the facility is requested to provide each surveyor with access to all resident electronic health records - do not exclude any information that should be part of the resident's medical record. It was noted by the survey team on 3/10/20 that there was not access to discharged residents. The Nursing Home Administrator (NHA) was informed of the surveyor lack of access to discharged residents. On 3/11/20 at 1:10 PM interview of the Dietitian (staff #15) revealed that she could not see her own dietary assessments for Resident #181.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined the facility failed to equip corridors with firmly secured handrails. This was evident on 1 of 3 nursing units observed. The findings include: Observation was made during the survey of missing handrail after room [ROOM NUMBER] in the 2nd floor corridor. An approximately 10-foot section of wooden handrail was noted missing at the initiation of the survey. Interview of the Maintenance Director on 3/17/20 at 12:45 PM revealed that he was awaiting a pex card so that he could buy the supplies required to fix the missing section of handrail.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and environmental rounds it was determined that the facility failed to maintain clean, intact walls in resident rooms. The findings include: On 11/16/2018 surveyors observed the following damage in resident's rooms: 1. In room [ROOM NUMBER]-2, the bathroom door was chipped near the door knob with wood missing. One interior wall in that bathroom was in disrepair. 2. In room [ROOM NUMBER]-2, the interior wall near bed 1 was in disrepair with plaster and wood particals scraping off the walls. The molding around the sink was detached from the wall with exposed nails. The bathroom interior wall was in disrepair with visible black plaster patches.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and environmental rounds it was determined that the facility failed to maintain clean, intact walls in the resident rooms. The findings include: On 11/16/2018 at 12:30 P.M.the surveyors observed the following damage in residents rooms: 1. In room [ROOM NUMBER]-2, the bathroom door, near the door knob, was chipped with wood missing. One interior wall in that bathroom was in disrepair. 2. In room [ROOM NUMBER]-2, the interior wall near bed 1 was in disrepair with plaster and wood scraping off the walls. The molding around the sink was detached from the wall with exposed nails. The Bathroom interior wall was in disrepair with visible black plaster patches. On 11/16/18 the nurse on the unit verified the environmental concerns in resident rooms [ROOM NUMBERS] during the survey process. The Administrator with the Director of Nursing were notified prior and during the survey exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined the facility failed to ensure that 2 vacutainers used to draw blood were not expired in 1 of 7 storage areas inspected during the survey. The findings include: On [DATE] at 10:57 AM while inspecting the Terrace medication storage room, 2 purple top vacutainers were found to have expired. One expired on [DATE] and the other on [DATE]. Vacutainers are special containers used when drawing blood. The findings were confirmed by staff Nurse #4.

Based on observation and staff interview, it was determined the facility failed to ensure personal hygiene equipment items meant for individual use were labeled and stored according to standard nursing infection control practice for roommates/residents #131 and #71 and roommates/residents #124 and #183. This was evident for 4 of 38 residents investigated during the survey. The findings include: On 11/19/18 at 9:00 A.M. while observing the morning medication administration, an unlabeled bedpan was found on the floor in a bathroom shared by Residents #131; #71; #124 and #183. Also, an unlabeled basin used for giving baths was sitting on the sink with unlabeled items inside of it: emesis basin, toothpaste, toothbrush and denture cup. It is standard nursing practice to ensure that these types of items are labeled with the resident's name or room and bed number when used in shared rooms or bathrooms. Bedpans are not to be stored directly on the floor. The findings were confirmed during an interview with staff nurse #1.