Complete Care At Annapolis

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (#65) of 2 residents reviewed for hospitalization during a recertification/complaint survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. During an initial screen of Resident #65 on 12/5/2024 at 7:51 AM, the resident stated that s/he was recently hospitalized . On 12/5/2024 at 8:48 AM a review of nurses' progress notes revealed a change in condition documentation dated 12/1/2024 at 7:16 AM that noted Resident #65 was sent to the ER (emergency room) via 911 on 12/1/2024 for altered mental status. Further review of the change in condition form revealed Resident #65's daughter was present at time of transfer…

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, staff interview, and observation, it was determined that the facility staff failed to provide an activities program to meet the needs and preferences of residents by 1) not performing activities with residents per care plan and 2) not documenting care plan activities. This was evident for 1 resident (Resident #31) reviewed during the Medicare/Medicaid recertification survey. The findings include: On 12/04/24 at 11:29 AM, during a phone interview with Resident #31's mother, she told the surveyor that Resident #31 had activities as part of his/her care plan, but the activity staff had not seen him/her. On 12/06/24 at 9:01 AM, the surveyor reviewed the electronic record for the resident and the care plan showed that Resident #31 had little, or no activity involvement related to physical limitations initiated on 05/06/2022, the goal was that Resident #31 will participate in activities of choice while in the room due to physical limitations and was revised on: 08/06/2024 with a target date of 11/30/2024. It also showed the intervention which was that the…

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

Based on observations, medication record review and interview with facility staff, it was determined that the facility failed to direct a resident (#45) to rinse their mouth after the administration of an inhaler as ordered by the physician. This occurred for one (Resident #45) of four residents observed during a medication observation during the recertification/complaint survey. The findings include: During medication observation on 12/10/24 at 9:22am, LPN (Licensed Practical Nurse) staff #16 administered Trelegy inhalation to Resident #45. Trelegy is a prescription medicine used long term to treat COPD (chronic obstructive pulmonary disease). Review of the medical record on 12/10/24 at 10:39am revealed a physician order dated 12/5/24 to administer Trelegy one inhalation Inhale orally (by mouth) one time a day for COPD. Rinse mouth after use. Staff #16 failed to instruct resident #45 to rinse his/her mouth after the inhalation of the Trelegy. During interview with the Director of Nursing on 12/10/24 at 12noon she verified the findings. She stated the nurse realized her error 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 a facility reported incident, medical record review, and staff interview, it was determined that the facility staff failed to provide adequate supervision to a resident to prevent unsafe wandering/elopement. This was evident for 2 (#98, #29) of 2 residents reviewed for elopement during a recertification/complaint survey. The findings include: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle A Wander guard bracelet is used to keep residents at risk of wandering/elopement comfortable and protected. It is discreet yet powerful, it triggers alarms and can lock monitored doors to prevent the resident leaving unattended. The Brief Interview for Mental Status (BIMS) score is a number between 0 and 15 that indicates a person's cognitive health:…

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, review of records and interview with facility staff and resident, it was determined that the facility failed to provide necessary respiratory care services for residents by failing to implement the physician order for a resident with tracheostomy. This was evident for 1 resident (Resident #54) reviewed for respiratory care during the Medicare/Medicaid recertification survey. The findings include: On 12/04/24 at 08:46 AM, during the initial tour of the facility, Resident #54 complained to the surveyor that his/her Passy-Muir valveSpeaking Valve (A Passy-Muir valve is a medical device that helps tracheostomy and ventilator patients communicate and maintain their airway) had not been changed since he/she got to the facility about one year ago. He/She added that he/she had a prescription from the Ear Nose and Throat (ENT) physician for a speaking valve since April 2024 and another prescription for the same valve and a tracheostomy collar in November 2024, but the facility had not replaced it. He/She provided a copy of the prescription to the surveyor. On 12/06/24…

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 staff interviews, it was determined that the facility failed to follow up with pharmacy recommendations after the monthly reviews were completed. This was evident for 2 (#56 and #10) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey. The Findings include: Abnormal Involuntary Movement Scale (AIMS) evaluation is a 12-item rating evaluation scale use to assess the severity of abnormal movements which is a side effect of certain antipsychotic medications. On 12/5/24 at 9:36 AM: Review of Resident #56's monthly pharmacy review from September to December 2024 revealed that the pharmacist found some irregularities in September, November and December. Further review showed that September and November recommendation forms could not be found. The Director of Nursing (DON) was asked to provide the reports. On 12/5/24 at 9:46 AM Review of the Pharmacy Drug regimen review from January to December 2024 for resident #10 revealed irregularities for the months of August, October and December, the facility provided the December…

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 staff interview it was determined that the facility failed to thoroughly investigate the allegation of misappropriation of property for a resident. This was evident for 1 of 1 resident (Resident #7) selected for review of misappropriation of property and 1 of 40 residents selected for review during the annual survey process. The findings include: The purpose of a thorough investigation is first to determine if abuse or misappropriation of property of the resident has occurred. It is the expectation that any allegation of abuse or misappropriation of property be investigated by the facility. This investigation includes interviews with all direct caregivers and staff for the reported allegation. Surveyor review of investigation of MD00132711 on 11/7/19 at 9:00 AM revealed that on 10/18/18, Resident #7 was missing $960.00 from his/her room. Resident #7 indicated the $960.00 was in the dresser drawer, in his/her pant pocket. Resident #7 informed the facility staff that the money went missing from his/her room between 8:30 AM and 10:30 AM on 10/18/19, and 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 resident interview, medical record review and staff interview, it was determined that the facility staff failed to conduct an accurate, comprehensive assessment for a resident with dental complaints. This was evident for 1 of 2 residents (Resident #4) reviewed for dental care issues during an annual recertification survey. The findings include: The Minimum Data Set (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 these individualized needs, and that the care is provided as planned to meet the needs of each resident. In an interview with Resident #4 on 11/05/19 at 1:17 PM, Resident #4 stated that s/he had not seen a dentist or been offered to see a dentist since being admitted to the facility in 2013. Resident #4 also stated that she/he has a broken tooth on his/her lower right side that has…

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 a medical record and staff interview, it was determined that the facility nursing staff failed to implement a comprehensive person-centered care plan regarding: 1) a resident's pain management and anxiety and 2) a resident's medical diagnosis. This was evident for 2 of 7 residents (Residents #59 and #40) reviewed for unnecessary medications during an annual recertification 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. A review of Resident #59's medical record on 11/14/19 at 10:00 AM revealed a physician's order, dated 07/24/19, that instructed the nursing staff to administer the pain medication Morphine, 5 mg (milligrams), every 2 hours as needed for moderate to severe chronic pain level of 4-10, maximum daily amount 60 mg. Further review of Resident #59's medical record on 11/14/19 failed to reveal a care plan that addressed Resident #59's chronic pain and nursing interventions to help alleviate Resident #59's pain. In 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.

Based on observation, reviews of a medical record, and staff interview, it was determined that the facility failed to: 1) obtain a physician order for the continued use of an abdominal binder, and 2) revise a comprehensive care plan for the use of an abdominal binder that listed specific nursing interventions for the care of Resident's skin and the application and removal of an abdominal binder. This was evident for 1 of 2 residents (Resident #50) reviewed for care planning during an annual recertification survey. The Findings: 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. During an observation of Resident #50 lying in his/her bed on 11/05/19 at 10:39 AM revealed that Resident #50 had the application of an abdominal binder to his/her person. In an interview with the facility Assistant Director of Nursing (ADON) on 11/06/19 at 1:19 PM, the ADON stated that Resident #50 has an abdominal binder on for his/her abdominal hernia and that the staff were just monitoring abdominal…

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 interview, it was determined the facility staff failed to provide a resident with the highest practicable well-being of care and the facility staff failed to follow physician orders as written for daily dressing change to the left stump. This was evident for 1 of 40 residents (Resident #7) selected for review during the survey process. The findings include: Medical record review on 11/6/19 at 9:00 AM for Resident #7 revealed that on 10/16/19 the physician ordered: cleanse left stump with soap and water, pat dry, apply dry dressing cover and secure with tape, every day for wound care. Surveyor observation of Resident #7 on 11/06/19 09:24 AM, revealed the date on Resident's #7 left stump dressing was last changed on 11/1/19. The facility staff failed to change Resident #7's dressing daily as ordered by the physician. Interview with the Director of Nursing on 11/6/19 at 9:30 AM revealed the facility staff failed to provide Resident #7 with daily dressing change as ordered by the physician.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to provide treatment/services to maintain vision. This is evident for 1 out of 40 residents (Resident #7) selected for review during the investigation stage of the survey process. The findings include: During an interview with Resident #7 on 11/6/19 at 9 AM, the resident stated he/she was waiting for an appointment with the eye doctor. The resident stated: I can't see; my glasses were broken a while ago. Review of the resident's medical record on 11/7/19 at 12:00 PM revealed the resident inventory sheet of personal belongings included a pair of eyeglasses when the resident was admitted to the facility on [DATE], and the MDS (Minimum Data Set) assessment on 08/12/19, revealed Section B Hearing, Speech and Vision was coded that the resident did have adequate vision with corrective lenses. Further review of the medical record revealed an eye doctor's appointment was never scheduled. Interview with the Director of Nursing on 11/7/19 12:43 PM confirmed…

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 interview, it was determined the facility staff failed to ensure residents were free from unnecessary medications. This was evident for 2 of 6 residents (Resident #318 and Resident #3) selected for review of unnecessary mediations and 2 of 40 residents selected for review during the annual survey process. The findings include: 1. Medical record review on 11/12/19 at 12:00 PM for Resident #318 revealed on 8/2/19 the physician ordered: Ciprofloxacin 250 milligrams by mouth 2 times a day for UTI (urinary tract infection) prophylaxis (prevention). Ciprofloxacin is used to treat a variety of bacterial infections. Ciprofloxacin belongs to a class of drugs called quinolone antibiotics. It works by stopping the growth of bacteria. Physicians often prescribe Ciprofloxacin for residents with UTIs, as these infections are usually bacterial and respond well to this drug. The usual process is for the physician to order a urinalysis, culture and sensitivity for the resident. A urinalysis is a test of the urine. A urinalysis is used to detect 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 medical record review and interview, it was determined the facility staff failed to conduct AIMs testing on a resident. This was evident for 1 of 40 residents (Resident #6) selected for review during the survey process. The findings include: The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was designed in the 1970's to measure involuntary movements known as tardive dyskinesia (TD). TD is a disorder that sometimes develops as a side effect of long-term treatment with neuroleptic (antipsychotic) medications. Tardive dyskinesia is a syndrome characterized by abnormal involuntary movements of the patient's face, mouth, trunk, or limbs, which affects 20%-30% of patients who have been treated for months or years with neuroleptic medications. Persons taking any kind of antipsychotic medication need to be monitored for movement disorders. The AIMS (Abnormal Involuntary Movement Scale) aids in the early detection of tardive dyskinesia as well as providing a method for on-going surveillance. Medical record review on 11/12/19 at 7:30 AM for Resident #6 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined the facility staff failed to properly store medications. This was observed twice during an annual recertification survey. The findings: The first observation was made on 11/08/19 at 11:00 AM outside room [ROOM NUMBER]. The surveyor observed one unattended and unlocked respiratory therapy supply cart. A respiratory therapy supply cart holds supplies and medications for the resident's residing on the facility's specialized ventilator care unit. No respiratory therapy nor nursing staff members were attending to the respiratory therapy supply cart at the time of the observation. The respiratory therapy manager was immediately made aware of finding and locked the open medication cart. The second observation was made on 11/14/19 at 9:25 AM outside room [ROOM NUMBER]. The surveyor observed one unattended medication cart that had 2 pill medications seated on top of the medication cart. A medication cart holds the medications for the resident's residing in the…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood specimen and urinalysis for Resident (#318). This was evident for 1 of 40 residents selected for review during the annual survey process. The findings include: 1A. The facility staff failed to obtain a routine urinalysis and culture and sensitivity for Resident #318. Medical record review on 11/12/19 at 12:00 PM for Resident #318 revealed on 8/5/19 the physician ordered: urinalysis, culture and sensitivity. A urinalysis is a test of the urine. A urinalysis is used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis involves checking the appearance, concentration and content of urine. A urine culture is a method to grow and identify bacteria that may be in the urine. Bacteria are germs that cause infections. The sensitivity test helps caregivers pick the best medicine to treat the infection if one is detected. Further record review and interview with the Director of Nursing on 11/13/19 at 11:30 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 resident interview, medical record review and staff interview, it was determined that the facility staff failed to take steps to obtain dental services for a resident with complaints of missing teeth and difficulty chewing. This was evident for 1 of 2 residents (Resident #4) reviewed for dental care issues during an annual recertification survey. The findings: In an interview with Resident #4 on 11/05/19 at 1:17 PM, Resident #4 stated that s/he had not seen a dentist or been offered to see a dentist since being admitted to the facility in 2013. Resident #4 also stated that she/he has a broken tooth on his/her lower right side that has been there for a while. Resident #4 also stated that s/he would like to see a dentist. Resident #4 stated that s/he has no teeth on his/her upper ridge which makes it hard to eat some foods that are too hard or too tough to chew. Review of Resident #4's nursing documentation and assessments 11/12/19 at 10:00 AM revealed an annual MDS assessment was completed with an assessment reference date (ARD) of 08/10/19. The assessment failed to capture…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined the facility staff failed to maintain confidential information located in a medication cart computer. This was observed twice during an annual recertification survey. The findings: The Health Insurance Portability and Accountability Act (HIPPA) Privacy Rule is the first comprehensive Federal protection for the privacy of personal health. The HIPPA Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients' rights over their health information, including rights to examine and obtain a copy of their…

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 administrative records and staff interviews, it was determined that the facility failed to take steps to provide staff education to all Geriatric Nursing Assistant (GNA) staff members regarding the care of ventilator dependent residents. This was evident for 3 of 6 GNA staff members (GNA #28, #29. #30) reviewed during the survey. The findings: The facility assessment will enable each nursing home to thoroughly assess the needs of its resident population and the required resources to provide the care and services the residents need. It should serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources and may include the operating budget necessary to carry out facility functions. A review of the facility assessment on 11/06/19 under section A.1. Resident Population revealed that the facility is able to except out of state residents that require the uses of ventilators. Reviews of other administrative records revealed that the facility is dually certified to accept up to 32 ventilator dependent…

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 a medical record and staff interview, it was determined that the nursing staff failed to maintain an accurate medical record by not documenting the administration of a narcotic pain medication 11 times in the resident's medical record (Resident #59 and not documenting a complete and accurate diagnoses list for Resident #40. This was evident for 2 of 7 residents (Resident #59 and #40) reviewed for unnecessary medications during an annual recertification survey. The findings include: 1. A medical record is the official documentation for 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. A review of Resident #59's medical record on 11/14/19 at 10:00 AM revealed a physician's order, dated 07/24/19, that instructed the nursing staff to administer the pain medication Morphine, 5 mg (milligrams), every 2 hours as needed for moderate to severe chronic pain level of 4 - 10, with 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.