Autumn Lake Healthcare At Arlington West

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 have a process to ensure that medication regimen reviews occur monthly for all residents and pharmacist recommendations were timely acted upon and documented in the resident's medical record. This was evident for 6 of 6 residents (Resident #24, #28, #31, #41, #67, #180) reviewed for unnecessary medications. Additionally, the facility failed to develop policies and procedures related to time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, 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 the review of the medical record review, observations, and interviews, it was determined the facility staff failed to: 1) maintain medical records in the most accurate form as the facility failed to completely identify the positions of staff in the electronic health record. All resident records are affected by this lack of staff identification; 2) maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. This was evident for 3 out of 8 residents (Residents #25 and #32 and #180) reviewed for medical records during the survey, The findings include: 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. While conducting medical record reviews during the survey it was discovered that progress notes would have a name of the clinician, but the note did…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined that the facility failed to maintain strict infection control processes evidenced by: 1) staff failing to keep a urinary catheter bag off the floor. This was evident for 1 of 4 residents (#57) reviewed for a foley catheter and 2) failed to provide education and convey updates to staff on COVID-19. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The findings include: A urinary catheter (also known as foley catheter) is a flexible tube placed in the body which is used to empty the bladder and collect urine in a drainage bag. (Foley Catheter definition on Merriam-webster) Germs can travel along the catheter and cause an infection in the bladder or kidney that could cause a catheter-associated urinary tract infection if proper infection control practices are not put in place and followed. (Centers for Disease Control guideline) 1) Observation was made on 4/25/22 at 11:50 AM 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 record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Parties (RPs) were provided education on Influenza and Pneumococcal vaccines before requesting consent. This was evident for 5 (Resident #25, #26, #32, #53, and #67) of 5 residents reviewed for Immunizations during the survey. The findings include: Pneumococcal vaccine help prevents pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people 65 years…

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

Based on the staff interview, review of facility policies, and facility's tracking record, it was determined the facility failed to provide COVID-19 testing for the unvaccinated staff. This was evident for 3 of 50 staff (Licensed Practical Nurse (LPN) #39, Registered Nurse (RN) #40, and Geriatric Nursing Assistant (GNA) #41) reviewed for COVID-19 testing during the survey. The finding includes: During the entrance conference with the Nursing Home Administrator (NHA) on 4/19/22 at 8:35 AM, she stated that the facility currently had three unvaccinated staff (LPN #39, RN #40, and GNA #41). On 4/28/22 at 1:40 PM during an interview with the Infection Control Preventionist (ICP), she stated that since the county COVID-19 rate was elevated, the facility had started to do the COVID-19 testing twice a week from the week of 4/18/22 for the unvaccinated staff. Before the week of 4/18/22, the facility performed a COVID-19 test once a week for the unvaccinated staff. The ICP also submitted the staff COVID-19 testing log. On 4/28/22 at 1:44 PM a review of the testing log revealed that 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 staff interview, it was determined the facility failed to: 1) document education provided regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents and staff, and 2)maintain a consent form in the residents' medical record. This was evident for 1 of 5 residents (Resident #67) and 8 facility staff members reviewed for COVID-19 vaccinations during the survey. The findings include: 1) On 4/27/22 at 2:30 PM, Resident #67's medical record review was conducted. The electronic medical record under the immunization tab revealed Resident #67 received the COVID-19 vaccine on 1/7/21, 1/29/21, and 10/20/21. However, no documentation was found for the consent form and evidence of education was provided under the resident's paper chart or electronic medical record. During an interview with the Director of Nursing (DON) on 4/28/22 at 9:00 AM, she stated Resident #67 received the COVID-19 vaccine from a pharmacy vendor. Since the vendor pharmacy received consent and provided a factsheet before the vaccines were given…

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 complaints, reviews of an active and closed medical records, and complainant and staff interviews, it was determined that the facility staff failed to immediately notify a resident's physician when: 1) a resident had a hypoglycemic event (Resident #65), and 2) when a resident was identified with a significant weight loss (Resident #176). This was evident for 2 of 9 complaints reviewed during an annual recertification survey. The findings include: 1) Reviews of complaint MD00175030 on 04/20/2022 at 9 AM revealed an allegation that Resident #65 was observed by a family member with a wound that was not identified by the nursing staff. In an interview with the complainant, on 04/21/2022 at 2:25 PM, the complainant stated that Resident #65 had just been observed by him/her to be unresponsive, sweaty, hot to touch, and unable to finish the therapy session this morning. The complainant stated that Resident #65 did not respond to his/her name when being called. The complainant stated that s/he was concerned…

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, staff and resident interviews it was determined that the facility staff failed to ensure that residents were free from abuse and neglect. This was evident for 3 of 6 residents (Resident #9, #225, #272) reviewed for facility reported incidents related to abuse and neglect allegations. The findings include: 1) Review of facility reported incident MD00172452 on 5/2/22 revealed that Resident #272 was verbally abused by staff. Review of the facility's investigation revealed Resident #272 had alleged that an agency Geriatric Nursing Assistant (GNA) #48 was verbally abusive. The facility administrative staff investigated the allegations and substantiated that the agency GNA was verbally abusive. The staffing agency was notified for the GNA not to return to the facility. The Director of Nursing (DON) was advised that the facility would be cited for abuse on 5/4/22 at 11:15 AM. 2) Review of facility reported incident MD00166279 on 5/2/2022 revealed that Resident #225 reported on 4/15/2021 that GNA #35 was rough, loud and would not let them sit back down when they…

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 reviews of a facility reported incidents, the facility abuse policy, and staff interview, it was determined that the facility failed to notify local law enforcement of an allegation of misappropriation of resident property. This was evident for 1 of 8 residents (Resident #181) reviewed for abuse during an annual recertification survey. The findings include: Review of facility reported incident MD00159199 on 04/25/22 revealed Resident #181 reported missing $95 from his/her wallet to the manager on duty on 10/10/2020. The facility reported the allegation of misappropriation of resident property to the State Long Term Care Agency at that time. Review of the facility self-report form, under the box heading, Local Law Enforcement Contacted? the facility administrator indicated NO. The facility completed the investigation into Resident #181's missing $95 on 10/12/2020 and was unable to substantiate the allegation of misappropriation of resident property or determine a possible perpetrator. Review of Resident…

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

Based on medical record review and staff interview it was determined that the facility failed to document the transfer or discharge of a resident was necessary for the resident's welfare and the resident's needs could not be met in the facility. This was evident for 1 of 4 residents (Resident #3) reviewed for discharges and transfers during an annual recertification survey. The findings include. Review of Resident #3's medical record on 04/27/2022 at 10:36 AM failed to reveal any transfer forms that Resident #3 received prior to being transferred to a sister facility on 01/13/2021. The nursing staff developed a COVID-19 care plan on 01/13/2021 that included the following intervention: to apply a sign on the door informing staff of Droplet & Contact precautions, encourage the resident to wear a mask, monitor poor appetite and dehydration and to report the findings to the resident's physician, and to obtain a temperature and perform a respiratory assessment every shift. In an interview with the facility Infection Control Preventionist (ICP) #4 on 05/03/2022 at 9:38 AM, the facility…

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

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 of 4 residents (Resident #28, #3) reviewed for facility-initiated transfers. The findings include: 1) Review of Resident #28's electronic and paper medical record on 4/20/22 at 2:17 PM revealed on 2/10/22 at 12:00 Noon, Resident #28 was transferred to the hospital for acute renal failure and altered mental status. Further review of Resident #28's medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party and/or resident was notified in writing of the hospital transfer. An interview was conducted with the director of nursing on 4/22/22 at 9:30 AM. She indicated that copies of a transfer form including the bed hold policy should be included in the medical record. She was informed that the transfer documents were not found in the medical record. At 11:10…

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 that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 of 4 residents (Resident #28) reviewed for hospitalization during the annual survey. The findings include. Review of Resident #28's electronic and paper medical record on 4/20/22 at 2:17 PM revealed the resident had a change in condition on 2/10/22 at 10 AM. The physician was notified and ordered for the resident to be transferred to the hospital for evaluation related to Acute Renal failure and Altered Mental status. There was no documentation as to what interventions were put into place before the transfer, what the resident was told and if the resident understood where he/she was going and why. An interview was conducted with the director of nursing (DON) on 4/22/22 at 9:30 AM. The DON reviewed Resident #28's medical record related to the transfer documentation and corroborated that there was no documentation related to the sufficient preparation and orientation 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 medical record review and staff interview it was determined the facility 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 3 of 5 residents (Resident #28, #3, #41) reviewed for transfers out of the facility. The findings include: 1) Review of Resident #28's electronic and paper medical record on 4/20/22 at 2:17 PM revealed the resident had a change in condition on 2/10/22 at 10 AM. The physician was notified and ordered for the resident to be transferred to the hospital for evaluation related to Acute Renal failure and Altered Mental status. Further review of Resident #28's medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party and/or resident was given a copy of the bed hold policy. An interview was conducted with the director of nursing (DON) on 4/22/22 at 9:30 AM. She was informed that the Bed Hold document was not found in the medical record. At 11:10 AM on 4/22/22…

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 medical record review, and staff interview it was determined that the facility failed to have an effective system in place to ensure care plans are thoroughly evaluated and revised by the interdisciplinary team after each assessment. This was evident for 3 of 3 residents (Resident #26, #32, #66) reviewed for care plan revision. The findings include. The Minimum Data Set (MDS) is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs. Assessments are conducted by trained nursing home clinicians on all residents at admission and discharge, in addition to other time intervals (e.g., quarterly, annually, and when residents experience a significant change in status) so that residents receive services in the most integrated setting appropriate to their needs. After the MDS is conducted, the intra-disciplinary team (nursing, dietician, activities, social worker, pharmacist and physician)…

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

Based on medical record review and interview it was determined that the facility failed to ensure staff followed physician orders as evidenced by: 1) failure to ensure ordered consults were addressed. This was evident for 1 of 4 (Resident #57) residents reviewed during the survey; 2) failure to change, label, date and initial oxygen tubing and humidifier bottle. This was evident for 1 of 8 residents (Resident #32) reviewed during the survey. Although this noncompliance resulted in no actual harm to the residents, it has a potential for more than minimal harm if the practice is not corrected. The findings include: 1) On Tuesday 4/19/22 at 10:35 AM, Resident #32 was observed receiving humidified oxygen via nasal cannula (plastic cannulas in the nostrils). There was no date and/or initial on the oxygen tubing or humidifier bottle indicating when these were changed. On Thursday 4/21/22 at 10:20 AM, surveyor observed that Resident #32's oxygen tubing and humidifier bottle were not labeled with a date or initial to show when they were changed. The humidifier bottle was almost empty. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of a clinical record, and complainant and staff interviews, it was determined that the facility failed to identify a resident who was at risk for pressure wounds and implement and take steps to create a baseline care plan with nursing interventions to prevent a pressure wound. This was evident for 1 of 5 residents (Resident #65) reviewed for pressure ulcers during an annual recertification survey. The findings include: A pressure ulcer also known as pressure sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to 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…

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, staff interview, and observation it was determined that the facility failed to ensure: 1) admitted with a Foley catheter was assessed for removal of the catheter timely (Resident #65); 2) follow a care plan which included positioning foley bag (Resident #57); 3) follow the physician's order for a follow-up appointment with a urologist 1 week after admission (Resident #57), and 4) follow a physician's order for catheter care (Resident #57). The failure of the facility to assess the foley catheter usage placed the resident at risk for infection. This was evident for 2 of 4 residents reviewed for foley catheters during the survey. A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Always place the drainage bag below the level of the bladder and off the floor to prevent getting infections. (Foley catheter definition on www.merriam-webster.com) 1) Review of Resident #57's care plan on 4/25/22 at 12:20 PM indicated the resident had a care plan for a foley…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined the facility failed to properly store medications as evidenced by failing to ensure that medication and treatment carts were locked when unattended. This was evident for 1 of 2 treatment carts observed on the 2nd floor unit. The findings include: Observation was made on 4/19/2022 at 9:12 AM while walking past resident room [ROOM NUMBER] and the bathing/shower room, of a treatment cart in the hallway which was unlocked and unattended. There were various ointments, resident labeled treatments, bandages, and other various nursing supplies observed in the cart. Approximately 1 minute later, the Assistant Director of Nursing (ADON) walked down the hall and observed that the treatment cart was left unlocked and unattended. The ADON stated the treatment cart was supposed to be always locked and then proceeded to lock it. Review of the Medication Storage policy that was given to the surveyor by the Director of Nursing (DON) on 4/22/2022 at 8:40 AM during 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, resident and staff interviews, and medical record review, it was determined that the facility failed to provide dental services within a reasonable time frame following a physician's dental consult request. This was evident for 1 of 2 residents (Resident #26) reviewed for dental. The findings include: During an introductory interview of Resident #26 on 4/20/22 at 12:51 PM, it was revealed the resident had a concern about a loose upper front tooth. Resident #26 acknowledged that staff was informed, and the resident was reportedly on a list to be seen by a dentist. Resident #26 was unaware of a date or time of schedule to be seen by a dentist. A review of Resident #26's medical record on 4/25/22 at 10:13 AM revealed a change of condition progress note written on 2/10/2022 at 2:45 PM. The summary of the change of condition was written as; Resident reported two shaky upper front teeth. attending MD made aware. The Resident verbalized that he/she is unable to drink cold water because of the painful sensation around the teeth when he/she does. MD orders Dental…

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 that the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This was found to be true for 1 of 2 units (3rd floor) observed during the environmental tour of the facility. This deficient practice has the potential to affect all residents, staff, and visitors on the unit. Findings include: An environmental tour of the facility was conducted on 05/03/22 at 1:25 PM with the facility maintenance director. Observation of the 3rd floor Long Term Care Unit revealed that 2 facility geri chairs were noted with armrests in disrepair. (A geri chair is a Medical Recliner Chair designed to allow someone to get out of the confines of their bed and be able to sit comfortably in a variety of positions while being fully supported.) These concerns were brought to the attention of the facility Administrator and Director of Nursing on 05/06/22 at 2:10 PM. These concerns were reviewed with the facility Administrator and Director of Nursing on 05/06/22 at 3:15 PM during…

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, it was determined that the facility staff failed to provide a resident with an adaptive type call bell that would allow the resident to summon staff while wearing bilateral hand mittens. This was evident for 1 (Resident #29) of 28 residents reviewed during an annual recertification survey. The findings include: During a tour of the facility on 10/29/18 at 12:16 PM, the surveyor observed Resident #29 to be lying in bed with bilateral hand mittens in place. Resident #29's call bell was within reach, but his/her call bell was the type that a person would need the use of their hand and available finger to press/engage to summon a staff member for assistance. Resident #29 was unable to use his/her hands and fingers to manipulate the call bell at this time.

Based on medical record review, resident and staff interviews, it was determined the facility staff failed to notify Resident (#6), the Guardian or Responsible Party (RP) verbally or in writing of a planned room change. This was evident for 1 of 28 residents selected for review during the survey process. The findings include: On 10/29/18 at 12:22 PM Resident #6 stated that s/he had a room change some time ago and wanted to know why s/he had to change rooms. Resident #6 stated that no one told her/him of the room change or why s/he had to move. Review of the medical record revealed 1 nursing note written on 4/17/17 stating Resident #6's room was changed; a call was placed to the Guardian and staff was unable to leave a voice message. Further review of the medical record failed to provide any additional documentation to show that Resident #6, her/his RP or guardian were provided with a notification or explanation verbally or in writing of the reason for the room change. In an interview with the unit manager Staff #4 on 10/31/18 she stated that Resident #6 was not getting along with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility staff failed to maintain a current advanced healthcare directive within the medical record indicating Residents (#2) choices regarding life sustaining treatment. This was evident for 1 of 28 residents selected for review during the survey process. The findings include: An advance healthcare directive, also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. The MOLST (Medical Orders for Life Sustaining Treatment) form makes treatment wishes known to health care professionals. Maryland MOLST is a portable and enduring form for orders about cardiopulmonary resuscitation and other life-sustaining treatments. Medical record review for Resident #2 revealed that upon admission on [DATE] the attending physician…

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

Based on review of administrative documents, complaint and staff interview, it was determined that a facility staff member failed to report an allegation of 1) missing money in a timely manner to the facility administrator, and 2) report an allegation of abuse to the State survey agency. This was evident for 2 (Resident #2 #71) of 28 residents reviewed during an annual recertification survey. The findings include: 1) Review of facility reported incident MD00132571 on 10/29/18 revealed, during a care plan meeting on 10/15/18 Resident #2 reported that s/he had approximately $100.00 stolen from a sock in his/her wardrobe cabinet. In an interview with Resident #2 on 10/30/18 at 10:10 AM resident confirmed that s/he was missing one hundred and some dollars and was still waiting to hear the outcome of the investigation. In an interview with the facility administrator on 10/30/18 at 1:18 PM, the facility administrator stated that he became aware of the missing money following the care plan meeting held on 10/15/18 and immediately began the investigation. Review of the facility…

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, staff and resident interviews it was determined the facility staff failed to initiate an investigation after an allegation of abuse was made by a resident (Resident #6). This was evident for 1 of 28 residents reviewed during the survey process. These findings included: During an interview with Resident #6 on 10/29/18 at 12:22 PM Resident #6 stated that, there is a guy down the other hall the last room on the left. He has pissed on me 3 times, he just came right over to my bed and said you can't get up and he just pissed on me. I told the nurses, but they didn't do anything but move me to this room. On 10/31/18 at 11:05 AM in an interview with the unit manager (Staff #4) surveyor asked if she was aware of the incident with Resident #6 and a previous roommate whom he/she said had urinated on him/her? She said she was aware, and stated that is what Resident #6 said but there was not any evidence of urine. She further stated that her/his roommate would urinate in the room, but they never saw any urine on Resident #6. On 10/31/18 at 1:45 PM interview with Social…

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 that the facility failed to notify the resident or their responsible party in writing with a copy to the state ombudsman of resident's (Resident #39, #40, #56) transfer to the hospital and the reasons for the transfer. This was evident for 3 of 28 residents sampled during the annual survey. The findings include: 1. On 9-16-18 Resident #56 was sent to the hospital due to a change in condition. The Administrator confirmed on 10/30/18 at 1:30 PM that the facility did not notify the resident's responsible party in writing of the transfer and the reason for the transfer. The facility also did not send a copy of the transfer to the state ombudsman. 2. A medical record review for Resident #40 was conducted on 10/30/18. Review of the physician order written on 9/5/18 revealed that Resident #40 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident…

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

Based on medical record review and interview, it was determined that the facility failed to notify the resident or the resident's responsible party in writing of the facilities bed-hold policy (Resident #39, #40, #56) before or soon after transferring them to the hospital. This was evident for 3 of 28 residents reviewed during the annual survey. The findings include: The bed-hold policy describes the facilities policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1. Resident #56 was transferred to the hospital on 9-16-18 due to a change in condition. The facility Administrator confirmed on 10-30-18 at 1:30 PM that the facility did not send a copy of their bed-hold policy to Resident #56's responsible party upon transfer to the hospital. 2. Review of the medical record for Resident #40 revealed the resident was transferred to an acute care facility on 9/5/2018. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold…

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 medical record and interviews with staff, it was determined that the facility staff failed to develop a comprehensive side or bed rail use care plan for a resident (#30). This was evident for 1 of 28 residents reviewed during the annual survey. The findings include: A care plan is a written guideline of care based on the individual resident's needs developed by an interdisciplinary team which includes nursing, rehabilitation staff, and dietary that communicates to other health care professionals. After assessment by the facility's physical therapist, ¼ side rails were placed on the bed for Resident #30's use. On 10-30-18 at 10:50 AM the 3rd floor Unit Manager confirmed Resident #30 did not have a care plan concerning side rail use to guide the facility staff.

Based on clinical record review and staff interview it was determined that the facility staff failed to 1) ensure that quarterly resident care plan meetings were held within the required timeframes, 2) follow a resident's protective device care plan by documenting that the staff is checking a resident's distal pulses, and 3) update a resident's care plan regarding the prolonged use of an antibiotic cream around a gastrostomy tube site (Residents #6, #11, #29). This was true for 3 out of 28 residents reviewed during a recertification survey. The findings include: The MDS is a federally-mandated assessment tool that is completed upon admission, quarterly and as needed for any significant change. The MDS helps nursing home staff gather information on each resident's strengths and needs. A review of Resident #6's clinical record revealed documented care plan meetings on 01/19/17 and 04/21/17 with an attendance roster. Electronic record review revealed multiple Social Work notes all labeled as Care Plan Notes. Review of all Social Work notes which were provided by the Administrator 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 review of a medical record and staff interview, it was determined that the facility staff failed to address the continued use of an antibiotic cream for a resident. This was evident for 1 (Resident #11) of 28 residents reviewed during an annual recertification survey. The findings include: Review of Resident #11's medical record on 10/29/18 revealed a physician's order, dated 04/08/18, instructing the nursing staff to apply the antibiotic cream, Silvadene, to Resident #11's gastrostomy tube site, twice daily, related to the site being sore. Further review of Resident #11 medical record revealed physician notes dated 05/27/18, 07/28/18, 08/23/18 and 10/27/18 that documented Resident #11's peg tube site as intact and that Resident #11's skin was warm and dry with no break down. Review of Resident #11's nursing quarterly care plan review, dated 08/18/18 at 7:42 AM, also indicated Resident #11's skin was intact.

Based on medical record review, resident observation and staff interview, it was determined that the facility staff failed to ensure that a resident's environment was free from potential accidents (Resident #30). This was evident for 1 of 28 residents selected for review in the annual survey. The findings include: On 10/29/18 at 10:50 AM during the initial resident interviews stage of the annual survey Resident #30 was observed in his/her room. Due to the disease process Resident #30 was unable to self transfer from the bed to the wheelchair or to return. Geriatric Nursing Assistant (GNA) #1 had Resident #30 in the sling of a bedscale/hoyer lift 10 to 12 inches off the bed in the air. A bedscale/hoyer lift is a mechanical device to weigh and transfer residents from the bed to the chair and the reverse. GNA #1 then left the room closing the door leaving Resident #30 alone hanging in the up position off the bed. GNA #1 returned to the room to pick up something and left a second time. This surveyor remained with Resident #30 during the incident. GNA #1 then returned at approximately…

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 staff failed to obtain consent from the resident or their responsible party before initiating side or bed rails on the resident's bed (Residents #30 and #56). This was evident for 2 of 28 residents reviewed in the annual survey. The findings include: 1. On admission on [DATE] Resident #30 signed the facilities care and services consents form. The form asked the resident if they wished to use side rails, considered a restraint, on their bed. Resident #30 checked the box that stated I do not wish to use side rails. On 09/04/18 the facility's therapy department assessed Resident #30 for use of side or bed rails. The therapy department determined the use of side rails would be beneficial for Resident #30 in providing a sense of security and for bed mobility. The side rails were instituted but Resident #30 did not sign a consent authorizing use nor did the facility obtain a physician's order for side rail use. This finding was confirmed with…

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