Autumn Lake Healthcare At Bridgepark

Based on surveyor observations, review of the medical record, and interview with facility staff, it was determined the facility staff failed to provide residents with respiratory care consistent with professional standards by failing to 1) properly date label oxygen tubing when changed and 2) Change the water in the humidifier. This was evident for 1 resident (Resident #10) out of 9 residents on oxygen reviewed during the Medicare/Medicaid recertification survey. The findings include: On 06/04/25 08:07 AM, during the initial tour of the facility, Resident #10 was seen in bed with nasal cannula and oxygen running at around 2 liters. The oxygen humidifier bottle was dated 04/21/2025 and the nasal cannula tubing had no dates. On 06/04/2025 at 8:10 AM, Licensed Practical Nurse LPN#4 was invited for a dual observation, and she confirmed that the nasal tubing was not dated, and the oxygen humidifier bottle was dated 04/21/2025. When she was asked what the process was after changing nasal tubing, she stated that the normal process should have been to date it. When asked how often the water…

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

Based on record review and interviews, it was determined that the facility failed to comply with State Regulations when the facility failed to provide nursing staff with a minimum of 2 hours of training on cognitive impairment annually. This was evident for 5 (Staff #13, Staff #14, Staff #15, Staff #16, and Staff #17,) of 5 nursing staff evaluated for cognitive impairment training and has the potential to affect all residents. The findings include: Maryland state regulations at 10.07.02.10 D. states, Ongoing training in cognitive impairment and mental illness shall be provided annually and consist of, at a minimum of 2 hours for employees who are licensed, certified, or registered under the Health Occupations Article, Annotated Code of Maryland, or who assist residents with activities of daily living. On 06/09/25 at 08:08 AM, as part of the sufficient and competent nurse staffing task, the surveyor asked the Director of Nursing (DON) to provide employee files of 5 randomly selected nursing staff. On 06/09/25 at 09:10 AM, the DON provided employee files for Staff #13, Staff #14,…

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 staff failed to maintain medical records on each resident that are complete and accurately documented. This was evident for 1) 1 (#94) of 3 residents reviewed for an injury of unknown origin, 2) 1 (Resident #86) out of 2 resident's reviewed for death in the facility, 3) 2 (Resident #33 and #60) of 5 residents reviewed for pressure ulcers, 4) 1 (Resident #30) of 3 residents reviewed for activities, and 5) 1 resident (Resident#104) out of 17 facility reported investigations reviewed during an annual survey.The findings include:1) Review of Resident #94's medical record on 6/4/25 at 10:21 AM revealed that the resident sustained an injury to his/her left ankle on 10/4/24. An x-ray confirmed a fracture, and the resident was sent to the hospital for further evaluation. During an interview on 6/4/25 at 1:10 PM the DON (Director of Nursing) indicated that the Medical Director determined that the fracture was pathological after the hospital confirmed the fracture on 10/7/24. Further review of Resident #94's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to provide reasonable accommodations of preferences by not honoring a resident's request for female only caregivers. This was found to be evident for Resident #105 during investigation of facility reported incident MD00186826. The findings include: On 06/11/2025 at 11:00 AM, facility reported incident MD00186826 was reviewed by surveyor. In the report, Resident #105 alleged that a male caregiver had sexually assaulted them while applying barrier cream during incontinence care on 12/15/2022. The facility initiated an investigation and found the alleged incident to be unsubstantiated. Further record review revealed that Resident #105 was admitted to the facility on [DATE] and transferred to another nursing facility on 2/17/2023. Additional review of facility reported incident MD00186826 on 06/11/2025 revealed that the facility had stated on the Comprehensive & Extended Care Facilities Self-Report Form that the resident, is to…

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

Based on record reviews and interviews it was determined that facility staff failed to notify a resident's representative of a change in the resident's medical condition and failed to inform the resident's representative of the resident's transfer to the hospital. This deficient practice was evident for one (#89) resident reviewed for notification of changes during the annual survey. The term resident representative means the following: An individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications. The findings include: Resident #89 was admitted to the facility August 2023 with medical history that includes aphasia ( language disorder that can affect a person's ability to speak, understand, read or write) among other conditions. A review of complaint intake MD00202589 on 06/10/25 at 7:33 AM reveals that the complainant reported not being notified by the facility about a change in Resident #89'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.

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 ensure that a resident remained free of abuse. This deficient practice was evident for one (#11) of five residents reviewed for abuse during the annual survey. The findings include: Review of the facility's investigation file related to the facility reported incident MD00208357 and compliant intake MD00208362 on 6/4/25 at 2:45 PM, revealed that the facility substantiated allegations of sexual abuse based on a witness account provided by Geriatric Nursing Assistant (GNA) #18. GNA #18 reported that while walking into room [ROOM NUMBER] on 8/2/24 as part of her initial shift rounding, GNA #18 witnessed Resident #27 who is cognitively impaired on their knees next to Resident #11's bed and was touching the resident's genital area. The GNA immediately intervened and redirected Resident #27 out of the room. The GNA reported the incident to her floor nurse as they attended to Resident #11. Resident #11 who is cognitively…

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

Based on review of facility reported incident investigation, review of record and interviews, it was determined the facility failed to 1) report an allegation of abuse in a timely manner to the state agency, immediately, but not later than two hours after the allegation was made, and 2) report an injury of an unknown source to the state agency as required. This was evident for 1 resident (Resident #106) of 17 residents reviewed for timely reporting an alleged violation, and 1 resident (#94) of 3 residents reviewed for an injury of unknown origin during an annual survey. The findings include:1) On 06/10/2025 at 8:41 AM, review of the investigation report of Facility Reported Incident (FRI), MD#00190620 revealed that on 03/28/2023 at 09:15 AM, Resident #110 reported to the administrator that Resident #106 might have been choked by Geriatric Nursing Assistant (GNA #21) on 03/27/2023 during the evening shift. On 06/10/2025 at 8:57 AM, further review of the investigation packet showed that on 03/27/2023, Certified Medicine Aide (CMA #32)'s in her statement stated that on that day at…

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 facility reported incident it was determined the facility failed to 1) ensure the thorough investigation of an allegation of abuse, and 2) provide residents with psychological evaluations and physician assessments following a substantiated incident of resident to resident sexual abuse. This was evident for 1 (Resident #106) out of 17 residents reviewed for allegations of abuse, and 1 (MD#00193881) of 17 Facility Reported Incidents (FRI) reviewed during the annual survey.The findings include:1) On 06/10/2025 at 8:41 AM, review of the investigation report of Facility Reported Incident (FRI), MD#00190620 revealed that on 03/28/2023 at 09:15 AM, Resident #110 reported to the administrator that Resident #106 might have been choked by Geriatric Nursing Assistant (GNA #21) on 03/27/2023 during the evening shift. On 06/10/2025 at 11:12 AM, when the surveyor requested copies of employee files/trainings for GNA #21 from the Nursing Home Administrator (NHA), she informed this surveyor that GNA #21 was from a nursing agency and added that the facility did not have his…

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 the facility staff failed to ensure that the required minimum information was provided to the receiving provider upon transfer from the facility. This was evident for 1 (#94) of 3 residents reviewed for an injury of unknown origin. The findings include: A review of Resident #94's medical record on 6/4/25 at 10:21 AM revealed a Change in Condition/Concurrent Review dated 10/4/24 12:53 (12:53 PM) which noted that the resident's left lower extremity was swollen, and left ankle was red and warm to touch. The Physician was contacted and ordered a STAT x-ray to rule out a fracture and an ultrasound to rule out a Deep Vein Thrombosis (blood clot). The Change in Condition form contained a section to document specific information in the event of a hospital transfer. The section was blank. The X-ray report dated 10/5/24 confirmed the resident had fractures of the ankle. A Nursing Note dated 10/6/24 03:13 (3:13 AM) noted that the on-call physician was notified of the results and ordered that the resident be sent to the hospital…

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

Based on record review and interviews, it was determined that the facility failed to revise care plans for residents. This was evident for 1 (MD#00207171) out of 17 facility reported investigations, 2 (Resident #100, #27) out of 5 residents reviewed for care plans reviewed during an annual survey.The findings include:1) On 06/09/2025 at 9:48 AM, the surveyor reviewed the facility's reported investigation packet for intake MD#00207171 in which the facility had stated that on 06/28/2024, Resident #64 was seen naked with another resident.On 06/09/2025 at 10:30 AM, further review of the investigative packets showed that the facility stated in the final report sent to the state agency that the corrective action to be taken would be to update Resident #64's care plan to reflect his/her wish for companionship with other residents but that his/her interactions would be supervised by staff, that no sexual interactions would take place due to resident's cognitive deficits and provide assistance with resolution as needed.On 06/09/2025 at 10:51 AM, review of the resident's care plan 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 record review and interviews, it was determined that the facility staff failed to provide a resident (Resident #92) with oral care. This was evident for 1 (MD#00206301) of 46 intakes reviewed during the recertification survey. The findings include: On 06/10/2025 at 10:00 AM, a review of confidential complaints reported to the state agency revealed complaint #MD00206301. This complaint alleged that Resident #92 did not receive oral care during their stay at the facility. On 06/10/2025 at 10:20 AM, a review of Resident #92's medical record was conducted. The review revealed that Resident #92 was admitted into the facility with a tracheostomy on 4/3/24 and was discharged to a hospital on 5/31/24. A tracheostomy is a surgical procedure that creates an opening in the neck, called a stoma, through which a tube is inserted into the trachea (windpipe) to provide an airway and facilitate breathing. The review of the care plan failed to mention any intervention for tracheostomy care or oral care. On 06/11/2025 at 9:49 AM, an interview with the Director of Respiratory Therapy (Staff…

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

Based on record review and interviews, it was determined that the facility failed to provide adequate physical therapy services to a resident (Resident #92). This was evident for 1 (MD#00206301) of 46 intakes reviewed during the recertification survey. The findings include: On 06/10/2025 at 10:00 AM, a review of confidential complaints reported to the state agency revealed complaint #MD00206301. On 06/11/2025 at 12:10 PM, the complainant was called. S/He alleged that Resident #92 did not receive physical therapy as ordered and as needed. On 06/11/2025 at 01:00 PM, a review of Resident #92's medical record was conducted. The review revealed that the resident had an order to receive physical therapy services 5 to 7 times a week for the recertification period of 4/4/24 to 5/2/24. On 06/11/2025 at 01:10 PM, the Director of Nursing (DON) was asked to provide physical therapy notes for the month of April 2024. On 06/11/2025 at 02:00 PM, the facility provided physical therapy notes. These documents were reviewed with a physical therapist (Staff #26), and revealed that Resident #92 did not…

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 provide needed care to Residents (#9, #78, #75, #83 and #66) to provide the highest practical well-being. The facility staff failed to administer medications to Resident #9 as ordered by the physician, failed to float heels for Resident #78, failed to obtain a neurology consultation for Resident #75, failed to obtain a neurology consultation for Resident #83 and failed to obtain a Heptalogy and GI consultation for Resident #66. This was evident for 5 of 52 residents selected for review during the annual survey process. The findings include: 1 A. The facility staff failed to administer medication to Resident #9 as ordered by the physician. Medical record review for Resident #9 on 11/2/21 at 1:30 PM revealed on 7/21/21 the physician ordered: Glatopa 40 mgs SQ in the mornings on MWF for MS. Glatopa is a prescription medicine used to treat relapsing forms of multiple sclerosis (MS). Interview with the resident on 11/2/21 at 11:45 AM revealed the resident stating that she/he does not always get…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident #9 with the prescribed diet as ordered by the physician; failed to obtain weights on Resident # 75 for 5 months, failed to withhold straw for Resident #83 and facility staff failed to thoroughly monitor and add interventions timely when the facility staff documented a significant weight loss for a resident (Resident #77). This was evident for 4 of 7 residents selected for review for nutrition and 4 of 52 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to provide Resident #9 with the prescribed diet as ordered by the physician. Surveyor interview and observation with Resident #9 on 11/4/21 at 8:40 AM revealed the resident not eating breakfast. When questioned, the resident stated that ham was being served and he/she does not eat pork. Observation of the resident's breakfast at that time revealed the resident was served a slice of ham.…

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, it was determined the facility staff failed to 1. address Consultant Pharmacy Drug Regimen Review in a timely manner for Residents (#9 and #22) and 2. document a monthly Consultant Pharmacy Drug Regimen Review in the resident's chart. This was evident for 2 of 5 residents reviewed for unnecessary medication and 2 of 52 residents selected for review during the annual survey sample The findings include: 1. Medical record review for Resident #9 on 11/3/21 at 8:45 AM revealed on 7/21/21 the physician ordered: Lidocaine patch 4%, apply to left knee topically in the morning for pain and on 7/21/21 ordered: Lidocaine patch 4%, apply to left shoulder topically in the morning for pain. Lidocaine 4% patch can be used for: it is used to stop pain and it is used to treat painful nerve diseases. It is also used to ease long-term pain problems. The recommendation that each patch should be worn for no longer than 12 hours is made because the patch may cause localized skin reactions if used beyond this duration. Lidocaine: Basics, Side Effects & Reviews -…

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 had been determined that the facility had not implemented infection control practices to prevent the spread of COVID 19 as evidenced by 1. facility staff failing to wear a face mask while working in the facility and providing during patient care (This was observed 3 times during an annual recertification survey) and 2. the facility staff failed to store/ handle dirty linens in a manner that would limit the spread of infections as much as possible and in accordance with the accepted national standard to decrease the spread of any infections (This was observed 1 time during an annual recertification survey). The findings include: 1. The facility staff failing to wear a face mask while working in the facility and providing during patient care. Consistent with the 4/2/2020 CMS guidance, on 4/27/2021, the Centers for Disease Control and Prevention (CDC) published updated guidance which stated, In general, fully vaccinated HCP (health care provider) should continue to wear…

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 1. ensure Resident #83's responsible party (RP) was provided the opportunity to consent to the flu vaccine for Resident #83 and 2. failed to ensure Resident #285 had a representative when signing documents. This was evident for 2 of 2 residents selected for reviewed for dignity and 2 of 52 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to have a resident's responsible party provide consent. Medical record review for Resident #83 on 11/5/21 at 10:43 AM revealed on 12/13/17 and 1/22/18 the resident was assessed by 2 physicians. At that time, it was determined that Resident #83 is unable to: understand and sign admission documents and other information, unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment, unable to make rational evaluation of the burdens, risk and benefits of the treatment and is unable…

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, staff interview and observation it was determined that the facility staff failed to ensure signage was posted to alert residents and visitors of the location of the survey results. This was evident for 4 out of 4 units. The findings are: This surveyor interviewed members of the resident council (Residents #9, #13, #24, and #40) on 11/4/21 at 11:04 AM. The residents said they were unaware of the survey results or where to find the results. This surveyor toured all 4 floors on 11/5/21 at 1:05 PM and did not see survey book or a sign telling residents where it is located. Staff #18 was interviewed on 11/9/21 at 10:40 AM. The observations were presented to her. Survey book had been pulled to find information regarding a question from the survey team. Signs were not posted prior to the exit conference.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review it was determined the facility staff failed to notify 1. the physician of results of an ammonia level (Resident #75) and 2. the physician and resident's family member of X-ray results (Resident #85). This was evident for 2 of 52 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to notify the physician of results of an ammonia level. Medical record review for Resident #75 on 11/3/21 at 11:30 AM revealed the facility staff obtained an ammonia level on 9/9/21 with the results of 80, normal level is 19-54. Ammonia is predominantly generated in the gut by intestinal bacteria and enzymes and detoxified primarily in the liver. Elevated ammonia levels can indicate liver disease. Further record review revealed the facility staff failed to notify the physician of the laboratory blood results. Interview with the Nursing Home Administrator and Chief Clinical Officer were notified of the concerns on 11/10/21 11:30 AM at exit. 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.

Based on a review of the beneficiary notices and staff interview it was determined that the facility staff could not provide sufficient evidence that the residents are provided the proper notice at the time of discharge regarding Medicare coverage (Resident #4, #139 and #140). This was evident for 3 out of the 3 reviewed for the beneficiary notice task. The findings are: The beneficiary notices for Residents #4, #139, and #140 were requested for review on 11/8/21. The beneficiary notices could be either a Notice of Medicare Non-Coverage (NOMNC) or an Advance Beneficiary Notice (ABN). The NOMNC is provided two days before the discontinuation of therapy services. The ABN is provided if the resident wishes to continue therapy even if Medicare might not cover it. The Administrator (#1) was interviewed on 11/8/21 at 12:37 PM. He could not provide copies of either a NOMNC or ABN for any of the three residents.

Based on observation it was determined that the facility staff failed to ensure the confidentiality of resident's #39 information. This was evident for 1 out of 52 residents that were part of the Annual survey process. The findings include: This surveyor observed on 11/4/21 at 11:22 AM a medication cart across from Unit three nursing station with the computer screen on and resident's #39 medical information visible. Staff members walked by including the Unit Manager and not one staff member closed the screen. The nurse returned to the cart at 11:30 AM and exit out of the computer. I informed the Unit Manager (staff #12) of my observation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviewed it was determined that the facility failed to ensure the resident, and/or their responsible party, received written notification of a transfer to the hospital, including appeal rights and ombudsman contact information (Residents #21, #22 and #77). This was found to be evident for 3 out of 6 residents reviewed for hospitalization during an annual survey. The findings include: 1. Review of Resident #21's medical record on 11/2/21 revealed the Resident was admitted to the facility on [DATE]. The Resident was discharged from the facility on 10/13/21 to the hospital. Further review of the Resident's medical record failed to reveal any documentation that a notice regarding the transfer had been provided to the resident or the resident's responsible party. Interview with the Acting Director of Nursing on 11/4/21 at 10:45 AM confirmed neither Resident #21 nor their responsible party had been sent a letter that notified them of the transfer to the hospital. 2. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined that the facility staff failed to provide residents and/or their representative (RP) with the proper paper documentation of the facility's bed hold policy (Resident #21, #22 and #77). This was found evident for 3 of 6 residents reviewed for hospitalizations during an annual survey. The findings include: A bed hold policy is written information to the resident or resident representative that specifies the duration that the resident is permitted to return and resume residence in the nursing facility. It is given before a nursing facility transfers a resident to a hospital or the resident goes out on therapeutic leave. 1. Review of Resident #21's medical record on 11/2/21 revealed the Resident had an unplanned transfer to the hospital on [DATE]. Further review of the medical record revealed that a copy of the facility's bed hold policy was not given to Resident #21 or their RP. Interview with the Acting Director of Nursing on 11/4/21 at 10:45 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 review, resident interview, and staff interview it was determined that the facility staff failed to ensure the accuracy of the facility assessments (Resident #60). This was evident for 1 out of the 52 residents reviewed as part of the survey process. The findings are: 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 for based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Resident #60 was interviewed on 11/3/21 at 9:22 AM. The resident stated he/she does not have a catheter but did have one recently. A review of the resident's clinical record revealed that the resident had a catheter on 7/27/21. Further review revealed there was no evidence that the catheter was continued or removed while in the facility. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. The facility failed to have quarterly care plan meetings with resident's responsible party. Review of Resident #21's medical record on [DATE] revealed the Resident was admitted to the facility on [DATE] from the hospital with a diagnosis to include vascular dementia. Vascular dementia is a decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and. nutrients. During an interview with Resident #21's responsible party (RP) on [DATE] at 8:45 AM, the RP stated the facility used to have care plan meetings every 3 months but they have not had one for the Resident in a long time. Review of the Resident's record on [DATE] confirmed no evidence of care plan meetings with the Resident's RP since [DATE]. The facility failed to hold a quarterly care plan meeting in April, July and [DATE]. Interview with the Social Worker on [DATE] at 1:40 PM revealed the facility is to hold care plan meetings every 3 months and the last care plan meeting…

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 record review, it was determined that the facility failed to administer medications within 1-hour time frame in accordance with professional standards for Resident #79. This was evident for 1 of 52 residents reviewed during the annual survey. The findings include: On 11/2/21 at 8:45 AM, an interview conducted with Resident #79, revealed Resident #79 had been alert and oriented to person, place, and time. Resident #79 expressed concern that he/she had been receiving his/her medications late. On 11/3/21 at 11:10 AM, observation on Unit 3 revealed Resident #79 standing at the nursing station requesting his/her 9 AM medications. The medications which had been schedule for 9 AM was administered at the nursing station at 11:10 AM. On 11/4/21 at 1:30 PM a record review of Resident #79's medication administration audit for September and October 2021, revealed Resident #79 had been receiving his/her medications late on a regular basis. In 9/2021, the following medications had been administered outside the 1-hour time frame: On 9/6/21 -Keppra 500 mg 3 tablets by mouth…

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

Based on complaint, reviews of medical record review and staff interview, it was determined that the facility failed to implement an ongoing resident centered activities program for 1 (Resident #37) of 52 residents reviewed for activities during an annual recertification survey. The findings include: During 2020 and 2021 the facility has had to take mitigating actions to prevent the spread of the COVID19 virus. At times, residents have had to stay in their rooms and were not allowed to attend group activities. To help prevent residents from suffering isolation, an implementation of a resident centered activities care plan may help prevent this isolation from occurring. The facility activities programs can help residents during these times. In an interview with Resident #37 on 11/08/21 at 11:51 AM, Resident #37 complained that the facility does not allow residents to have access tot the Internet nor does the facility have the local news paper delivered to the facility. The resident complained that he/she does have anything to do while residing in the facility. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers and arterial wounds (Resident #10 and #21). This is evident for 2 of 52 residents reviewed during an annual survey. 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). The findings include: 1. Review of Resident #10's medical record on 11/5/21 revealed the Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of a medical record, and staff interview, it was determined that facility staff failed to obtain podiatry consultation for Resident #37 as ordered by the physician. This was evident for 1 of 52 residents selected for review during an annual survey. The findings include: In an interview with Resident #37 on 11/08/21 at 11:51 AM, Resident #37 came into the conference and approached the nurse surveyor with a complaint that he/she has not been seen by a Podiatrist since being admitted to the facility. Medical record review for Resident #37 on 11/08/21 at 1:30 PM revealed Resident #37 was originally admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE]. On 11/04/2020, Resident #37's physician wrote an order instruction the nursing staff to obtain a podiatry consult as needed. Further review revealed an endocrinology consult, dated 09/30/21, requesting the facility staff to please arrange for a podiatry appointment. As of 11/09/21, no podiatry 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 record review it was determined the facility staff failed to ensure Resident #83 received restorative nursing program (RNP) as ordered by the physical therapist and speech language pathologist in conjunction with the physician. This was evident for 1 of 5 residents selected for review of range of motion and 1 of 52 residents selected for review during the annual survey. The findings include: Restorative nursing is person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible. It is a different way of looking at the care that is regularly given. A restorative nursing program has nursing interventions that promote the resident ' s ability to adapt and adjust to living as independently and safely as possible. Restorative nursing program together with therapy (physical, occupational or speech) because restorative programs build from the base of progress made in therapy. 1 A. The facility staff failed to provide restorative nursing program for Resident #83. Medical record review…

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 observations, it was determined the facility staff failed to provide fall mats next to the bed of Residents #75, 78 and #81. This was evident for 3 of 52 residents selected for review during the annual survey process. The findings include: Fall mats are made from high-impact foam and are designed to help prevent injury from potential falls and are usually placed next to the bed where most falls occur. 1. The facility staff failed to provide fall mats next to the bed of Resident #75 as ordered by the physician. Medical record review for Resident #75 on 11/3/21 at 10:45 AM revealed on 9/2/15 the physician ordered: fall mat, both side of the bed, when in bed. Surveyor observation of the Resident #75 on 11/2/21 at 9:00 AM, 11/3/21 at 8:45 AM, 11/4/21 at 8:30 AM and 11/5/21 at 8:00 AM revealed the resident in bed; however, the facility staff failed to apply fall mat on either side of the as ordered by the physician. 2. The facility staff failed to place fall mats next to the bed of Resident #78 as ordered by the physician. Medical record review for…

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

Based on medical record review and interview, it was determined the facility staff failed to ensure Residents #9 and #57 were provided pain medication when requested. This was evident for 2 of 2 residents reviewed for pain and 2 of 52 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to ensure pain medication was available and administered to Resident #9 when requested. Medical record review for Resident #9 on 11/3/21 at 9:30 AM revealed on 7/21/21 the physician ordered: Tramadol 50 milligrams by mouth, 2 tablets every 6 hours as needed for severe pain, 7-10. Tramadol is used to help relieve moderate to moderately severe pain. Interview with Resident #9 on 10/4/ 21 at 10:00 AM revealed the resident stated that he/she requested the Tramadol early in the morning. The resident stated he/she was informed by the facility staff that there was no medication available. Interview with the staff #17 at that time revealed that the sticker should have been pulled and sent to the pharmacy for a refill. The medications are supplied…

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 staff failed to complete the Dialysis record communication sheet and obtain post dialysis weights and vital signs for Resident #47. This is evident for 1 of 1 resident reviewed for dialysis during the annual survey. The findings include: Review of Resident #47's medical record on 11/3/21 at 7:20 AM revealed the resident receives dialysis treatments three times a week on Tuesdays, Thursdays and Saturdays. Dialysis is a treatment that filters and purifies the blood using a machine. This helps keep your fluids and electrolytes in balance when the kidneys can't do their job. On 11/4/21 at 11:30 AM interview with the United manager (staff #12) revealed that dialysis residents are sent to an outside facility for dialysis treatment and that the outside facility does not have access to the residents' electronic medical record. Resident information is communicated to the dialysis center by completing the Dialysis Communication Form which is sent with the Residents to dialysis. Further review of Resident #47's…

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

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure medications were administered within ordered parameters. This was evident for 2 (#5 and #9) out of 7 residents reviewed for medications. This was evident for 2 of 5 residents selected for review of unnecessary medications and 2 of 52 residents selected for review during the annual survey process. The findings are: 1. A review of resident #5's clinical record revealed the resident was ordered Clonidine 0.1 mg by mouth two times a day for hypertension hold if systolic [top number of blood pressure] is less than 100 or pulse is less than 60. A review of the November Medication Administration Record (MAR) revealed the resident had a blood pressure of 96/56 on 11/8/21 at 5:00 PM and was administered the medication instead of it being held per the physician's order. Staff #18 was interviewed on 11/9/21 at 10:40 PM. She was informed of the medication being administered outside of parameters. 2. The facility staff failed to ensure Resident #9 was free from unnecessary medications.…

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 observation of medication administration, it was determined the facility staff failed to maintain an error rate below 5%. Observation of medication administration resulted in an error rate of 10.26%. This was evident for 2 of 4 (#33 and #13) residents observed and 4 of 39 opportunities for error. The findings include: Error 1: The facility staff failed to administer a medication as ordered by the physician. Medical record review for Resident #33 on 11/4/21 at 12:30 PM revealed on 5/5/20 the physician ordered: Cholecalciferol 2000 UT, 1 tablet by mouth 1 time a day as a supplement. Cholecalciferol is vitamin D3. Vitamin D helps the body absorb calcium. Cholecalciferol is used as a dietary supplement in people who do not get enough vitamin D in their diets to maintain adequate health. Observation of medication pass on 11/4/21 at 8:45 AM revealed staff #16 failed to administer the medication as ordered by the physician. Error 2: The facility staff failed to administer a medication as ordered by the physician. Medical record review for Resident #33 on 11/4/21…

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 properly store medications in a locked compartment that were only accessible to authorized staff. This was observed on two different nursing units during an annual recertification survey. The findings include: 1) During an observation of the facility on 11/10/21 at 5:40 AM, the nurse surveyor observed an unlocked an unattended medication cart, on the fourth floor, in the vicinity of the nurse's station. A medication cart houses Resident's medications that can be wheeled to each resident's room. A medication cart may have, but is not limit to, containing injectable medications, oral medications, and scheduled II (or pain) medications 2) During an additional observation of the facility on 11/10/21 at 5:43 AM, the nurse surveyor observed an unlocked an unattended treatment cart located in the vicinity of the third-floor elevator. A treatment cart contains medications, lotions and supplies that the nursing staff may use when assisting a physician with or providing wound care to residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review it was determined the facility staff failed to obtain laboratory specimens as ordered by the physician for Residents #66, #75, #83 and #85. This was evident for 4 of 52 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to obtain laboratory blood test for Resident #66 as ordered by the physician. Medical record review for Resident #66 on 10/18/21 at 11:45 AM the resident had an ammonia level obtained with the result of 62, normal 19-54. Ammonia is a nitrogen waste compound that is normally excreted in the urine. An elevated blood ammonia level is an excessive accumulation of ammonia in the blood. An elevated blood ammonia level occurs when the kidneys or liver are not working properly, allowing waste to remain in the bloodstream. Further record review revealed the resident was to have another ammonia level obtained on 10/25/21; however, the facility staff failed to obtain the ammonia level as ordered by the 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 complaint, reviews of a medical record, and staff interview, the facility failed to provide dental services for a resident (Resident #22). This was evident for 1 out of 52 residents selected for review during the annual survey process. The findings include: In an interview with Resident #22's responsible party on 11/03/21 at 10:29 AM, Resident #22's family member stated that he/she was unable to look into Resident #22's mouth and did not recall the last time Resident #22 was seen by a dentist. Review of Resident #22's medical record revealed a physician order, date 09/08/21, that instructed the nursing staff to obtain a dental consult annually and as needed. Interview with the Assistant Director of the Nursing (ADON) on 11/08/21 at 08:54 AM, the ADON stated and confirmed that Resident #22 has not been seen by the facility dentist since being admitted in 2016. The ADON also stated that the 09/08/21 order to see a dentist was just written after Resident #22 was readmitted from the hospital in September 2021.

Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record for Residents #81 and #184 in the most accurate and complete form. This was evident for 2 of 52 residents selected for review during an annual survey. The findings include: 1. The facility staff failed to maintain the medical record for Resident #81 in the most complete and accurate form. The medical record forms a permanent account of the care a resident has received. The clarity and accuracy of the medical record is paramount for effective communication between healthcare professionals and residents. The maintenance of good medical records ensures that a resident's assessed needs are met comprehensively. Medical record review for Resident #81 on 11/4/21 at 11:48 AM revealed that the physician completed a MOLST on 10/19/21. At that time, the MOLST revealed- Part A- Certifications for the basis of these orders and the physician documented: the resident's surrogate as per the authority granted by the Health Care Decisions Act. It was also revealed on the MOLST…

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, staff interview it was determined that the facility failed to maintain kitchen equipment in safe operating condition. This deficient practice has the potential to affect all residents. The findings include: 1. On 11/5/21 at 10:10 AM observation of the facility's kitchen with the Dietary Manger revealed a non-operational hot water faucet handle. The hand sink is located on the kitchen's tray line. This was the closest hand sink available to the 3 staff working on the tray line at the time of observation. 2. The 2 compartments sink; hot water faucet had a steady drip and would not turn off completely to stop the flow of hot water. 3. The wall by the exit door had peeling paint. 4. The floor outside the utility closet had an area of missing tile. These concerns were discussed with the Director of Nursing and Administrator during the exit conference on 11/5/21.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility staff failed to 1) provide a written notice for emergency transfers to the resident and/or the resident representative, and 2) ensure the local ombudsman was notified of a facility initiated resident discharge or transfer. This was found to be evident for 6 out of 46 (Residents #36, #39, #18, #64, #26, #70) residents reviewed for a facility-initiated transfer during an annual re-certification survey. The findings include: 1. A medical record review for Resident #36 was conducted on 11/27/18. Review of the physician order written on 4/1/2018, revealed that Resident #36 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 representative and the ombudsman. 2. A medical record review for Resident #39 was conducted on 11/27/18. 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, observation, and staff interview, it was determined that the facility staff failed to provide Residents #18, #36 and Resident #39 with services to maintain/attain the highest level of mobility. The facility staff failed to apply splints as ordered by the physician. This was evident for 3 of 46 residents selected for review during the annual re-certification survey. The findings include: 1. Medical record review for Resident #18 revealed on 10/19/18 the physician ordered: Bilateral leg braces on for 24 hours daily; Skin check every 2 hours; If any skin tissue, stop the braces and resume when area is healed; Remove for ADL's; Every shift for contracture management. A splint/boot or brace are devices used for holding a part of the body stable to decrease pain and prevent further injury. Splints support and protect injured soft tissue and can also reduce pain, swelling, and muscle spasm. Surveyor observation of Resident #18 on 11/19/18 at 8:30 AM, 11/27/18 at 10:30 AM, and 11/28/18 at 1:30 PM, revealed Resident #18 was in his/her room in bed, however, the…

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

Based on observation during the initial tour of the main kitchen it was determined the facility staff failed to 1. discard expired food, date and label food stored in the walk-in refrigerator, 2. properly label and store open containers in dry storage and throughout the kitchen, and 3. maintain a clean environment. The findings include: Observation was made during the initial tour of the kitchen on 11/19/18 at 7:35 AM of the walk-in refrigerator with the following concerns identified: 1) A portable rack with 2 large containers of Iced tea and fruit punch covered with plastic not labeled or dated with the date prepared. 2) On a storage shelf there was a tray containing pudding in dishes that were not labeled or dated as to when prepared or to be used by. 3) A container of opened mandarin oranges with no date indicating when opened. 4) A whipped topping container and a bottle of syrup with no expiration dates. 5) 2 boxes of juice cups with no expiration dates on the juice containers. 6) A carton of 6 eggs with no expiration date. 7) A box with 10 Cantaloupe dated 10/25/18 which were…

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 keep the air intake unit in the main kitchen in a clean and safe operating condition. This was evident during the initial tour of the kitchen. The findings include: Observation was made on 11/19/18 at 7:35 AM of the air intake unit in the main kitchen. The front of the unit appeared dirty with dust, paper and other debris that was stuck to the grate and appeared to be occluding several of the holes in the grate. There was very little force to the air coming through the vents. In an interview with the Maintenance Director on 11/20/18 at 8:25 AM surveyor requested the cleaning schedule for the air intake unit. The Maintenance Director stated that it is done monthly. When asked for a schedule or record of the monthly cleaning he stated there is no book he just does it monthly and in fact it was on the schedule for that day. In a follow-up visit to the kitchen on 11/20/18 at 9:10 AM the Maintenance Director was observed cleaning and changing the filters in the unit. Following the cleaning there was 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 staff interview, it was determined that the facility failed to follow a resident's wishes to obtain a laboratory test. This was evident for 1 (Resident #82) of 4 residents reviewed for choices during an annual recertification survey. The findings include: Review of Resident #82's MOLST form on 11/19/18, revealed that Resident #82's health care agent wanted Resident #82 to be a full code and also wanted all aspects of life sustaining treatment to be performed including any medical testing indicated to diagnose and/or treat a medical condition. On 10/17/18, Resident #82 was admitted to the facility hospice provider. Further review of Resident #82's medical record revealed a pharmacy consultant request, dated 10/30/18, requesting Resident #82's physician to order a Vitamin D level to check Resident #82's Vitamin D replacement therapy. Resident #82 was receiving Vitamin D as a supplement. On 11/01/18, Resident #82's physician disagreed with the facility pharmacy consultant and indicated the reason for not obtaining a Vitamin D level for Resident #82…

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 complaint, reviews of administrative records including a resident's personal funds records, individual resident account statements, transaction reports, transaction receipts, and staff interview, it was determined that the facility staff failed to maintain a system that ensures a full and complete accounting of a resident's personal monies entrusted to this facility. This was evident for 1 (Resident #55) of 1 resident reviewed for personal property during an annual recertification survey. The findings include: In an interview with Resident #55 on 11/19/18 at 8:10 AM, Resident #55 stated that s/he does not get enough money. In an interview with the facility director of nursing (DON) on 11/27/18 at 02:29 PM, the DON stated that the facility does not have a business office manager. In an interview with Employee #21 on 11/28/18 at 08:04 AM, Employee #21 stated that resident money and resident balance sheets come from the corporate offices in New York. A review of Resident #55's cash withdrawal receipts from 07/01/18 thru 09/19/18 revealed Resident #55 had a -$51.98…

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

Based on review of facility administrative records and staff interview, it was determined that the facility staff failed to immediately report an allegation of abuse to the facility administrator. This was evident for 1 (Resident #195) of 4 residents reviewed for abuse during an annual recertification survey. The findings include: A review of the facility reported incident MD00126351, revealed documentation of an allegation of staff to resident abuse involving Resident #195 that occurred on 05/05/18. The facility documentation indicated the facility initiated an investigation into the alleged staff to resident abuse on 05/07/18. In an interview with Employee #19 on 11/21/18 at 7 AM, Employee #19 stated s/he witnessed the 05/05/18 incident and stated that the local police had been notified and came to the facility to investigate the incident. Employee #19 stated that he documented the incident on the daily security form but also stated that this form is not provided to the facility administrative staff. Employee #19 also stated that s/he did not speak to anyone about the incident…

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 staff failed to implement a care plan for a resident who smokes. This was evident for 1 (Resident #89) of 2 residents reviewed for smoking during an annual re-certification survey. The findings include: During an observation of the smoking area on 11/26/18 at 09:05 AM, Resident #89 was observed outside smoking. A review of Resident #89's medical record failed to reveal an updated safe smoking assessment and a care plan for safe smoking. Resident #89's medical record did have an admission smoking assessment completed on 10/27/18 but Resident #89 was receiving a medicated smoking cessation patch at that time. Resident #89 medicated smoking cessation patch was discontinued in early November 2018. Resident #89's 10/27/18 smoking assessment indicated that he/she was not allowed to smoke. A review of the facility smoking policy manual, which is kept in close proximity to the smoking area, revealed a list of all smokers in the facility but failed to list Resident #89 as an identified…

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

Based on observation during a medication pass, it was determined the nurse failed to follow standards of practice regarding medication preparation and poured an excess of dispensed medication back into the medication container. This was observed one time during a medication pass observation. The findings include. During the observation of the medication administration on 11/21/18 at 10:00 AM Employee #10 was observed measuring Resident #67's Keppra (seizure medication) into a medication cup and then pouring the excess back into the original bottle twice until the desired amount was obtained. The Director of Nursing was informed of the findings on 11/21/18. No evidence to dispute this finding was presented to the team prior to exit.

Based on resident interview, reviews of a medical record, and staff interview, it was determined that the facility staff failed to obtain an eye consultation. This was evident for 1 (Resident #89) of 1 resident reviewed for communication difficulty and/or sensory problems during an annual recertification survey. The findings include: In an interview with Resident #8 on 11/19/18 at 12:10 PM, Resident #89 stated that he/she needed to see an eye doctor for poor vision. Review of Resident #89's medical record revealed a physician order, dated November 2018, instructing the nursing staff to obtain an Optometry consult as needed. Further review of Resident #89's medical record revealed a social service note indicating a care plan conference had been held on 11/08/18 and Resident #89's family member had requested the facility staff to obtain an vision consult for Resident #89. In an interview with the facility social worker on 11/27/18 at 10 AM, the facility social worker stated that Resident #89 had not been seen by an eye doctor and that an appointment had not been scheduled.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to ensure that a psychotropic medication had an adequate indication for use. This was evident for 1 (Resident #89) of 5 residents reviewed for unnecessary medications during an annual recertification survey. The findings include: Review of Resident #89's medical record revealed a physician order, dated October 2018, instructing the facility nursing staff to obtain a psychiatric assessment as needed and to administer an antipsychotic medication every evening for the indication of mood disorder. A review of Resident #89's physician assessment dated [DATE] indicated Resident #89 to be calm, cooperative, with an appropriate mood, and able to follow commands. Resident #89's physician assessment dated [DATE] indicated that psychiatry was onboard assessing Resident #89. Further review of physician assessments, dated 11/19/18…

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

Based on staff interview and clinical record review it was determined that the facility staff failed to 1) ensure the residents' behaviors were monitored and recorded routinely, and 2) to conduct behavior monitoring for a resident receiving an psychotropic medication. This was evident for 2 (Resident #87 and #43) out of the 5 residents selected for a review for unnecessary medications during an annual recertification survey. The findings are: 1) A review of Resident #87's clinical records revealed that the resident was being administered Remeron 45 mg (an anti-depressant), Depakote delayed release 125 mg to treat a behavioral issue, and Seroquel (an antipsychotic medication) 50 mg twice a day. A form or log to monitor the specific behaviors these medications were prescribed for was not in the chart. A review of the care plans revealed that the care plan for depression included an intervention to Monitor/document/report to Nurse/MD s/sx [signs and symptoms] of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive…

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 ensure the treatment and medication carts were locked and secured. This was true for 2 out of 4 nursing units. The findings are: 1. Surveyor observed an unlocked treatment cart on 11/21/18 at 9:10 AM in front of room [ROOM NUMBER]. Inside the treatment cart were several creams and ointments. The items included were Lanolin (skin protectant), Metaphen (anti-infective ointment), Santyl (a debriding enzyme), and Nitro Bid ointment (nitroglycerin). Two nurses and the unit manager were informed on 11/21/18 at 9:15 AM. The treatment cart was then locked. 2. During an observation of the 400's-nursing hall on 11/29/18 at 10:30 AM, the surveyor observed a medication cart unlocked outside room [ROOM NUMBER]. There were no staff. One resident (#43) was sitting in a wheelchair near the unlocked medication cart. Employee #15 was in the lobby area with his back to the medication cart, looking out the window and talking on a cell…

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, reviews of a medical record, and staff interview, it was determined that the facility staff failed to obtain dental services for a resident. This was evident for 1 (Resident #55) of 1 resident reviewed for dental services during an annual recertification survey. The findings include: A review of Resident #55's medical record revealed a physician order, dated 10/26/17, instructing the nursing staff to obtain a dental consult as needed. Further review of Resident #55's medical record failed to reveal any documentation a dental consult had been offered or obtained since Resident #55 was admitted to the facility. A review of Resident #55's annual Minimum Data Set (MDS) dated [DATE] indicated Resident #55 had all of his/her teeth. During an observation of Resident #55 on 11/19/18 at 8:07 AM, Resident #55 was observed with some missing teeth to his/her right upper ridge with several discolored teeth. In an interview with Employee #7 on 11/27/18 at 10:34 AM, Employee #7 confirmed Resident #55 had…

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 complaint, medical record review and staff interview, it was determined that the facility therapy staff failed to evaluate and take steps to reassess a resident's wheelchair. This was evident for 1 (Resident #6) of 1 resident reviewed for rehabilitation and restorative nursing services during an annual recertification survey. The findings include: In an interview with Resident #6 on 11/29/18 12:25 PM, Resident #6 stated that s/he was currently having problems with his/her wheelchair when ambulating throughout the facility. Resident #6 stated that his/her arms were hitting the backrest poles when trying to wheel himself/herself around the facility. Resident #6 stated that s/he received the wheelchair approximately two years ago and that his/her weight had increased several pounds since being originally fitted for the wheelchair. Resident #6 stated that s/he had difficulty sitting in an upright position in his/her wheelchair due to a previous injury and surgical condition. Review of Resident #6's medical record failed to reveal that a follow-up wheelchair sitting…

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 staff failed to maintain an accurate medical record by not including documentation from the facility hospice service provider in the medical record. This was evident for 1 (Resident #82) of 2 residents reviewed for hospice services during an annual recertification survey. The findings include: Review of Resident #82's medical record on 11/21/18 revealed Resident #82 was admitted to the facility hospice services provider on 10/17/18. Further review of Resident #82's medical record failed to reveal any hospice documentation of care in Resident #82 medical record. In an interview with the facility social worker on 11/21/18 at 10:00 AM, the facility social worker stated that s/he was unable to find any of the hospice documentation in Resident #82's medical record.

Based on administrative record review and staff interview, the facility staff failed to track and monitor a resident with an infection upon admission. This was evident for 1 (Resident #193) of 2 residents reviewed for infections during an annual recertification survey. The findings include: During an interview with the corporate infection control practitioner on 11/29/18 at 10:52 AM, the corporate infection control practitioner stated that all residents admitted with an infection and receiving antibiotics from the hospital are placed on a surveillance list that monitors each residents progress. Reviews of Resident #193 medical record revealed Resident #193 was admitted in October from the hospital with an infection and was receiving intravenous antibiotics through a large bore central line. The corporate infection control practitioner reviewed each of the facility nursing unit documents to see if Resident #193 was on the list that the staff were monitoring for infections. The corporate infection control practitioner indicated there were no records Resident #193 had been monitored…

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 staff failed to identify a resident as a smoker, assess the resident to be a safe smoker, implement a care plan for smoking, and update the facility list of smokers. This was evident for 1 (Resident #89) of 2 residents reviewed for smoking during an annual recertification survey. The findings include: During an observation of the smoking area on 11/26/18 at 09:05 AM, Resident #89 was observed outside smoking. A review of Resident #89's medical record failed to reveal an updated safe smoking assessment and a care plan for safe smoking. Resident #89's medical record did have an admission smoking assessment in October 2018 but Resident #89 was receiving a medicated smoking cessation patch at that time. Resident #89's medicated smoking cessation patch was discontinued in early November 2018. A review of the facility smoking policy manual, which is kept in close proximity to the smoking area, revealed a list of all smokers in the facility but failed to list Resident #89 as 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.