Autumn Lake Healthcare At Long Green

Based upon observation and interview, it was determined that the facility failed to maintain a clean and homelike environment. This was evident for 3 Resident's (Resident #8, Resident #48 and Resident #109) of 3 resident rooms and the first-floor Nourishment Room reviewed during the annual survey. On 01/22/2026 at 1:45 PM, Resident #8 was interviewed and complained of feeling cold. The door to the bathroom was open, and a cold breeze was felt by the surveyor coming from the bathroom. The window was observed to be broken with some clear tape on the broken part of the window, but the tape did not adhere to the broken piece of glass in the windowpane, allowing cold air to enter. On 01/22/2026 at 2:03 PM, the Administrator and Staff #28, the Regional Director of Nursing, were shown the broken windowpane in Resident #8's bathroom. They were asked how this window had been broken. They stated that the bathroom had just been renovated. They acknowledged that the broken window was an issue and stated the maintenance man would cover the broken window until the pane could be replaced. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the staffing sheets and interview it was determined that the facility staff failed to record the actual hours worked by categories of licensed and unlicensed nursing staff each shift. This deficient practice was discovered during the recertification survey.The findings include:On 01/23/26 at 10:45 am a review of the staffing sheets provided by the facility staff revealed the staffing sheets dated 01/21/26, 01/22/26, and 01/23/26 did not include the total number of licensed & unlicensed nursing staff providing direct nursing care each shift.On 01/23/26 at 12:42 PM during an interview with Staffing Scheduler #26 the surveyor asked if they were aware the posted daily schedule must include the facility name, date, census, and the total number of actual hours worked by licensed and unlicensed staff who provide resident care. Staffing Scheduler #26 verbalized they were not aware; that they just write the HPPD and the supervisor does not update it with the numbers. The surveyor and scheduler went 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 observations and medical record review it was determined that the facility failed to ensure appropriate infection control practices during the maintenance of oxygen concentrators. This was evident for 2 out of 2 residents reviewed with oxygen concentrators during the recertification survey.The findings included:During the initial resident screening, it was observed that the humidifier bottle and the oxygen delivery tubing did not have the date it had been installed. This was evident for Residents #67, and #89. With medical record review it was noted that 2 residents had provider orders that instructed staff on the amount of oxygen to be delivered and that the humidifier bottle and oxygen delivery tubing was to be changed weekly and that the date those changes were made were to be labeled on the bottle and tubing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with facility staff, it was determined that the facility failed to maintain clean and operational ventilation systems, thereby impairing proper airflow throughout the premises. This was evident in 2 of 2 janitors' closets, 2 of 2 utility closets, 2 of 2 residents toilet and shower rooms, and the mechanical dishwasher ventilation systems reviewed during the annual survey. Local Exhaust Ventilation ([NAME]) systems are designed and engineered to capture and remove contaminants such as excessive heat, steam, condensation, vapor, smoke, odor, and fumes. This is achieved through the calibration of the total pressure, which is calculated as the sum of the static pressure exiting and entering the system, minus the velocity pressure entering the system. In addition, the fan speed, pressure, and power must be adjusted to account for the specific gravity of the contaminant being captured and removed by the [NAME] system, while considering the specific size and air changes of the room.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews it was determined that the facility failed to developed and implement a person centered care plan. This was evident for 2 Resident's, Resident #12 and Resident #103 reviewed during the annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. On 2/3/2026 at 10:30 AM, medical records were reviewed and revealed that a care plan for Diabetes Mellitus was not developed or implemented for Resident #12. On 02/03/2026 at 11:01 AM, the Director of Nursing, DON, was interviewed and asked who was responsible for implementing and updating the care plan for each resident. The DON stated that the admitting nurse did the baseline care plan, which included skin, falls, pain, medications, and diet. The Unit Managers, UM, would then update the care plan based on the Minimum Data Set, MDS, the resident's diagnosis, and any change…

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 a review of the electronic health record and interview it was determined that the facility staff failed to obtain an order to monitor a resident's blood glucose levels and obtain parameters when the physician should be contacted which is the standard for nursing practice. This deficient practice was evidenced in 1 (#103) of 4 medical records reviewed during the recertification survey. The findings include:On 01/22/26 at 12:31 PM a review of Resident #103's electronic health record (EHR) revealed the resident's glucose was being monitored at least BID (twice a day) since the resident was admitted on [DATE]. A review of the residents' diagnoses revealed the resident had a history of Diabetes Mellitus Type I. Further review of the EHR revealed there was not an order for glucose readings or parameters to notify a physician if the readings were out of a selected range.On 01/22/26 at 12:50 PM during an interview the Director of Nursing the surveyor reported the resident's glucose was being monitored without…

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.

Number of residents sampled: Number of residents cited: Based on review of residents' medical records and interview with facility staff, it was determined that the facility failed to ensure that a physician's order for daily pedal pulses and weekly abdominal girth measurements to be recorded and reviewed by the provider. This is evident in 1 of 1 residents (resident #25) reviewed in the annual certification.The findings include:During an initial interview of resident #25 it was noted that they had severe edema in both of their feet and ankles . When reviewing the medical record it it was noted that the resident's provider had ordered that the resident have pedal pulses taken every shift and that it be documented either positive or negative. That order was written on 11/13/2025. The resident also had an order for the weekly measurement of their abdominal girth dated 9/24/2025. Though in the Task Administration Record) TAR, it was documented that these tasks were completed, no data of the measurements was recorded in the TAR, the resident's chart or any other line of communication 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 employee record review and interviews it was determined that the facility staff failed to ensure a Certified Nursing Assistant (CNA) received their Geriatric Nursing Assistant (GNA) Certification within 4 months of their hire date. This deficient practice was evidenced in 1(#32) of three CNA employee records reviewed during the recertification survey. The findings include:On 01/23/26 at 2:04 PM the surveyor requested that Human Resources Director #22 provide documentation when each CNA received their GNA certification. On 01/23/26 at 2:26 PM during an interview with Human Resource Director (HRD) #22, the surveyor asked when a CNA is hired what amount of time are they allowed to work in Long Term Care (LTC) before receiving their GNA certification. HRD #22 verbalized they believed the timeframe was four months. The surveyor reported that CNA #32's hire date was 06/27/25 and they should have received their GNA certification within four months which would have been 10/27/25. On 01/28/26 at 10:53 AM during an interview with the DON, the surveyor reported that CNA #32's employee…

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

Based on observations and staff interviews it was determined that the facility failed to properly store medication. This was evident in 1 of 3 medication carts reviewed during the annual recertification.The findings include:During the review of medication administration and storage during the annual recertification, it was discovered that a large number (52) of different medication tablets and capsules had fallen into the bottom of the medication cards' drawer. The surveyor removed the tablets and capsules in the presence of employee # 12 who was administering medication at the time and made sure the employee was aware of the problem. The surveyor then spoke with the DON and employee #29 who were made aware of the loose medications found in the cart drawer and the medications were disposed of by the DON

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews with staff, it was determined that the facility staff failed to obtain a diagnostic test and get the results as ordered for Resident (#106) in a timely manner. This was evident for 1 of 21 residents selected for review during the annual survey process. The findings include: On 2/2/2026 at 10:30 AM a review of the medical records showed that Resident #106 was admitted to the facility on [DATE]. The weekly skin evaluation documented that Resident #106's skin the color, temperature, turgor was normal and the integrity of their skin had a healed wound, which was an old scab. On 6/23/2025 an addendum note was reviewed and the note stated that On admission, the area to the sacrum was documented as scabbed area. This is consistent with the hospital discharge summary description of excoriation. As of today, the area was reassessed and was noted to have deteriorated. The scab has been noted to detached naturally. This note is intended to reflect clinical reassessment. Also,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that the facility failed to ensure that the residents received meals that were palatable, attractive, appetizing, adequately portioned, and served at preferred temperatures. This was evident for 1 (Resident #48) of 1 Resident interview and 2 of 2 dining observations conducted during the recertification survey. The findings include: On 01/21/2026 at 12:35 PM, the surveyor interviewed Resident #48, who expressed ongoing concerns regarding the unappetizing nature of the foods served, specifically noting that they were frequently served cold. At 12:45 PM, lunch was delivered to Resident #48's room. The meal ticket indicated a double portion of Stir-Fried [NAME] with Chicken was served. The Stir-Fried [NAME] with Chicken, which had a watery consistency, contained rice, chopped chicken, chopped celery, and several unidentified ingredients. The resident sampled the food and stated that it was cold and spicy. Therefore, the resident requested a substitution of 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 observation and interviews with facility staff, it was determined that the facility failed to ensure the appropriate location and maintenance of the exterior dumpster to prevent the harborage and infestation of pests and insects. The findings include: On 01/21/2026 at 8:40 AM, the surveyor observed the exterior dumpster positioned at the loading dock. Staff #6 and the Maintenance Director were interviewed concerning the placement of the dumpster in this area.At 8:55 AM, the surveyor and the Maintenance Director proceeded outside the rear kitchen entrance door to assess the dumpster area, where they discovered a piece of 4-inch by 12-inch plywood situated next to the rear kitchen entrance door. The Maintenance Director acknowledged that the plywood may have been utilized to prop open the rear kitchen door during food deliveries and/or the removal of trash from the facility.Both the surveyor and the Maintenance Director continued down the loading dock staircase leading to the dumpster area and observed trash and debris scattered around the dumpster location. The Maintenance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews with facility staff, it was determined that the facility failed to ensure a call bell system was accessible to residents. This was evident for 3 (Resident #1, #44 and #109) of 3 residents' toilet facilities call bell systems reviewed during the annual survey.The findings include:On 01/21/2026 at 1:15 PM, the surveyor observed that the call bell cord was missing in Resident #1's restroom.On 02/02/2025 at 2:00 PM, the surveyor toured the [NAME] unit with the Maintenance Director and observed that the call bell cord was missing in Residents #44 and #109 restrooms.At 2:10 PM, the Maintenance Director acknowledged the missing call bell cords for Residents #1, #44, and #109 would be installed as soon as possible.

Based on observation, record review, and interviews with staff and residents, it was determined that the facility failed to maintain a rodent and insect free environment for the residents. This was evident in 2 of 2 resident rooms and the conference room reviewed during the annual survey.The findings include:On 01/21/2026 at 12:45 PM, an interview with Resident #48 indicated that the resident had sighted a rodent within the resident's room.At 12:55 PM, Resident #39 acknowledged that the condition of the resident's room was conducive to pest harborage and confirmed that a rodent had been observed in the room.At 2:00 PM, a review of Resident #39's Care Plan, updated on 9/3/2025, revealed that facility staff had encouraged and educated the resident on the importance of maintaining a clean and clutter-free room.On 01/22/2026 at 9:45 AM, an interview with the Administrator was conducted concerning the facility's intervention process for Resident #39 to clean and declutter the room. The Administrator explained that staff had provided containers to organize belongings, but the resident has…

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

Based on observation, interviews with residents and staff, and a review of facility processes, the facility failed to ensure an adequate supply of clean, well-maintained linen was available to meet the needs of residents. This deficient practice affected 4 (Resident #5, #10, #15, #16) of the 16 residents reviewed during the complaint survey. The findings include: On 10/1/2025 at 10:15am, the surveyor reviewed two complaints from residents #5 and #10 regarding the facility's failure to supply well-maintained linen to its residents. On 10/2/2025 at 12:30pm, interview with resident #15 revealed a complaint of a lack of well-maintained linen being available to the residents of the facility.On 10/3/2025 at 1:20pm, interview with resident #16 revealed a complaint of the facility's failure to supply enough linen to the residents. Resident #16 alleged that the linen that was supplied to the residents was in ill-repair. On 10/6/2025 at 8:00am - 8:15am, the complaint survey team made several observations of linen carts on all units that failed to have enough linen to supply the residents on…

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

Based on observation, interviews with residents and staff, and a review of facility processes, the facility failed to ensure an adequate supply of clean, well-maintained linen was available to meet the needs of residents. This deficient practice affected 4 (Resident #5, #10, #15, #16) of the 16 residents reviewed during the complaint survey. The findings include: On 10/1/2025 at 10:15am, the surveyor reviewed two complaints from residents #5 and #10 regarding the facility's failure to supply well-maintained linen to its residents. On 10/2/2025 at 12:30pm, interview with resident #15 revealed a complaint of a lack of well-maintained linen being available to the residents of the facility.On 10/3/2025 at 1:20pm, interview with resident #16 revealed a complaint of the facility's failure to supply enough linen to the residents. Resident #16 alleged that the linen that was supplied to the residents was in ill-repair. On 10/6/2025 at 8:00am - 8:15am, the complaint survey team made several observations of linen carts on all units that failed to have enough linen to supply the residents on…

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

Based on medical record review and interview with staff it was determined the facility failed to notify a resident/resident representative in writing of a room change, including the reason for the change. This was evident for 1 (Resident #1) of 6 residents reviewed for a facility reported incident during the complaint survey.The findings include:On 10/3/25 at 10:00 AM, a review of Resident #1's EMR (electronic medical record) revealed documentation that Resident #1 resided on the Main Street Unit, in same room, in A bed, since 4/11/25. On 10/3/25 at 12:30 PM, an observation of the room where, per the medical record Resident #1 resided found the resident's name posted outside of the room, indicating Resident #1 resided in A bed, in the room. At that time, Resident #1 was not observed to be in the room.On 10/6/25 at 10:35 AM, an observation of Resident #1's room revealed the A bed mattress was bare and without linens, Resident #1 was not in the room at that time. As the surveyor was leaving the room, Resident #16, who resided in B bed in the room, asked the surveyor if s/he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with facility staff and residents it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on all nursing units. The findings include: The following environmental concerns were observed during the survey: 1) room [ROOM NUMBER]: The resident entrance door into the room was observed with chipped wood on the edge of the door frame. 2) room [ROOM NUMBER]: 8 floor tiles were lifting from the floor; dark black stains was observed on the vinyl flooring. Food was noted under the bed. The laminate on the over the bed tray table was chipped on the corner approximately 3 inches around the corner with particle board exposed and the footboard was cracked and loose on the right side. 3) room [ROOM NUMBER]: The base molding by the air conditioner had approximately 8 inches pulled away from the wall by the radiator. There was a hole on the bottom sheet on the left side. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview with facility staff and residents, it was determined that facility staff failed to follow professional standards of nursing practice when administering medications to residents. This was evident for 2 (Resident #9 and #88) of 7 residents selected for a medication administration audit record (MAAR) review during the survey. The findings include: 1) During observation rounds on 7/23/24 at 11:30am Resident #9 stated s/he does not receive his/her medications on time. Review of the Medication Administration Record (MAR) on 7/23/24 at 1pm revealed a physician order to administer Methadone HCL 30mg (milligrams) by mouth two times a day for opioid dependency. According to the MAR, the medication was scheduled to be administered at 9am and 9pm. Review of the MAAR revealed the following: On 6/8/24 the resident's 9:00am dosage of Methadone was not signed off as being administered until 6/8/24 at 11:32am. On 6/13/24 the resident's 9:00am dosage of Methadone was not signed…

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

Based on observations and interviews it was determined that the facility failed to ensure: 1) appropriate temperature monitoring was maintained for the medication refrigerator, 2) expired medications were properly discarded, and 3) appropriate labeling and storage of medications. This was evident in 2 out of 2 medication storage rooms observed in the facility and 4 of 7 medication carts observed in the facility. The findings include: On 07/29/24 at 08:29 AM, the surveyors and charge nurse, Staff #54, conducted an observation of the second-floor medication storage room located behind the nurse's station. The temperature log was not documented from 07/28/24 to 07/29/24 and there was no date/signature on the second page of the temperature log to ensure proper monitoring. On 07/29/24 at 08:38 AM, the surveyors found the following expired items on a shelf in the medication storage room: adhesive remover wipes with expiration date of 12/20/21, self-adhesive fabric with expiration date of 04/2020, and fluocinonide ointment with expiration date of 03/17/2024. On 07/29/24 at 08:53 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with facility staff, it was determined that the facility failed to ensure residents' rights to dignity and privacy as evidenced by 1) not ensuring that a resident's foley drainage bag was covered, this was evident for 1 (Resident #86) of 2 residents reviewed for dignity and 2) the facility staff not putting the residents' clothing away in drawers or hanging them in the armoires. This deficient practice was evidenced in 30 of 33 residents screened during the Medicare/Medicaid survey. The findings include: A foley drainage bag, or urinary drainage bag, is a medical device used to collect urine from a catheterized resident. The drainage bag is usually worn on the leg or attached to a bed. 1) During observation rounds on 7/22/24 at 7:50 am, Resident #86 was noted to have a foley catheter bag attached to their bed. The foley drainage bag was uncovered and had amber colored liquid visible. The bag was attached to the door side of the bed. Resident #86's door was open, and the 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.

Based on observations and interviews it was determined that the facility staff failed to ensure residents had their call bells readily accessible when assistance was required. This deficient practice was evidenced in 3 (#11, #13, & #14) of 33 residents reviewed for accommodations of needs during the survey. The findings include: On 07/22/24 at 1:58 pm the surveyor observed Resident #11 in bed with a torn diaper. The surveyor asked the resident if they had a call bell and the resident replied, no. The surveyor observed Resident #11 call bell attached to their roommates' bed. Unit Manager #8 confirmed the resident's call bell was on their roommate's bed. Unit Manager #8 verbalized each resident was supposed to have their own call bell to request assistance when needed. Unit Manager #8 was unable to determine why Resident #11's roommate had both call bells. On 07/29/24 at 9:46 am the surveyor observed Residents #13's and Resident #14's call bells on the floor in their room. Resident #13's call bell was on the left side of the bed on the floor. Resident #14's call bell was on the right…

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

Based on administrative record review and interviews with facility staff it was determined the facility failed to ensure that a resident was free from misappropriation of their funds while residing in the facility. This was found to be evident for 1 (Resident # 111) of 3 resident's reviewed for personal property during the survey. The findings include: MD00178630 was reviewed on 7/24/24 at 9:00 AM for misappropriation of resident funds of $1000.00 that was reported to be taken without the resident permission from an account. An interview was conducted with the Administrator (Staff # 1) on 7/24/24 at 11:00 AM and he was asked if he remembers Resident # 111 and he stated that he was very familiar with the resident. The Administrator was then asked if he withdrew $1000.00 from the resident account, and he went on to explain that if a resident has an overage of $2500.00 the facility would do a care cost spend down. The survey team requested a copy of the resident's account from the date of the resident's admission. On a subsequent visit, the Administrator provided a copy 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 record review and interview with facility staff, it was determined that the facility failed to timely report allegations of abuse within the required two hour timeframe to the Survey Agency, the Office of Health Care Quality (OHCQ). This was evident for 2 (MD00204913 and MD00202949) of 5 facility related incident reports reviewed during the survey. The findings include: 1) On 07.22.24 at 1:00 PM the surveyor reviewed MD00204913 which was related to the allegation of inappropriate sexual relations between Residents #8 and #81. The alleged incident occurred on 04.11.24 around 4:00 PM per the documentation submitted by the facility. Review of the facility's documentation related to this incident report revealed the administrator did not submit the initial report to OHCQ until 8:15 PM on 04.11.24. During an interview with the DON and the administrator the surveyor reviewed the late submission of the initial report. Both the DON and the administrator stated that they were aware of the requirements to submit initial reports related to abuse within a two-hour time period. 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 interview with facility staff, it was determined that the facility failed to complete a thorough investigation of an allegation of abuse. This was evident for 1 of 10 residents (Resident #36) reviewed for abuse during the survey. The findings include: The facility's investigation related to facility reported incident MD00206051 was reviewed on 7/24/24 at 3:58 PM and revealed that, on 5/26/24, Resident #36 had reported to the Nursing Home Administrator (NHA) that his/her assigned Geriatric Nursing Assistant (GNA) allegedly threw a cup of water in his/her face. Further review of the facility investigation documents revealed interviews of the alleged incident from the alleged perpetrator, another GNA, and the nursing supervisor of each of the aforementioned staff members. The investigation did not include an interview of the alleged victim, Resident #36. On 7/22/24 at 1:48 PM review of Resident #36's medical record revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicates the resident's cognition was intact. In an…

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

Based on medical record review and interviews with facility staff it was determined the facility failed to complete a baseline care plan on a resident admitted with a stage four pressure ulcer. This was evident for 1 (Resident # 98) reviewed for pressure ulcers during the facility's annual survey. 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. A written care plan decreases the risk of incomplete, incorrect or inaccurate care. A baseline care plan must be completed within 48 hours of a resident's admission to the facility. A stage 4 pressure ulcer, also known as a bedsore, is the most severe type of pressure ulcer and can be life-threatening. It's characterized by full-thickness skin loss that extends through the fascia and into the muscle, bone, tendon, or joint. A medical record review was completed for resident # 98 on 7/22/24 at 1:30pm and it revealed the resident was admitted…

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, observation and interviews with facility staff, it was determined that the facility failed to ensure comprehensive care plans were developed and implemented. This is evident for 2 (Resident #98 and #88) of 37 residents reviewed during the 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. A written care plan decreases the risk of incomplete, incorrect or inaccurate care. A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure or friction 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), and Stage IV…

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 reassess a resident's blood pressure (BP) when it was outside of the resident's usual parameters. This deficient practice was evident in 1 (#68) of 1 resident reviewed for follow up after abnormal vitals during the survey. The findings include: On 07/24/24 at 9:11 am a review of Resident #68 vital signs revealed on 07/23/24 at 10:07 pm the documented BP was 180/92. There was not another BP documented after the elevated BP was recorded. The surveyor checked the nursing notes for documentation from Certified Medication Aide # 66 who recorded the BP or from the nurse overseeing the resident's care. The resident was ordered Hydralazine 100 mg by mouth at 10 pm. The medication was signed off as given. A review of Resident #68 care plan for coronary heart disease dated 08/14/23 revealed medication for hypertension should be given as ordered and a response to the medication should be documented. On 07/24/24 at 10:32 am Director of Nursing #2 (DON) was made aware Resident #68's BP was elevated…

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 ensure that treatment that was ordered for a resident with urinary incontinence was implemented. This was evident for 1 (#93) of 3 residents reviewed for bladder incontinence. The findings include: During observation rounds on 7/26/24 at 12 noon resident #93 was sitting in the hallway with his/her Foley bag sitting in the wheelchair. The Foley bag was filled to the top with a yellow-colored fluid and a large piece of tape was noted attached to the bag. This surveyor asked the resident why, his/her foley bag was not attached to the wheelchair and the resident stated, my Foley bag has a hole in in. I told the nurse instead of changing it he just taped it. Review of the medical record on 7/26/24 at 12:30pm revealed a physician order to change the catheter/foley bag when needed and to empty the foley drainage bag at least once every eight hours or when it becomes half to 2/3 full. The DON Director of Nursing was made aware of the findings at 12:45pm. During a follow-up interview with the DON 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 surveyor observation, interview with facility staff, and review of the medical record, it was determined the facility staff failed to provide necessary respiratory care services for residents by failing to date label oxygen administration equipment and failing to administer oxygen as prescribed. This was evident for 1 (Resident #60) of 37 residents reviewed during the survey. The findings include: On 7/19/24 at 8:07 AM Resident #60 was observed receiving oxygen via nasal cannula at a flow rate of 4.25 liters per minute (L/min). A nasal cannula is a device that delivers oxygen directly to a person's nostrils via a flexible plastic tube. During a second observation that took place on 7/19/24 at 2:16 PM, Resident #60 was noted to still be receiving oxygen at a flow rate of 4.25 L/min. On 7/19/24 at 2:21PM in an interview with Licensed Practical Nurses (LPN) #14 when asked about oxygen administration equipment he stated the tubing should be labeled with initials and the date/time it was changed. During the interview he stated if the humidifier bottle is running out, that is…

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 medical record and interview with facility staff, it was determined that the facility failed to respond to the pharmacy recommendations after a monthly clinical review was done and failed to ensure the attending physician reviewed the pharmacy reviews. This was evident for 2 (Resident # 93 and #88) of 5 residents reviewed for unnecessary medications during the survey. The findings include: 1) Resident # 93's medications were reviewed on 7/30/24 at 1:00pm for unnecessary medications. Upon review of the Consultant Pharmacist Medication Regimen Review Medical Director Report dated 6/20/24, it indicated the following: Recommendation: Please clarify a frequency for Magnesium Hydroxide PRN (when needed) (ex. once daily PRN.) Magnesium hydroxide is used to treat occasional constipation in adults on a short-term basis. There was no response indicated on the form. An interview was conducted with the Assistant Director of Nursing (ADON) on 7/30/24 at 1:20pm, she was asked to provide copies of the facility's response to the pharmacist's recommendations. During 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 a review of the medical record and interviews with facility staff it was determined that the facility failed to respond to the pharmacy recommendations after a monthly clinical review was done. This was found to be evident for 1(Resident # 93) of 5 residents reviewed for unnecessary medications during the facility's annual survey. The findings include: Anxiolytic drugs, also known as anti-anxiety medications or minor tranquilizers, treat anxiety and related conditions. Resident # 93 medications were reviewed on 7/30/24 at 1pm for unnecessary medications. Upon review of the Consultant Pharmacist Medication Regimen Review Medical Director Report dated 6/20/24 it indicated the following: The resident has a PRN (when needed) order for an anxiolytic, without a stop date. Recommendation: is to consider discontinued PRN Diazepam, tapering as necessary. If medication cannot be discontinued at this time, please document the indication for use. The intended duration of therapy and the rationale for the extended time of period. There was no response indicated on the form. An interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on administrative record reviews, observations, and interviews the failed to (1) ensure sanitary practices were followed in accordance with professional standards for food service safety, (2) maintain a clean working environment, #3) to remove expired canned food from the kitchen, (4) maintain safe temperatures in a unit refrigerator, and (5) to remove outdated food from unit refrigerators. These deficient practices related to the unit refrigerators were identified to be present on 2 out of 4 clinical units and the facility kitchen. The findings include: On 07.19.24 at 07:50 AM the surveyor performed the initial observation of the kitchen as part of the facility task and escorted by Staff #16, director of dietary services. The tour initiated in the dry storage area. The surveyor observed that two of the closed bins in which dry cereal was stored did not have an expiration date on the sticker/label. Also, the surveyor found one can of pears with an expiration date of 05.2023 on another shelf. On 07.19.24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with facility staff, it was determined that the facility failed to ensure that resident's medical records were accurately documented in accordance with accepted professional standards. This was evident for 1 (Resident #68) out of 8 resident's records reviewed during the survey. The findings include: On 07/22/24 at 03:12 PM, during an interview with Resident #68's daughter, she told surveyors that the resident had lost some weight. On 07/24/24 at 09:01 AM surveyors reviewed the section K of the Minimum Data Set (MDS) assessment dated [DATE] and it showed that Resident #68 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. On 07/24/24 at 09:05 AM, surveyors reviewed Resident #68's weights in the Electronic Health Record and discovered significant weight discrepancies. On 03/05/25, it was recorded that resident weighed 151.9 lbs and a month later,on 04/1/24, it was recorded that the resident weighed 150.3 lbs. On 04/02/24 (one day…

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

Based on observations and interviews with facility staff it was determined the facility failed to ensure that infection control practices were maintained to prevent the spread of germs and transmission of microorganisms. This was evident for 1 (Resident #39) of 37 residents reviewed and found to be present when observations were made during the survey. The findings include: 1) On 7/26/24 at 11:30 AM an observation was made of the food on the floor in the Atrium near the dining room. There were round substances that resembled meatballs that were noted underneath the equipment stored in a cove in this area. Along a side wall there was a splatter noted to the base boards. The Administrator who was walking past the area at the time of the observation was made aware. The Administrator stated that he would have housekeeping services clean the area. Housekeeping services arrived at 11:40 AM to clean the area. 2) An observation was made on 7/30/24 at 11:40 AM of the hallway that leads to the laundry area and kitchen. Trash was observed on the floor and the floor was dirty with large dark…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with facility staff it was determined the facility failed to ensure that the resident's environment was maintained in a safe and homelike manner. This was found to be evident for multiple residents that resided in rooms (#121,122,123,124,126, 219 and 226) of 7 resident rooms observed during the facility's survey. The findings include: MD00178628 was reviewed on 7/25/24 at 9:30 AM for multiple concerns including concerns regarding the resident's physical environment. On 7/25/24 at 11:50 AM a tour of the building was conducted and while touring the first floor the following concerns were identified: Observations were made of the air conditioner (ac) units in the following rooms: #121, #123, #124 and #126 and there was dust, dirt and debris present on the front of the units and inside along the screen filters. On the same date at 12:10 PM the Administrator (Staff #1) and the Director of Nursing (DON) (Staff #2) was made aware of the concerns that were observed and summoned the…

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

Based on observations and interviews of facility staff it was determined the facility failed to ensure an effective pest control program as flies and fruit flies were observed throughout the building. This was found to be evident during the facility's survey. The findings include: 1) Observations were made of flies noted in the conference room on July 23, 24, 25, 26, 29, 30 and 31, 2024. The conference room is located on the first floor along the hallway where resident rooms are also located. On July 25, 2024, at 11:50 AM flies were observed in the hallway along the first floor, and in resident rooms # 121, and 123. Flies were also observed in the bathroom located between these rooms. On the same date at 12:10 PM the Administrator (Staff #1) and the Director of Nursing (DON) (Staff #2) was made aware of the concerns that were observed, and the Administrator summoned the Maintenance Assistant (MA) (Staff # 62) to accompany the surveyor and administration team to the first floor. The Administrator confirmed the above-mentioned findings. Review of the pest control service summary…

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 facility reported incidents, record review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 4 (#15, #36, #13, #18) of 54 residents reviewed during a complaint survey. The findings include: 3) On 11/1/23 at 11:16 AM a review of facility reported incident MD00184497 revealed Resident #13 was allegedly hit in the face by staff while trying to get off the unit to purchase soda on 10/15/22 between 1:00 AM and 2:00 AM. Review of the facility's investigation packet revealed documentation that geriatric nursing assistant (GNA) #29 alleged the incident took place, however, did not report it until the day shift came to work which was not within 2 hours of alleged abuse. Review of the facility's email confirmation documented that the initial report was sent to OHCQ on 10/15/22 at 10:19 PM which was not within 2 hours of being informed of the alleged…

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, medical record review and interview, it was determined that the facility staff failed to create and implement care plans related to resident's specific needs. This was evident for 5 (#4, #19, #30, #32, #7) of 54 residents reviewed during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 11/6/23 at 7:52 AM complaint MD00195656 was reviewed and alleged Resident #4 was visited twice and both times was found…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and complaint review, it was determined the the facility staff failed to administer medications and provide treatments as ordered by the physician and failed to provide care in accordance with professional standards of practice and resident's choices. for residents. This was evident for 6 (#2, #25, #26, #19, #1, #5) of 54 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to administer medication as ordered by the physician for Resident #2. Review of Resident #2's medical record on 11/9/23 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include exocrine pancreatic insufficiency. During telephone interview with the Resident on 11/14/23 at 9:29 AM, the Resident stated he/she does not receive his/her medications on time and especially wants to make sure he/she receives his/her pancreatic medication with meals so it does not mess with his/her stomach. Resident also stated at that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to include a resident's representative (RP) in the A) admission process and B) care planning (Resident #41). This was evident for 1 of 54 residents reviewed during a complaint survey. The findings include: Review of Resident #41's medical record on 11/13/23 revealed the Resident was admitted to the facility from the hospital on [DATE] with a diagnosis to include altered mental status after Resident was found confused at home. Review of a nurse's note on 11/20/20 at 11:35 PM stated: Patient is confused, consent will be needed from RP to administer pneumonia vaccine. Further review of the Resident's record revealed a physician's history and physical on 11/23/20 that states: Review of systems - limited participation secondary to dementia. A nurse practitioner's (NP) note on 11/24/20 states: Patient seen in bed awake, alert but confused, yelling he/she is hungry and could not remember when he/she had lunch and later said he/she had lunch…

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

Based on review of complaint, medical records, and interview, it was determined that the facility failed to review the admission agreement, which includes a notice of the resident's rights, with a resident at the time of admission and failed to ensure the admission agreement was signed and documented. This was evident for 1 (#23) of 54 residents reviewed during a complaint survey. The findings include: On 11/8/23 at 10:10 AM a review of complaint MD00176640 was conducted and alleged that an admissions contract was never executed. Review of Resident #23's electronic and paper medical record failed to produce a signed copy of the admissions contract. On 11/8/23 at 9:59 AM an interview was conducted with Staff #18, the Director of Admissions. Staff #18 was asked if residents received an admissions contract upon admission. Staff #18 stated, yes, as soon as they are admitted . If they come on Friday after I leave, then I do it on Monday or Tuesday. I do the contract that day if I am here or if not here the next day. Staff #18 stated, I was still on the floor doing unit clerk work when…

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 complaint, interview, and medical record review, it was determined the facility failed to notify the physician when medications were not available to be administered to residents. This was evident for 1 (#5) of 54 residents reviewed during a complaint survey. The findings include: On 11/2/23 at 11:57 AM a review of complaint D00195632 alleged that Resident #5 failed to timely receive certain medications in July and August 2023. On 11/2/23 at 12:12 PM an interview was conducted with Resident #5. Resident #5 stated he/she missed the blood pressure medication Metoprolol 100 mg. for several days in July and had tachycardia and felt like he/she was going to pass out. Resident #5 stated he/she also missed Linzess for 3 days. Linzess is used to treat irritable bowel syndrome. Resident also added that he/she saw a physician this past Monday and was prescribed a medication for a yeast infection and it had not been started yet. On 11/2/23 at 12:40 PM Resident #5's medical record was reviewed and revealed a 7/27/23 medication administration note that documented, Metoprolol…

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, facility documentation and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff (Resident #18). This was evident for 1 of 54 residents reviewed for abuse during a complaint survey. The findings include: Review of Resident #18's medical record on 11/7/23 revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation following multiple gun shot wounds. During interview with Resident #18 on 11/14/23 at 12:30 PM, Resident #18 stated about a month ago he/she got upset with Staff #25 about drinks being served. Resident #18 stated he/she was cursing at Staff #25 and they were cursing back at him/her. Resident #18 stated he/she said F (expletive language) you to Staff #25 and Staff #25 responded with you can't, your D (expletive language) is too small. Resident #18 at that time stated he/she feels safe in the facility, he/she was okay with Staff #25 caring for him/her but doesn't think she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility reported incidents, facility investigations, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse and neglect. This was evident for 3 (#15, #36, #14) of 54 residents reviewed during a complaint survey. The findings include: 1) On 11/1/23 at 2:15 PM a review of facility reported incident MD00181791 revealed on 8/4/22 at 5:45 PM Resident #15's mother reported that Resident #15 alleged that he/she had been sexually assaulted. Review of the facility's investigative documentation revealed the social worker's written statement of 3 male residents, the written statement from Resident #15's mother, a typed statement from the Director of Nursing (DON) of the phone call she received from the Assistant Director of Nursing (ADON), and a typed note from the Nursing Home Administrator (NHA). A head-to-toe assessment was done, and the resident was sent to the hospital for evaluation. There were no other staff interviews and no other resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded (Resident #43). This was evident for 1 of 54 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #43's medical record on 11/9/23 revealed the Resident was admitted to the facility on [DATE]. Further review of the Resident's medical record revealed a Skin Integrity Report was initiated on 12/5/19 for the Resident #43's left heel deep tissue injury (DTI). Review of a nurse's note on 2/5/20…

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

Based on record review and interview with facility staff, it was determined that the facility failed to ensure that a recapitulation of the resident's stay was completed following a resident's discharge from the facility. This was evident for 1 (#30) of 54 residents reviewed during a complaint survey. The findings include: On 11/7/23 at 9:50 AM a record review was conducted for Resident #30. Resident #30 was admitted to the facility in September 2021 for physical and occupational therapy following an amputation of the left leg above the knee. On 9/8/21 the social services department documented that they began the discharge planning for Resident #30. Initially, Resident #30 was going to be discharged home to his/her mother, however the mother stated she was unable to care for Resident #30. On 9/24/21 social services documented that Resident #30 agreed to look into being discharged to a recovery program for people with substance abuse issues. On 10/21/21 the social worker documented Resident #30 was accepted in a treatment/housing program where the resident would be in treatment for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide activities of daily living (ADL) to a dependent resident (Resident #21). This was evident for 1 of 54 residents reviewed during a complaint survey. The findings include: Review of Complaint MD00177333 on 11/7/23 alleged the Resident #21 was saturated with urine and feces on a daily basis. Review of Resident # 21's medical record on 11/7/23 revealed the Resident was admitted to the facility on [DATE] with diagnosis to include hemiplegia and hemiparesis following cerebral infarction affecting right side which rendered Resident #21 dependent on staff for activities of daily living. The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on…

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. This was evident for 3 (#16, #33, #43) of 54 residents reviewed during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure Ulcer Advisory…

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, record review, and interview, it was determined the physician/nurse practitioner failed to review the resident's total care as evidenced by documenting the resident was still being followed by physical and occupational therapy even though the resident was discharged from therapy. This was evident for 1 (#1) of 54 residents reviewed during a complaint survey. The findings include: On 11/9/23 at 10:40 AM a review of complaint MD00198561 alleged that Resident #1 was not receiving rehabilitation to strengthen Resident #1's body to stand and walk. Review of Resident #1's medical record revealed a 6/1/23 physician's history and physical that documented that Resident #1 was admitted to the facility with ambulatory dysfunction after a recent fall. Resident #1 was admitted to the facility for subacute rehabilitation and management of ongoing medical conditions. Physical and Occupational therapy were ordered. On 11/2/23 at 10:34 AM an interview was conducted with the Director of Rehabilitation, Staff #9 who stated Resident #1 started rehabilitation at the end of May of…

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

Based on review of a complaint, interview, and medical record review, it was determined the facility failed to timely provide medication to meet the needs of the residents. This was evident for 2 (#5, #44) of 54 residents reviewed during a complaint survey. The findings include: 1) On 11/2/23 at 11:57 AM a review of complaint MD00195632 alleged that Resident #5 failed to timely receive certain medications in July and August 2023. On 11/2/23 at 12:12 PM an interview was conducted with Resident #5. Resident #5 stated he/she missed the blood pressure medication Metoprolol 100 mg. for several days in July and had tachycardia and felt like he/she was going to pass out. Resident #5 stated he/she also missed Linzess for 3 days. Linzess is used to treat irritable bowel syndrome. Resident also added that he/she saw a physician this past Monday and was prescribed a medication for a yeast infection and it had not been started yet. On 11/2/23 at 12:40 PM Resident #5's medical record was reviewed and revealed a 7/27/23 medication administration note that documented, Metoprolol Succinate Capsule…

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

Based on interview and medical record review, it was determined the facility failed to adequately monitor the resident's heart rate and blood pressure while taking an antihypertensive medication and failed to monitor the heart rate and blood pressure when a resident was not administered the medication while waiting for delivery of the medication from the pharmacy. This was evident for 1 (#5) of 54 residents reviewed during a complaint survey. The findings include: On 11/2/23 at 12:12 PM an interview was conducted with Resident #5. Resident #5 stated he/she missed the blood pressure medication Metoprolol 100 mg. for several days in July and had tachycardia and felt like he/she was going to pass out. On 11/2/23 at 12:40 PM Resident #5's medical record was reviewed and revealed a 7/27/23 medication administration note that documented, Metoprolol Succinate Capsule ER 24 Hour Sprinkle 100 mg. pharmacy not delivered yet. A 7/29/23 medication administration note documented, Metoprolol Succinate Capsule ER 24 Hour Sprinkle 100 mg. med not available. A 7/31/23 medication administration note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of complaint, medical record review, and interview, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (#32) of 54 residents reviewed during a complaint survey. The findings include: On 11/7/23 at 2:00 PM a review of complaint MD00173277 was conducted and alleged that Resident #32 had not received routine dental care in several years. The complainant alleged that it was requested that the resident be put on a list for [name] of dental provider at which time the facility reported that the resident was added to the list on 7/16/21 and had still not been seen as of October 2021. On 11/7/23 at 2:00 PM Resident #32's medical was reviewed and revealed a 9/7/19 physician's order for podiatry, dental and ophthalmology consult, and treatment as needed for patient health and comfort. Two requests for services/consultation were found in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with facility staff it was determined that the facility failed to stored food in a sanitary manner. This was observed on 1 of 4 nursing units. The finding include: On 11/14/23 at 11:05 AM observation was made of a banana and 2 health shakes sitting on the handrail in the hallway outside of room [ROOM NUMBER] on the [NAME] nursing unit. The unit manager, Staff #27 was with the surveyor at the time of the observation. One of the health shakes was for a resident in that room, however the other health shake and the banana were for other residents on the unit. At the time of observation, Staff #27 told a GNA to remove the items from the handrail and pass them out to the residents. On 11/14/23 at 11:45 AM the Director of Nursing was informed of the observation of food stored on a handrail rail for all residents and the public to touch.

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 ensure a resident went to scheduled out of the facility physician visits in a timely manner. This was evident for 2 (#17, #28) of 54 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to ensure Resident #17 went to a urology appointment in a timely manner. Review of Resident #17's medical record on 11/9/23 revealed the Resident was admitted to the facility from the hospital on [DATE] with a urinary catheter. Review of the Resident's hospital Discharge summary dated [DATE] stated: Urology recommended keeping urinary catheter to straight drainage. Outpatient follow up with cystoscopy for removal of the retained piece of balloon and voiding trial thereafter. Further review of Resident #17's medical record revealed a physician order on 12/6/21 to schedule a urology follow up with no documentation of a urology follow up. There is another physician order on 1/6/22 to schedule a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 4 (#19, #42, #17, #43) of 54 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 11/7/23 at 7:54 AM Resident #19's paper medical record was reviewed. Towards the back of the medical record, after the University of Maryland Medical Center notes for admission dated 11/30/21, there was an Explanation of Form SSA-827 (3) pages for Resident #24. There was also a Maryland DDS Request for Information dated 12/8/21 with an Authorization to disclose information to the Social Security Administration (SSA)…

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 multiple observations it was determined the facility failed to maintain an environment that was clean, comfortable, and homelike for residents. This deficient practice had the potential to affect all residents. The findings include: 1) Surveyor tour of the facility on 8/5/19 at 8:40 AM revealed the following concerns: room [ROOM NUMBER]: foot board was off bed, drawer to dresser was broken, and the wheelchair back and seat were cracked. room [ROOM NUMBER]: briefs were on the floor as well as a used glove, the TV cable was not secured, and the foot board of bed was broken room [ROOM NUMBER] A: the privacy curtain was soiled and there was a soiled washcloth on the floor room [ROOM NUMBER] B: the feeding pump was dirty room [ROOM NUMBER]: the privacy curtain was soiled room [ROOM NUMBER]: small flies were noted in the shower room near room [ROOM NUMBER] room [ROOM NUMBER]: the bedspread had holes in it and the sheet was stained Surveyor tour of the facility on 8/6/19 at 11:00 AM revealed: There was a very…

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 resident council meeting minutes and interview with residents and facility staff, it was determined that the facility failed to give adequate responses to grievances presented by the resident council. This was found evident in the review of the monthly resident council meeting minutes and facility responses for the months of November 2018-July 2019. The findings include: Review of the resident council meeting minutes on 8/5/19 at 1:30 PM revealed repeat concerns regarding the type of briefs the facility was using. The complaint related to the briefs started at the November 2018 resident council meeting, residents stated that they changed them, we want the other ones back, they are tight, soak through smelling up clothes, room and hallway. Review of the December 2018 resident council meeting minutes form, under discussion of old/unfinished business: no change with diapers, [residents] feel as though they are cheap, leak; scratch skin. In the section under concerns/suggestions for Administration it was noted that: [residents] feel like they always have the same…

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

Based on reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to: 1) conduct a yearly performance review of geriatric nursing assistants, and 2) ensure that all geriatric nursing assistant (GNA) staff completed a minimum of 12 hours of education per year. This was evident for 6 of 7 GNA records reviewed during the investigative stage of the survey. The findings include: 1) Review of administrative records revealed that GNA #4, #6, #7, #8 and #9 did not have performance evaluations for 2018. In an interview with the Director of Nursing (DON) on 08/08/19 at 1:00 PM, the facility Director of Nursing confirmed the findings. 2) On 08/08/19, a review of 7 random GNA staff members' educational records for 2018, revealed that GNA #5 failed to complete at a minimum of 12 hours of education for the year of 2018.

Based on the interviews from residents and the results from a test tray it was determined that the facility failed to maintain adequate temperatures over 135 degrees for hot cooked meals. This was evident during the testing of a breakfast and lunch tray, tested for palatability and temperature. The findings include: On 8/5/19 at 8:03 AM an initial tour of the kitchen was completed. The temperature logs were reviewed for the breakfast meals and no concerns were noted in the documentation. However, during initial tour of the facility and interview with residents from both floors, it was mentioned to the surveyors that food was cold, and it varied for all meals. This was also reported in the resident council meeting minutes. On 8/8/19 at 8:28 AM a breakfast test tray was received. The test tray consisted of the main meal and the alternative. They came off the mobile cart that was stationed on the rehabilitation unit that was last to be served breakfast and brought directly to the conference room. The plates consisted of; pancakes and ham as the main meal and the alternative was eggs,…

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 failed to provide a resident with dignity and respect by improperly transporting a resident down the hall. This was evident during a random observation. The findings include: During observation of breakfast on 8/6/19 at 7:42 AM, Surveyor observed staff Geriatric Nursing Assistant (GNA) #1 pulling Resident #37 down the hall backwards to the 2nd floor lounging area. Resident #37 was positioned in a Geri chair (medical clinical style recliner). GNA #1 was observed walking forward with her arm extended backwards pulling the Geri chair down the hallway and turned into the lounging area and passed the mobile serving cart. Resident #37 could not be observed from the staff's position and was not checked on by the staff during this observation. The observation continued with Staff GNA #2 setting up and feeding Resident #37 at 7:53 AM, while standing with her hand on her hip and with no communication to Resident #37 but spoke with the other GNA staff. GNA #2 was also observed at this time standing over Resident #21 and Resident #90…

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 that the facility staff failed to take proper steps to void an older Medical Orders for Life-Sustaining Treatment form located in a resident's active medical record. This was evident for 1 of 28 residents (Resident #63) reviewed during an annual recertification survey. The findings include: A Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. The proper way to void a previous MOLST form is to draw a line thru the page and also write VOID on the page. Review of Resident #63's medical record on 08/08/19 revealed 2 active MOLST forms with 2 different dates (01/08/16 and 09/03/17) of when each of the MOLST forms went into effect. The 01/08/16 MOLST form indicated Resident #63 wanted to be a full code and have all life…

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

Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Quarterly Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to accurately code a resident's medication use. This was evident for 1 out of 28 (Resident #77) records reviewed during the investigation stage of the survey. The findings include: The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Review of the medical record for Resident #77 on 8/7/19 at 7:34 AM revealed diagnoses including diabetes, major depressive disorder and vascular dementia with behavioral disturbances. Further review of the resident's medical record revealed that in April and July 2019, the resident was receiving an antidepressant and insulin daily for his/her related medical conditions. According to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff and family interview it was determined the facility failed to develop and implement a care plan that addressed: 1) the need for supervision with meals for a cognitively and functionally impaired resident (Resident #59) who experienced significant weight loss; and 2) Resident #65's desire to have scheduled times to get out of bed. This was evident for 1 of 3 resident's review for care plan development during this annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) The facility failed to develop and implement an individualized care plan that addressed the need for supervision with meals for Resident #59. Medical record review on 8/6/19 revealed Resident #59 was a long-term care resident with diagnoses that included but were not limited to Cerebrovascular Accident (CVA or stroke) with left sided weakness,…

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

Based on medical record review, staff and family interviews it was determined the facility failed to 1) demonstrate evidence of collaboration between the facility and hospice services in the development of an individualized care plan that addressed comfort and care needs (Resident #71) and 2) revise a resident's safe smoking care plan (Resident #63. This was evident for 2 of 28 residents (Resident #71 and #63) reviewed during an annual recertification survey. The findings included: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Hospice Care means a comprehensive set of services identified and coordinated by an interdisciplinary group (IDG) to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care. (42 CFR 418.3) 1) Medical record review on 8/7/19 revealed Resident #71 was a long-term care resident who was admitted to hospice care on 6/27/17. The resident'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 observation, medical record review and interview of facility staff, it was determined that the facility failed to promote the activities of daily living (ADL's) of an individual by encouraging him/her to eat as identified in their care plan (Resident #25). This was identified during a meal observation. The findings include: During the observation of breakfast on 8/6/19 at 7:42 AM, Resident #25 was noted sitting at the dining table on the second floor. His/her tray was delivered at 7:45 AM. There were 4 other residents noted sitting at the table who were also served and began independently eating their meal. Resident #25 sat and stared at the plate until 7:52 when s/he picked up the fork and attempted to take a bite of the eggs. Resident #25 sat until 7:58 and made another attempt at taking a bite of eggs. By this time 3 of the residents had left the table as they had completed their breakfast. One resident remained who was still eating his/her meal that was almost finished. Staff were present on the other side of the room during this observation. Staff stayed on that side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to: 1) provide evidence that a functionally impaired resident (Resident #53) received assistance with activities of daily living or documented a rationale for not providing the care; 2) consistently document the provision of showers and baths for Resident #71 and #55 reasons for refusal of care and interventions to address refusals. This was evident for 3 of 3 residents reviewed for Activities of Daily Living during this annual recertification survey. The findings include: Activities of Daily Living, or ADLs, are the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name 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 the facility failed to evidence the implementation of an ongoing program of activities based on the abilities, interests and treatment needs of Resident #65 and Resident #4. This was evident for 2 of 3 residents reviewed for activity needs during this annual recertification survey. The findings include: The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The MDS assessment directs the facility staff on issues that may need to be addressed. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Medical record review on 8/5/19 revealed Resident #65 was a long-term care resident with diagnoses that include but are not limited 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 medical record review, it was determined that the facility staff failed to address a pharmacy recommendation and obtain a diagnosis and a reason to continuously administer a nasal steroid spray daily for 2 months when the resident no longer had symptoms. This was evident for 1 of 6 residents (Resident #97) reviewed for unnecessary medications during an annual recertification survey. The findings include: Steroid Nasal Sprays work very well to reduce congestion, sneezing, and itchy, watery eyes. They also help stop a drippy nose. They're often the first drug recommended for allergies, but can take a week before symptoms improve. Side effects can include headache, sore throat, nosebleed, or cough. Review of Resident #97's medical record revealed a physician order, dated 01/27/19, instructing the facility nursing staff to administer the nasal steroid spray, Fluticasone, into each nostril once every day. On 04/02/19, the facility pharmacist conducted a review of Resident #97's medications and noted that Resident #97's nasal congestion had resolved but the nursing staff 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 medical record review and staff interview it was determined the facility staff failed to discontinue Ativan (anti-anxiety medication) that was ordered to be given as needed or document a rationale for continuing the order beyond 14 days. This was evident for 1 of 3 residents (Resident #71) reviewed for unnecessary medication use during this annual recertification survey. The findings include: The facility failed to provide a documented rationale for the continuation of Ativan for Resident #71, that was prescribed PRN, beyond 14 days. PRN (medications given as needed) orders for psychotropic drugs are limited to 14 days. In the absence of a documented rationale to continue the medication it should be discontinued. Medical record review on 08/08/19 at 2:20 PM revealed an order for Ativan PRN. The medication was ordered on 6/13/19 for anxiety and agitation. Review of the Medication Administration Record (MAR) for July 2019 revealed the resident received the medication on 7/18/19. A progress note dated 7/18/19 at 10:57 PM reported the resident received the medication 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 observation and staff interview, it was determined the facility staff failed to properly store medications. This was observed three times during an annual recertification survey. The findings include: 1) An observation was made on 08/08/19 at 10:12 AM on the main hallway nursing unit were the surveyor observed an unattended medication cart that had a dose of Magnesium Oxide left on top of the medication cart. The nursing Unit Manager #24 was made aware of the findings on 8/8/19. 2) During an observation with CMA #1 (Certified Medicine Aide) on 08/07/19 at 8:12 AM, CMA #1 failed to lock and secure the medication cart after preparing Resident #3's and #82's medication. The CMA prepared medications for both residents in the hall outside of the room and then the CMA proceeded into the room without locking the medication cart. The findings were reviewed with the Director of Nursing (DON) on 8/7/19 at 9:42 AM. 3) During an observation of breakfast while sitting at the nurses station on 8/6/19 at 7:36 AM, surveyor noted a large gray bag sitting on the floor marked pharmacy…

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 meal service it was determined that a facility staff failed to serve the meal under sanitary conditions. This was evident during a breakfast service for dependent residents. The findings include: Surveyor observed breakfast from 7:42 AM - 8:06 AM on 8/6/19 on the second floor. At 8:04 AM Geriatric Nursing Assistant (GNA) #2 was observed feeding Resident #21, while standing. When she finished, she went and poured juice in a cup for Resident #90 who was sitting next to Resident #21. She then proceeded to put jelly on Resident #90's toast and fed it to him/her with her bare hands. This was after she was observed feeding Resident #21, going to the juice cart, pouring juice and never washing or sanitizing her hands in between residents or surfaces and then touching Resident #90's food. She continued this practice of picking up Resident #90's toast with her bare hands and giving him/her a drink until the toast was gone. The Unit manager was notified at 8:07 AM on 8/6/19 regarding the observations and she verbalized understanding. In addition, GNA #2 was still…

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.