Autumn Lake Healthcare At Spa Creek

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews it was determined that the facility failed to ensure that the required parties were notified appropriately. This was found to be evident for 1 (Resident #16) out of 3 Residents reviewed for discharge during the recertification survey.The findings include: During a review of Resident #16's medical record conducted on 08/04/25 at 9:46 AM, it was discovered that the Resident was transferred to a local hospital's emergency room on [DATE] where he/she was later admitted . Further review of the Resident's medical record revealed a change in condition/concurrent form. The form did not show that the Resident Representative had received a bed hold or transfer summary. During an interview conducted on 08/04/2025 at 11:31 AM, the Nursing Home Administrator (NHA) provided this surveyor with the bed hold notice dated 07/10/25, a list sent to the ombudsman, and the change in condition/current form.A review of the Ombudsman weekly list for discharge notifications did not show 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 observation, Resident and staff interviews and surveyor record review it was determined that the facility failed to accurately complete a Minimum Data Set (MDS) assessment on a Resident. This finding was found to be evident in 1 (Resident #82) out of 2 Residents reviewed for accuracy of MDS assessments. The findings include:On the initial tour of the facility on 7/30/2025, the surveyor observed Resident #82 who was alert and oriented x4, in no distress and lying in bed. Resident #82 stated that he/she was diabetic and received insulin injections.Minimum Data Set (MDS) assessment is a standardized assessment tool used to evaluate the health and functional capabilities of nursing home Residents. It is a federally mandated process for all Medicare and Medicaid certified nursing homes. MDS assessments are performed by trained clinicians at admission, discharge, and other intervals, such as quarterly or annually. The MDS gathers information on physical, psychological and psychosocial functioning,…

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 reviews it was determined that the facility failed to ensure care plan meetings were held in a timely manner. This was found to be evident for 1 (Resident #3) out of 1 Resident reviewed for care plan meetings during the re-certification survey.The findings include: According to CMS (Centers for Medicare & Medicaid Services) care plan meetings, which are part of the comprehensive care planning process for long-term care facilities, require regular review and revision based on resident assessments. These meetings ensure that residents receive person-centered care that meets their individual needs and preferences. A comprehensive care plan meeting should be held within seven days of completing the MDS (Minimum Data Set) assessment. This applies to all comprehensive assessments, including admission, annual, and significant change assessments, but not discharge assessments. The care plan must be reviewed and revised after each subsequent assessment. During an interview conducted on 07/30/2025 at 11:29 AM, Resident #3 stated that he/she did not recall…

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 reviews it was determined that the facility failed to ensure Activities of Daily Living (ADL) were provided to a Resident. This was found to be evident for 2 (Resident #108 and #42) out of 5 Residents reviewed for ADL care during the recertification survey.The findings include: 1) According to Centers of Medicare and Medicaid Services (CMS) Activities of Daily Living (ADLs) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. If a sample person has difficulty performing an activity by himself/herself and without special equipment or does not perform the activity at all because of health problems, the person is deemed to have a limitation in that activity. During a random observation conducted on 07/30/25 at 12:18 PM, Resident #108 appeared uncleaned, hair disheveled and in a night gown. The Resident also had an odor of urine. During an interview conducted 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 observation, interview and record review, it was determined that the facility failed to follow the physician orders for the management of constipation. This was evident for 1 (Resident #33) of 1 resident reviewed for constipation/ diarrhea during the recertification survey.The findings include:Milk of Magnesia (MOM) is an over-the-counter laxative that can be used to treat occasional constipation.Dulcolax suppository is a type of laxative that is inserted into the rectum to relieve constipation.An Enema is the process of introducing liquid through the anus to relieve constipation.On 7/30/2025 at 9:26 AM, Resident #33 was observed grimacing, sitting in the wheelchair inside his/her room with lights off. The resident stated that he/she wanted the lights off because he/she was feeling terrible. He/she added that he/she had not slept during the night due to abdominal discomfort. He/she revealed that he had been having constipation for a week now and stated that the staff have been informed about it, however, he/she claimed to have received only Milk of Magnesia. At 9:36 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 record reviews and interviews, it was determined that the facility failed to ensure Pharmacy Recommendations were 1) reviewed in a timely manner and 2) implemented accurately. This was found to be evident for 2 (Resident #60 and #9) out of 5 Residents reviewed for Medication Regimen Review during the recertification survey. This deficient practice was identified as past non-compliance.The findings include: 1) A pharmacy medication review, also known as medication therapy management (MTM), is a service where a pharmacist evaluates a patient's medications to optimize their use and improve health outcomes. It involves identifying potential medication-related problems, such as adverse drug events, drug interactions, or adherence issues, and recommending solutions to the patient and their prescriber. CRCL stands for Creatinine Clearance Rate. It is a measure of kidney function that indicates how effectively the kidneys remove creatinine, a waste product, from the blood. A review of Resident #60's Consultation Report from Omnicare was conducted on 08/06/25 at 9:42 AM. The report…

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 failed to provide adequate monitoring for resident on anticoagulant medication. This was evident for 1 (Resident #33) of 2 residents reviewed for Anticoagulants during the recertification survey.The findings include:The Mayo Clinic describes anticoagulants or blood thinners as medications that help prevent blood clots from forming. Anticoagulant medications increase the risk of bleeding, and patients taking these medications need to be carefully monitored. On 7/30/2025 at 9:28 AM, Resident #33 was observed with bruising on both posterior hands and arms. He/she stated that it was caused by the blood thinner that he/she was taking. On 8/04/2025 at 6:55 AM, a review of the active physician orders revealed that Resident #33 was prescribed an anticoagulant, Xarelto Oral Tablet 10 MG (Rivaroxaban) Give 10 mg by mouth one time a day for Deep Vein Thrombosis (DVT) prophylaxis. Take 1 tablet by mouth daily after dinner. On 8/04/2025 at 7:16 AM, a review of the progress notes written on 7/2/2025 by 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 and interviews it was determined that the facility failed to ensure staff practiced infection control. This was evident for 2 (LPN # 4 & LPN#11) staff out of 2 staff observed for infection control during the recertification survey.The findings include: During a medication administration observation conducted on 07/31/25 at 7:31 AM, this Surveyor observed Licensed Practice Nurse (LPN) #4 obtain the Resident's blood pressure. After the LPN obtained Resident #55's blood pressure the LPN failed to sanitize the blood pressure equipment and cuff. Following obtaining the blood pressure, the LPN returned to the medication cart and prepared the Resident's medication without practicing hand hygiene. The LPN entered the Resident's room and administered the medication again without first practicing hand hygiene.During an interview conducted on 07/31/25 at 7:37 AM, LPN #4 advised that the facility's expectation was to always practice infection control which included sanitizing shared medical equipment and hand hygiene when delivering direct care to the Resident.During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On 6/3/25 at 8:40 AM the following environmental observations were made on 3 of the 4 hallways on the second-floor nursing unit: In room [ROOM NUMBER]B there were (2) areas on the night stand where the laminate was missing on the right top and the left lower corner. In the bathroom the toilet riser frame had rust in the front middle bar and on the legs. In room [ROOM NUMBER]A laminate was peeling off the bed's footboard approximately 6 inches on the left side and on the right corner. In room [ROOM NUMBER]B the vinyl on the left wheelchair armrest was cracked on the front side. The laminate on the dresser was peeling on the third drawer on the right and left side. There was no handle on the drawer. In room [ROOM NUMBER]A the laminate on the over the bed tray table was missing about 5 inches by 4 inches with the particle board exposed. The laminate was missing on the night stand top right corner. In room [ROOM NUMBER]A the laminate was peeling off all four of the dresser drawers and a 6-inch by 3-inch area 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 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 (#26, #18, #22, #33) of 38 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 5/29/25 at 7:45 AM Resident #26's medical record was reviewed. Review of the November 2024 Medication Administration Record (MAR) documented that Resident #26 received Oxycodone (Opioid) for pain on 11/1/24 and 11/4/24. Review of the MDS assessment, with an assessment reference date (ARD) of 11/6/24, failed to capture the use of an Opioid. On 6/3/25 at 1:47 PM an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease. This was evident on 1 of 2 nursing units observed during a complaint survey. The findings include: 1) On 6/3/25 at 8:40 AM GNA #15 was observed feeding Resident #37. GNA #15 finished feeding Resident #37 and proceeded to walk to the next bed and set up Resident #9's breakfast tray. GNA #15 then walked back to Resident #37. She did not sanitize her hands in between patient contact. 2) On 6/3/25 at 9:07 AM GNA #15 was observed in the second-floor dining room standing to feed Resident #38. GNA #15 wiped Resident #38's mouth and cleaned up the breakfast tray, put it on a rack and retrieved another soiled tray to place on the food tray rack. GNA #15 then walked down the center hallway and walked into room [ROOM NUMBER]. GNA #15 did not sanitize her hands after contact with Resident #38 and the soiled breakfast trays. 3)…

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 the facility's and vendor's pest control logs, observations and interviews, it was determined that the facility failed to maintain an effective pest control program. This was evident for kitchen, nurses stations, pantries, and 26 of 70 resident rooms during a complaint survey. The findings include: During investigation of multiple complaints from residents and families regarding pest control, the Surveyor reviewed the pest control logs maintained at the front lobby of the facility from January 2025 through May 2025 and vendor pest control reports from January 2025 through May 2025 1. Review of the facility's pest control logs revealed the following: a) 2/3/25 roaches room [ROOM NUMBER] b) 2/10/25 roaches elevator c) 2/16/25 roaches pantry 1st floor d) 2/16/25 roaches 2nd floor employee lounge e) 2/16/25 ants room [ROOM NUMBER] f) 2/16/25 roaches guest services g) 2/17/25 roaches room [ROOM NUMBER] h) 2/24/25 ants room [ROOM NUMBER] i) 2/24/25 roaches room [ROOM NUMBER] j) 3/10/25 roaches room…

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

Based on observation and staff interview, it was determined the facility staff failed to treat each resident in a dignified manner by standing over a resident while feeding the resident and speaking to a resident in a harsh tone. This was evident for 3 (#37, #9, #38) of 38 residents reviewed during a complaint survey. The findings include: 1) On 6/3/25 at 8:40 AM the surveyor walked into Resident #37 and Resident #9's room. Geriatric Nursing Assistant (GNA) #15, from a staffing agency, was standing to feed Resident #37. GNA #15 was observed quickly shoveling the food in the resident's mouth. While GNA #15 was standing to feed Resident #37, the surveyor observed the roommate, Resident #9 sleeping, curled up in a fetal position, covered with a blanket, on the bed. The over the bed tray table was next to the bed and had Resident #9's breakfast tray on the top, which was covered. The surveyor proceeded to walk into the resident's bathroom, which was by the exit door, to observe the contents of the bathroom. While standing in the bathroom the surveyor observed GNA #15 state in a harsh…

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 reviews of facility reported incidents and interview, it was determined the facility failed to report allegations of abuse to the regulatory agency, the Office of Health Care Quality (OHCQ) within 2 hours of the allegation. This was evident for 1 (Resident #13) of 17 residents reviewed for facility reported incidents during a complaint survey. The findings include: On 6/2/25 at 9:05 AM a review of facility reported incident MD00197617 was conducted and revealed an allegation that housekeeping staff reported on 9/27/23 at 5:45 AM they saw Resident #13 sitting at the first-floor nursing station in a wheelchair with a bed sheet that appeared to be tied around the resident's back in a knot. The investigation documented that there was no one to report the issue to on the first floor so the housekeeper went up to the second-floor nursing unit and reported it to a geriatric nursing assistant (GNA). The charge nurse on the second floor overheard the conversation and immediately reported it to the first-floor charge nurse. Review of the facility's documentation revealed the initial…

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, medical record review, and staff interview, it was determined the facility failed to properly perform neuro checks after a fall for residents (Resident #33 and #34). This was evident for 2 of 22 residents reviewed during a complaint survey. The findings include: A neuro check after a fall refers to a neurological assessment performed by a healthcare professional to evaluate potential brain injuries by checking a person's level of consciousness, orientation, pupil response, muscle strength, sensation, and coordination. 1. Review of Resident #33's medical record on 5/28/25 revealed the Resident was admitted to the facility in February 2025 with a diagnosis to include history of falling. Further review of Resident #33's medical record revealed a nurse's note from Staff #10 on 2/8/25 at 3:44 PM that stated: Resident had a fall around 1:30 PM. This writer heard a loud sound while in another resident room. As this writer walked down the hallway checking on each resident, this writer came upon resident in bathroom on the floor kneeling. Review of Resident…

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

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 provide treatment/services to prevent/heal pressures ulcers. This is evident for 2 (Resident #15 and #16) of 4 residents reviewed for pressure ulcers during a complaint survey. The findings included: 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). A deep tissue injury (DTI) is a unique form 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 review of a complaint, record review, and interview, it was determined the facility failed to provide timely medication to meet the needs of the residents. This was evident for 1 (#17) of 22 residents reviewed for complaints during a complaint survey. The findings include: On 5/30/25 at 8:11 AM a review of complaint MD00199890 alleged that the facility failed to have prescribed medications available for Resident #17 after the resident was admitted . Review of Resident #17's medical record revealed the resident was admitted to the facility on [DATE] around 2:00 PM from an acute care hospital. Resident #17 was treated at the hospital for a fall off a roof which resulted in a displaced fracture of the left humerus, a closed fracture of the ribs, and a fractured pelvis. Review of the hospital discharge summary documented the order for Hydromorphone 2 mg. every 4 hours PRN (when necessary) for moderate pain or 2 tablets every 4 hours PRN severe pain, Alprazolam (Xanax) 2 mg. for anxiety, Lorazepam (Ativan) 2…

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 outside services for residents in a timely manner. This was evident for 2 (Resident #15 and #16) of 22 residents reviewed for complaints during a complaint survey. The findings include: 1. The facility staff failed to schedule a follow up neurologist appointment for Resident #15. A neurologist is a medical doctor specializing in diagnosing and treating diseases of the brain, spinal cord, and nerves. Review of Resident #15's medical record on 6/2/25 revealed the Resident was admitted to the facility in August 2023 with diagnosis to include cerebral infarction. Cerebral infarction, often referred to as a stroke, is a serious medical condition that occurs when blood flow to the brain is interrupted, leading to a lack of oxygen and nutrients to brain tissue. Review of Resident #15's hospital Discharge summary dated [DATE] revealed a discharge instruction to follow up with neurology and call for an appointment…

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

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (Resident #16) of 22 residents reviewed for complaints 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. Review of Resident #16's medical record on 5/29/25 revealed the Resident was admitted to the facility in January 2023 with a diagnosis to include bladder neck obstruction. Further review of the Resident's medical record revealed an order for a cystoscopy on 10/23/23. Review of the electronic and paper medical record did not reveal the results of the cystoscopy. Interview with the Administrator on 5/30/25 at 9:00 AM confirmed Resident #16's medical record did not contain the results of…

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

Based on observation, medical record review and interviews, it was determined that the facility staff failed to promote care for residents in a manner and in an environment that maintained or enhanced the resident's dignity and respect. This was evident in 3 (residents #54, #66, #459) of 12 residents observed for dignity during the annual survey. The findings include: On 01/06/09 at 11:59 am when the surveyor walked into Resident #54 room, the resident was sitting in the wheelchair near the bathroom. The surveyor noticed the resident's bed did not have any linen and the mattress was exposed. The resident's call bell was on the opposite side of the bed from where he/she was located which was not within the resident's reach. On 01/06/23 at 12:09 PM, the surveyor asked the Assistant Unit Manager Lighthouse #19 to go to the resident's room. The Assistant Unit Manager Lighthouse #19 confirmed the resident's bed did not have any linen and the call bell was not within the resident's reach. On 01/06/23 at 1:38 PM Resident #54 still did not have linen on the bed. On 01/11/23 at 1:19 PM, 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 and interview, the facility failed to accommodate the needs of residents by failing to ensure resident meal trays reflect the resident-completed meal slips, (Residents #6, #14, #18, #27, #36, #44, #46, #61, #63, #65, #67, #69, #82, #147, #203). This was evident in 15 of 91 residents reviewed during the facility's annual survey. The findings include: On 1/9/2023 at 7:50 am, the surveyor interviewed resident's #69 and #147 regarding the facility's failure to ensure meal trays reflect the meal slips present with the meal tray. The surveyor compared the meal slips that accompanied the meal trays for residents #69 and #147 and discovered that the meal tray food selections did not match the meal slips. On 1/10/2023 at 2:10 PM, the surveyor attended a resident council meeting. Residents #6, #14, #18, #27, #36, #44, #46, #61, #63, #65, #67, #82, #203 complained of the facility's failure to ensure meal trays reflect the meal slips present with the meal tray. On 1/17/2023 at 3:30 PM, the surveyor interviewed Dietary Manager #16 regarding resident complains of the meal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS) assessments which should have included the resident's participation in the resident interviews, and failed to complete MDS assessments timely. This was evident for 8 of 12 residents reviewed for assessment reviews during an annual survey (Residents #12, #23, #53, #66, #67, #89, #142, and #452) . The Findings Include: The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate the residents' progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. The Minimum Data Set (MDS) assessments are an integral part of the RAI and include completion of standardized assessment questions. There are comprehensive MDS assessments and periodic non-comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews it was determined that the facility failed to use the instructions from Resident Assessment Instrument (RAI) to reflect resident's status accurately as of the Assessment Reference Date (ARD). This was found to be true for 5 of 6 residents (Residents #39, #86, #88, #452, and #303) reviewed for assessment accuracy during a annual survey. The Findings Include: The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate the residents progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. The RAI process is the basis for the accurate assessment of each resident The Minimum Data Set (MDS) assessments are an integral part of the RAI and include completion of standardized assessment questions. There are comprehensive MDS assessments and periodic…

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 provide a written notice to a resident, responsible party, and/or family member with a reason why the room assignment was changed. This was evident in one (Resident#112) of 2 resident records reviewed for changed room assignments. The findings include: On 01/30/23 at 1:29 pm during an interview with Resident #112 family member, he/she reported the resident was moved to a different room multiple times and the family was not aware until they went to visit the resident. A review of the electronic medical record (EMR) on 01/31/23 at 11:01 am the resident had multiple room changes per the census. The EMR revealed the resident was transferred from room [ROOM NUMBER] A to 130-B on 02/17/22. The Director of Nursing (DON) verified there was no documentation to confirm the resident, the responsible party, or the family were made aware of the room change. If the resident was not transferred to another room, there was no documentation 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 observations and interviews with facility staff it was determined the facility failed to ensure that a resident environment was homelike and maintained in an orderly manner. This was found to be evident for the 2nd floor of the facility and 1 of 91 residents (resident #9) observed during the facility's annual Medicare/Medicaid survey. Findings include: An observation was made on 1/9/23 at 11:13 AM of resident # 9 room and the following concerns were identified: Inside the resident's bathroom, there was a marring noted on the wall and on the bottom of the door. An opened scraped area on the lower wall was approximately 1-2 feet long. A hole was noted in the wall near the entrance of the resident's room and located where the door handle meets the wall when the door is completely opened. The hole was stuffed with a brown napkin. An interview was conducted with the Maintenance Director (MD) Staff # 29 on 1/26/23 at 11:00 AM and he was made aware of all the environmental concerns. The MD was asked if any of…

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

Based on review of the facility investigation; review of other pertinent documentation and interview with staff it was determined that the facility failed to protect resident #131 from and verbal abuse and protect residents from potential verbal abuse. This occurred in on 1 of 10 residents reviewed for abuse. The findings include: On 2/1/23 at 2:42 pm, A review of the facility reported incident MD00123643 revealed that on 05/25/2019 GNA (Geriatric Nursing Assistant) staff #61 reported; to the Nurse Supervisor (staff #63) that the housekeeper (staff #60) and resident (#131) were at the residents' door. Resident # 131 asked staff #60 could she get some of the water and food crumbs off the floor. Staff # 60 responded to the resident, If you want the shit up get it up your damn self. You (Resident #131) don't tell me how to do my Job. Further review of the facility investigation revealed staff #60 refused to give a statement regarding the incident, walked out of the facility dropping her badge off to the with the Department Manager. According to the facility investigation the allegation…

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 the facility failed to protect residents from being forced to stay in their rooms by staff tying a sheet to the doorknob and outside corridor rail. This was evident in 2 (Resident #2 & #119) of 2 residents reviewed for involuntary seclusion. The findings are: On 01/18/23 during the investigation of the Facility Reported Incident (FRI) MD #00178083 revealed, on 05/21/22, 05/22/22, and the morning of 05/23/22 Resident #2 and Resident #119 who resided in room [ROOM NUMBER] were held in their room by a bed sheet tied to corridor arm rail and the doorknob which prevented the ambulatory residents from exiting the room. A review of Resident #2's medical record on 01/17/23 at 11:30 am revealed his/her medical diagnoses included but were not limited to Dementia with Agitation, Anxiety Disorder, Adjustment Disorder with Depressed Mood, and a history of other Mental and Behavioral Disturbances. A review of the Minimum Data Set (MDS) dated [DATE], 04/18/22, and 5/19/22…

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 an administrative record review and interviews with facility staff, it was determined the facility failed to complete a thorough investigation into allegations of abuse. This was found to be evident for 3 of 91 residents (Resident # 8, #108 & #134) reviewed during the facility's annual Medicare/Medicaid survey. Findings include: Resident #8 was admitted with the following but not limited to diagnosis: Fracture of Lateral Malleolus of Right Fibula and Vascular Dementia. On 01/09/23 at 03:25 PM, an interview was conducted with resident #8 who is alert and oriented x 3 to person, place, and time, was asked if s/he was abused by anyone, and the resident stated the following: A male resident tried to get in bed with me about 6-12 months ago. The resident went on to say, s/he pressed the call light and called for the nurse. The nurse on duty responded immediately and removed the male resident who had climbed on top, and he was taken out of the room. Resident # 8 confirmed that nothing happened. On 01/11/23 at 01:15 PM, an interview was conducted with the Administrator. She 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 record reviews and staff interviews it was determined that the facility failed to: 1) complete Quarterly Minimum Data Set (MDS) assessments which should have included the resident's participation in the resident interviews and 2) failed to ensure that Quarterly MDS assessments were completed within the required time frame. This was evident for 18 of 20 residents (Residents # 8, # 18, # 21, # 27, # 34, # 38, # 39, # 40, # 46, # 54, # 61, # 63, # 76, # 78, # 79, # 86, # 88, and # 303) selected for assessment reviews during the survey. The Findings Include: The Minimum Data Set (MDS) is a standardized assessment tool that measures health status in nursing home residents. MDS assessments are completed Quarterly (every 3 months) or more often, depending on circumstances. An Assessment Reference Date (ARD) is the date that shows the end of the look back (observation) period. This date is used to base responses to all MDS coding items during the MDS assessment. The regulations require that the MDS must be completed no later than 14 days after the ARD. (The ARD + 14 calendar days).…

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 with facility staff, the facility failed to update a resident's care plan after a change of status, and failed to consistently conduct quarterly care plan meetings. This was found to be evident for 5 of 91 residents reviewed during the facility's annual Medicare/Medicaid survey (Resident # 9, #48, #53 #122, and #144). Findings include: 1. Resident # 9 was admitted to the facility with the following but not limited to diagnosis: Acquired Absence of Specified Leg Below Knee and Cerebrovascular Disease. On 1/27/23 at 12:00 PM a medical record review was completed for resident # 9. Upon review of a care plan initiated on 12/7/22, it revealed the resident has skin breakdown (MASD) which is Moisture Associated with Skin Damage on the sacrum area as evidenced by limited mobility and incontinent (having no voluntary control over urination or defecation. Further review of a skin/wound note dated 12/8/22 at 16:49 (4:49 PM) as follows: Initial/Current stage and locations: MASD…

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

Based on observation and interview it was determined the facility failed to provide oral care in a timely manner to a resident dependent on activities of daily living care (ADL). This was evident in one (#78) of three residents reviewed for dependent ADL care. The findings include: On 01/09/23 at 11:45 am while in Resident #78 room, the surveyor asked the resident to open her mouth. The surveyor observed thick white secretions in the resident's oral cavity. A review of Resident # 78 electronic medical record (EMR) on 01/09/23 at 12:01 pm revealed there was an order for the resident to receive oral care daily at 9:00 am. It was after 12 pm and oral care was not completed, and the surveyor bought it to Lighthouse Assistant Unit Manager # 19 attention. During an interview with Lighthouse Unit Manager #18 on 01/26/23 at 10:41 am the Geriatric Nursing Assistants (GNAs) have their tasks and they should be aware of what needs to be done for the residents. They are supposed to receive a report from the outgoing shift. She will speak with the GNAs if something is not done. GNA #34 is 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 observations, interview with family and review of medical records it was determined that the facility staff failed to ensure residents are provided with activities that meet the resident's needs based on their assessment. This was evident for 1 out of 4 (R#453) residents reviewed for activities during the investigation stage of the long-term care survey. The findings include: On 1/5 and 1/6 Resident # 453 was observed in her/his room with the television on and family present. During the interview with the resident's family on 1/6 at 10:30 AM, they had concerns about the lack of activities for the resident. They also revealed that since admission they had not seen anyone from activities. On 1/19/23 at 11:30 AM the initial activity assessment for resident # 453 dated 12/21/2022, was reviewed. It revealed that it was important for resident to listen to music and have magazines or papers read to her/him. Further review of the medical records failed to reveal documentation for activities. Surveyor requested from the administrator any documentation related to activities for the…

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

Based on medical record review and interviews, the facility staff failed to administer medication according to a physician's order and failed to clarify a physician's order prior to administering oxygen. This was evidenced in 2 of 5 resident records reviewed for medication administration during a facility's annual survey (Resident #66 & #458). The findings include: On 01/11/23 at 12:55 pm, a review of Resident #66 Medication Administration Record (MAR) revealed a physician's order written on 11/25/22 as wean oxygen (02) as tolerated, goal 02 > 90%, use the lowest effective dose of 02 via nasal cannula (NC) to achieve goal every shift for COPD, Hypercapnia use lowest effective dose of 02 via NC to support the goal of >90% Sp02 (oxygen saturation). The order did not indicate how much oxygen the resident should receive, and the nurses did not reach out to the physician to clarify the order. When the surveyor asked the assigned nurse how much 02 the resident was receiving, LPN #37 was unable to answer the question. Further review of the electronic medical record (EMR) revealed 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 interviews it was determined the facility failed to monitor a resident's weight who was identified as being at risk for weight loss. This was evident in one (#112) of one resident record reviewed for weight loss during the annual survey. The findings include: On 01/31/23 at 11:01 am a review of Resident #112 electronic medical record revealed the resident was admitted to the facility on [DATE]. The resident's weight on 12/18/22 at 6:40 pm was documented as 168.3 pounds. The resident's weight on 01/18/22 at 6:17 pm was documented as 163.8 pounds; the resident was weighed in a wheelchair. On 01/20/22 the resident fell and sustained a head injury while in the facility. Consequently, Resident #112 was sent to the hospital for further medical evaluation. On 01/31/23 at 11:45 am a review of John Hopkins Medicine Endocrinology Consultation dated 01/24/22 revealed Resident #112 weight was documented as 148 pounds 13 ounces on 01/21/22. Further review of the resident's electronic…

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

Based on record review and interviews it was determined the facility failed to maintain the daily staffing schedule for 18 months. This deficient practice was evident in one of the units observed during a facility's annual survey. The findings include: On 01/11/23 at 1:43 pm, the surveyor requested a copy of the unit Lighthouse daily assignment sheet from Unit Secretary #35. Unit Secretary #35 confirmed the assignment was not completed on 01/11/23 during the 7am - 3 pm shift. On 01/11/23 at 1:45 pm the surveyor requested a copy of the unit Lighthouse assignment sheets for all shifts on 01/10/23 from Unit Secretary #35. Unit Secretary #35 confirmed the assignment sheets were not completed on 01/10/23 for any shift. On 01/11/23 at 1:45 pm during an interview with Lighthouse's Unit Manager # 18 who reported the outgoing shift completes the assignment sheet for the next shift. and if the charge nurse doesn't complete the form any of the nurses can complete the assignment sheet.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide necessary behavioral health services for the diagnosis of adjustment disorder (resident #352). This was found to be true for 1 of 96 residents reviewed during a facility's annual survey. The findings include: Care Plan - This term refers to document which is the written plan of how a long-term care facility will provide care. This plan is based on resident health assessments, preferences and goals. Minimum Data Set (MDS) - clinical assessment required for federally funded long term care facilities. The MDS assesses resident's functional capabilities and assist federally funded long term care facilities identify health problems. On 1/6/23 at 9:45 am, the surveyor interviewed resident #352 regarding any complaints about his/her care at the facility. The resident expressed distress about personal finances, property, and the future costs and quality of his/her health care. On 1/23/23 at 11:27 am, the surveyor reviewed the resident's medical…

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, a review of the facility's policies and interviews of the facility's staff. it was determined that the facility failed to ensure that the medication refrigerator temperature logs were maintained, and the medication storage room was always locked. This was found to be evident during observations made during the facility's annual Medicare/Medicaid survey. The findings include: On 01/20/23 at 11:03 AM while touring the first floor an observation was made of the medication storage room. The medication refrigerator temperature logs were reviewed, and they revealed missed temperature entries for the following dates: November 2022: 1,2,3,4,5,6,7, 8, 10,13, 15, 24, 25, and 29 December 2022: 2, 4, 5,6,7,8,9,10,11, 22, 27, and 31 January 2023: 5, 10, 16, and 19. On 01/23/23 at 09:42 AM during another medication storage room observation, the first-floor medication storage room was observed unlocked. There was no staff present at the surrounding nurse station. At that time the floor nurse, Staff # 28 entered the nurse station, and she was informed that the medication…

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 the facility staff failed to monitor the temperature of the refrigerator located in the pantry located on the Unit Lighthouse. This deficient practice has the potential to affect all the residents who reside in Unit Lighthouse. The findings are: On 01/05/23 at 8:41 am during the initial walk through of the facility the surveyor entered the pantry located on the Unit Lighthouse with Lighthouse Assistant Unit Manager #19; there was no temperature log for the month of January 2023. The surveyor observed a half-eaten pie on the lower shelf, a plate of food, an opened carton of milk, a container of pasta, a sandwich bag with slices of an orange, and a container of food in the refrigerator. None of the contents in the refrigerator were labeled or dated. On 01/05/23 at 8:47 am during an interview with Lighthouse Assistant Unit Manager #19 who stated the refrigerator is used for the residents. The temperatures are supposed to be done daily and the managers are supposed to make sure they are done. The surveyor received 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 medical record review and interview, the facility failed to provide an accurate matrix for all current residents. This deficient practice was found during a facility's annual survey. The findings includes: Minimum Data Set (MDS) - clinical assessment required for federally funded long term care facilities. The MDS assesses resident's functional capabilities and assist federally funded long term care facilities identify health problems. On 1/5/23 at 10:03 am, at the entrance conference, the team leader provided a list of required documents that are required upon the survey team's entrance in the facility. The Administrator confirmed that he/she understood what needed to be provided. On 1/5/23 at 12:30 pm, the Assistant Director of Nursing (ADON) provided the matrix of the facility's new admissions in the last 30 days. On 1/5/23 at 2:01 pm, the team leader interviewed the ADON regarding failure to receive the complete matrix of all residents. The ADON was unable to explain why the survey team failed to receive the complete matrix because the matrix is completed in the MDS…

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

Based on medical record review and interview it was determined the facility failed to maintain medical records according to professional standards. This was evident in one (#66) resident of thirteen medical records reviewed during the annual survey. The findings include: On 01/23/23 at 12:22 pm, the surveyor received a copy of the Resident and Family grievances Policy and Concern Forms related to Resident #66 from the Director of Guest Services #50. The Concern Forms and the Action Form to address the concern were not filled out completely. The incomplete Concern Forms were dated 12/15/22, 01/04/23, and 01/13/23. The incomplete Action Forms were dated 12/15/22, 01/19/23, and 01/20/23. When interviewed, the Director of Guest Services #50 reported the forms were supposed to be completed in their entirety. On 01/23/23 at 02:48 pm a review of the Concern Form dated 12/15/22, revealed Resident #66's daughter requested to have keys to the resident's drawer. During an interview with the Director of Guest Services #50, she believed the resident received keys to the locked drawer in her room…

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 provide a safe, functional, sanitary, and comfortable environment for residents and staff. This deficient practice has the potential to affect all the residents who reside in the unit Lighthouse. The findings include: On 01/05/23 at 8:27 am while on the unit Lighthouse, the surveyor entered the unlocked Soiled Utility Room which had a Biohazard sign on the door. There was gray tape over the door latch which prevented to door from locking. The sink had standing water, a trash can was on the counter, and the hand sanitizer dispenser was broken. The door to the Clean Utility Room was unlocked and the contents in the trash can were overflowing onto the floor. The door to the Respiratory Room which has respiratory supplies was unlocked. On 01/05/23 at 8:50 am Lighthouse Assistant Unit Manager #19 confirmed problems with the Clean Utility Room, the Soiled Utility Room, and the Respiratory Room. During an interview with Maintenance Director #29 on 01/26 23 9:38 am, his responsibilities include making sure…

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 administrative and medical record review and staff interview it was determined the facility failed to: 1. report a subnormal temperature to the physician and monitor the resident (Resident #255) after noting the change in condition and 2. failed to ensure initial smoking and elopement evaluations accurately reflected a resident's (Resident #67) diagnosis of dementia. This was evident for 2 of 3 residents reviewed for quality of care during this annual survey. The findings include: 1. The facility staff failed to monitor and report a subnormal body temperature for Resident #255. Normal body temperature varies by person, age, activity, and time of day. The average normal body temperature is generally accepted as 98.6 degrees F (37 degrees C). Some studies have shown that the normal body temperature can have a wide range, from 97 degrees F (36.1 degrees C) to 99 degrees F (37.2 degrees C). www.mayoclinic.org Review of complaint #MD00121537 revealed a concern that facility staff failed to monitor and address a subnormal temperature reading for resident #255. A Nurse…

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

Based on medical record review and interview it was determined the facility staff failed to establish and maintain a system for ensuring accuracy in weight measurements for a nutritionally compromised resident, and failed to ensure that physician ordered weekly weights were obtained and recorded as ordered. This was evident in 2 of 5 residents (Resident #24 and #11) reviewed for nutrition during this annual survey. The findings include: 1. The facility failed to ensure facility staff implemented consistent measures for ensuring accuracy of weight measurements for Resident #24. Medical record review revealed Resident #24 was a long-term care resident with diagnosis that included but were not limited to Lymphedema. Lymphedema is a condition that results in swelling of the upper and lower limbs. A Nutritional Assessment, dated 8/16/18, revealed the resident's weight was 208 pounds. The resident was noted to have a significant weight gain over the last 6 months primarily related to edema (swelling due to fluid retention) of both lower extremities. Further review of the medical record…

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 administrative record review and interviews with facility staff it was determined the facility failed to ensure that there was not greater than 14 hours between the residents receiving their last meal for the evening and the next scheduled meal. This was found to be evident during the facility's annual survey. Findings include: The facility's scheduled meals were reviewed on 10/31/18 and revealed that there is greater than 14 hours between dinner being served to residents in the evening and breakfast being served the following morning. The facility's breakfast begins at 7:40 AM and dinner is served at 5:20 PM. Additionally, the residents reported during the resident council meeting held on 10/30/18 at 10:36 AM that the facility does not provide snacks to residents when requested or to diabetic residents. Cross reference F-565 An interview was conducted with the Director Nursing and Nursing Home Administrator (NHA) on 10/30/18 at 3:50 PM and they were made aware of all concerns. The NHA stated that s/he presented this to Quality Assurance Committee to be addressed, as 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.

Based on observations and interviews with facility staff it was determined the facility failed to ensure that sanitary conditions were maintained in the kitchen and food was stored properly. This was found to be evident during an initial tour of the facility during the facility's annual survey. Findings include: On 10/28/18 at 8:45 PM an initial tour of the facility was conducted and the following concerns were identified: Upon entry into the kitchen there was a cart that contained greater than 20 trays that had dirty dishes with food on each plate that was not disposed. To the right and inside of the room where the dish wash machine is located, there was standing puddles of water observed on the floor. There were dirty dishes on the counter top next to the dish washer. Inside of the dry storage area, on top of the shelf was a plastic bag of cake mix that was 1/2 filled, opened package of hamburger buns, Penne Pasta x 5 bags (1 pound each), a 5 pound bag of Uncle Bens Rice. All of the items did not have a date label on them. Inside of the refrigerator were a tray of small cups that…

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

Based on interviews with residents and staff and a review of resident council meeting minutes it was determined the facility failed to give adequate responses to grievances that were presented by the resident council. This was found to be evident during a resident council meeting that was conducted during the facility's annual survey. Findings include: The survey team conducted a resident council meeting on 10/30/18 at 10:36 AM and the following residents were in attendance: Resident #72, Resident #38 and Resident #15. The residents expressed the following concerns: The staff does not always respond to grievances. Resident #72 reported that an employee bleached clothing items that belonged to him/her and the staff was made aware of this and as of 10/30/18, those items had not been replaced. Resident #38 reported that an aide spilled a cup of water on his/her tablet and as a result it had not worked due to it being wet. Resident #38 stated that s/he told every staff that would listen about this incident including the Director of Nursing (DON). All three residents reported that…

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

Based on medical record review, observation and interview it was determined that the facility failed to ensure a chair alarm was only used when there was a physician order for the use of the alarm. This was found to be evident for 1 out of the 2 residents (Resident #35) reviewed for the use of restraints during the survey. The findings include: Review of Resident #35's medical record revealed a diagnosis of dementia and a dependence on a wheelchair for moving around the facility. On 10/29/18 at 2:07 PM the resident was observed in the wheelchair independently wheeling himself/herself down the hall of the unit. A position change alarm [also known as a tab alarm] was observed on the wheelchair and was attached to the resident's clothing. A tab alarm is a device that is put on the resident's wheelchair and a string is then attached from the alarm to the resident's clothing by use of a clip. When a resident stands up, or otherwise leaves the chair, the string pulls free of the device causing the alarm to sound. On 10/31/18 review of the medical record failed to reveal a physician order…

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

Based on medical record review and interviews it was determined that the facility failed to have an effective system in place to ensure residents and responsible parties were provided written notification regarding the reason for a hospital transfer, the location to which the resident was transferred, a statement of appeal rights or the contact information for the ombudsman. This was found to be evident for 1 out of 5 residents (Resident #11) reviewed for hospitalization during the investigative portion of the survey. On 10/30/18 review of Resident #11's medical record revealed the resident had been discharged to the hospital in July 2018 with a readmission several days later. Further review of the medical record failed to reveal any documentation that the resident or a responsible party was provided any information in writing in regard to the hospital transfer. On 10/31/18 at 10:41 AM the Director of Nursing reported that nursing does not provide any written notification regarding a hospital transfer but that she would check to see if medical records was doing something about that.…

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

Based on on medical record review, interview and review of recent facility discharge practices, it was determined that the facility failed to provide residents and or the resident representative (RP) with the proper paper documentation of the facility's bed-hold policy when a discharge to the hospital occurred, and failed to ensure correct information was shared when contact was made regarding the bed-hold policy. This was evident for 3 of 3 resident records (Resident #13, #47 and # 11) reviewed regarding planned and unplanned hospitalizations. The findings include 1. Review of the medical record for Resident #13 on 10/31/18 at 2:06 PM revealed diagnosis including a history of stroke and respiratory failure. During interview with Resident #13 on 10/29/18 at 10:33 AM s/he stated that s/he had a hospitalization in September 2018 related to another stroke. Review of Resident #13's medical record on 10/31/18 at 2:06 PM revealed that s/he was sent out 9/24/18 for symptoms related to a stroke. Further review of the medical record revealed a bed-hold carbon copy form that was blank. 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 medical record review, observation and interview it was determined that the facility failed to ensure accurate Minimum Data Set (MDS) assessments as evidenced by 1. failure to assess the use of a chair alarm; 2. failure to assess a resident who is dependant on g-tube feeding for nutrition as being totally dependant for eating. and 3. failed to identify a resident's weight loss and therefore, code a significant weight loss on the MDS correctly. This was found to be evident for 3 out of the 29 residents reviewed (Resident #35, #74 and # 88) during the survey. The findings include: The MDS is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1. Review of Resident #35's medical record revealed diagnosis of dementia and a dependence on a wheelchair for moving around the facility. On 10/29/18 at 2:07 PM the resident was observed in the wheelchair…

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 with facility staff it was determined the facility failed to complete a baseline care plan on a resident admitted with a Deep Tissue Injury (DTI), a pressure related injury to subcutaneous tissue under the skin. This was found to be evident for 1 resident (Resident #253) reviewed for pressure ulcers during the facility's annual survey. Findings include: A medical record review was completed for Resident #253 on 10/29/18 and it revealed the resident was admitted on [DATE] with a left buttock stage 3 pressure ulcer and a DTI to the left heel. Upon review of the resident care plan, it revealed a care plan for an actual pressure ulcer to left buttock. There was no care plan for the DTI located to the resident left heel. An interview was conducted with the Director of Nursing (DON) on 10/31/18 at 1:00 PM and s/he was asked if the resident had a care plan for the DTI to the left heel. The DON was unable to provide the survey team with a baseline care plan for 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 3. Failed to ensure care plans were updated to reflect current functional maintenance program (FMP) interventions: A. On 11/1/18 review of Resident #26's medical record revealed the resident was admitted in 2016 and whose diagnoses included stroke with right sided weakness, high blood pressure, diabetes and lung disease. Review of the 8/16/18 Minimum Data Set (MDS) assessment revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15; with clear speech and ability to understand and make self understood verbally. Further review of the 8/16/18 MDS revealed the resident was not steady during transfers and walking, and was only able to stabilize with staff assistance. On 10/29/18 at 11:25 AM the resident reported a concern regarding his/her toe related to poor circulation. Review of the medical record revealed a change in condition form on 9/24/18 that revealed documentation regarding pain and redness of the right great toe, the resident also received…

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 update the care plan that addressed: 1. the risk for fluid volume excess for a resident and 2. the use of a gait belt for a resident with a history of falls. This was evident for 2 residents (Resident #24 and #252) reviewed for care plan updates during this annual 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. 1. The facility failed to update the care plan that addressed the risk for fluid volume excess for Resident #24 to include current treatment needs. Medical record review on 11/1/18 revealed Resident #24 was a long-term care resident with diagnosis that included but were not limited to Lymphedema. Medical record review revealed a Nurse Practitioner's note, dated 3/29/18, that reported the resident had edema of both lower extremities. Recommendations included the administration of Lasix (diuretic), the application of ace wraps to the lower legs 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 interview and review of medical records it was determined that the facility failed to ensure staff reported when a resident sustained a fall. This was found to be evident for 1 out of 6 residents (Resident #26) reviewed for falls during the survey. The findings include: On 11/1/18 review of Resident #26's medical record revealed the resident was admitted in 2016 and whose diagnosis included stroke with right sided weakness, high blood pressure, diabetes and lung disease. Review of the 8/16/18 Minimum Data Set (MDS) assessment revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15; with clear speech and ability to understand and make self understood verbally. Further review of the 8/16/18 MDS assessment revealed the resident was not steady during transfers and walking, and was only able to stabilize with staff assistance. The MDS is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning…

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 employee files and interview it was determined that the facility failed to have a system in place to ensure annual evaluations and required dementia training had been completed by the geriatric nursing assistants (GNAs). This was found to by evident for 3 out of the 3 GNAs (GNA's #20, #21 and #22) reviewed for annual evaluations. The findings include: On 11/5/18 review of GNA #20's employee file revealed a hire date in May 2016. No documentation was found that an annual evaluation had been completed in the past year. No documentation was found of in-service education having been completed by this GNA in the past year. On 11/5/18 review of GNA #21's employee file revealed a hire date in 2013. No documentation was found that an annual evaluation had been completed in the past year. No documentation was found of in-service education for dementia or abuse training during the past year. On 11/5/18 review of GNA #22's employee file revealed a hire date in 2006. No documentation was found that an annual evaluation had been completed in the past year, the most recent…

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 administrative and medical record review and staff interview it was determined the facility failed to promptly dispose of Morphine Sulfate, prescribed for Resident #103 upon the resident's death. This was evident for 1 of 3 residents reviewed for narcotics accountability during this annual survey. The findings include: Morphine Sulfate is a pain reliever used to treat moderate to severe pain. Resident #103 was admitted to the facility for palliative care with diagnoses that included but were not limited to cancer with associated cardiac complications. A Nurse Practitioner documented on [DATE] that s/he was asked by nursing staff to see the resident regarding complaints of shortness of breath and abdominal pain. The Nurse Practitioner documented that s/he would prescribe Morphine Sulfate 5 milligrams sublingually (under the tongue) twice a day and every 4 hours as needed. Review of the physician's orders revealed an order that was entered in the electronic medical record system, on [DATE] at 11:47 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 medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure monthly pharmacist reviews were completed for each resident. This was found to be evident for 1 out of 6 residents (Resident #11) selected for unnecessary medication review. The facility also failed to respond to pharmacy irregularities that were identified by the pharmacy. This was found to be evident for 1 resident (Resident # 49) reviewed. The findings include: 1. On 10/31/18 review of Resident #11's medical record revealed the resident had several admissions to and discharges from the facility in the past year. Review of the Minimum Data Set assessments revealed the resident had been re-admitted to the facility in mid May 2018. On 10/31/18 review of the medical record failed to reveal any documentation that a pharmacist had completed a medication regimen review during the month of June 2018. On 10/31/18 at 1:57 PM the surveyor reviewed the concern with the Unit Nurse Manager #14 that there was no evidence that a pharmacy review had been completed…

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.

2. Review of the medical record for Resident #79 on 10/30/18 at 10:00 AM revealed diagnoses including Parkinson's disease and chronic pain syndrome. Further review of Resident #79's medical record revealed physician orders on 10/3/18 for Percocet to be administered every 6 hours as needed for moderate to severe pain (4-10 on a pain score). Review of Resident #79's medication administration record (MAR) revealed administration of the Percocet 25 of 29 days in October 2018, one to four times a day. According to the MAR the medication was documented as E for effective. A closer look at the residents nursing notes revealed that the E for effectiveness was not documented or assessed within an hour after the medication was administered. This was evident in only three days of review were there were five occasions between 10/7/18 and 10/10/18 that the effectiveness of the medication was not documented or assessed within an hour of administration. The concern that the effectiveness of the Percocet was not assessed on a consistent basis throughout the month of October 2018 according to the…

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

Based on observation and medical record review it was determined that the facility failed to administer medications and maintain an error rate of less than 5% by following physician orders. This was evident during the observation of medication pass by 4 nurses and 5 residents and 30 medication opportunities. The findings include: 1. During the observation of medication pass on 10/30/18 at 9:10 AM with Staff Nurse #41 during the preparation of medication pass a Centrum Vitamin fell onto the nursing cart. Staff #41 threw the medication into the trash, leaving the medication accessible for any resident that may pass in the hall. At the end of observation of medication pass, Staff #41 was notified of the potential that this was a medication error that the Centrum was not disposed of properly. Interview with the Director of Nursing (DON) on 10/30/18 at 10:53 AM revealed that it was the expectation that any medication (non-narcotic) that was not given to a resident that needed to be destroyed should go into the sharps container. The DON was notified at that time that this would be…

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 failed to 1. ensure medical records were accurately documented as evidenced by failure to ensure staff did not document services which were not provided, and 2. document evidence of ongoing monitoring of a resident (Resident #103) with a change in condition that required the administration of narcotic pain medication. This was found to be evident for 2 out of 29 residents (Resident #26 and Resident #103) reviewed during the survey. The findings include: 1. On [DATE] review of Resident #26's medical record revealed the resident was admitted in 2016 and whose diagnoses included stroke with right sided weakness, high blood pressure, diabetes and lung disease. Review of the [DATE] Minimum Data Set (MDS) assessment revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15; with clear speech and ability to understand and make self understood verbally. Further review of 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 medical record review and interview with staff it was determined that the facility failed to have an effective system in place to ensure influenza consents were obtained from the appropriate party and administration of the influenza vaccine were administered to newly admitted residents. This was found to be evident for 1 out of the 5 resident's (Resident #151) reviewed for administration of the influenza vaccine. The findings include: On 11/1/18 review of Resident #151's medical record revealed two Physician Certifications Related to Medical Condition, Decision Making and Treatment Limitations forms, signed by physicians on 10/17/18 and 10/18/18, which documented that the resident lacks adequate decision making capacity. Further review of the medical record revealed the Influenza Immunization Informed Consent form had been signed by the resident on 10/27/18 and witnessed by a licensed practical nurse. On 11/1/18 at 3:16 PM the Unit Nurse Manager #14 reported that to identify the responsible party you access the electronic health record (EHR). Review of the EHR face sheet…

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.