Autumn Lake Healthcare At Overlea

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility staff failed to consistently provide a clean, comfortable and home-like environment. This deficient practice was discovered during the recertification survey. The findings include: During observation rounds on 04/23/25 at 8:16 AM the clothing armoire door was hanging off in room [ROOM NUMBER]. At 8:32 AM the surveyor observed an empty bottle of Pepsi, a folded piece of paper, two small blue packs of a snack, and tissues under Resident #25's bed. At 8:41 AM the surveyor observed the toilet paper dispenser was broken and the middle light bulb was out in the shared bathroom between Rooms 213 & 215. Geriatric Nursing Assistant (GNA) #28 confirmed the surveyor's findings. At 8:47 AM the surveyor observed room [ROOM NUMBER]-B did not have a privacy curtain. At 8:50 AM the surveyor observed room [ROOM NUMBER]-B did not have a privacy curtain. At 8:53 AM the surveyor noticed the faucet was loose and the surveyor was unable to turn the water off 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.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean, comfortable and homelike environment. This was found to be evident in 2 (G10 and G11) out of 11 ground floor rooms reviewed during the annual survey. The findings include: On 04/29/25 at 10:33 AM, the surveyors observed the environment of the resident's room. The room was dirty, sticky on the floor when stepped on, and the bathroom wall had brown stains smeared on the wall. On further observation, the surveyors saw that the window blinds were broken, the ceiling tiles were coming apart, the toilet pipe wasn't fixed in the wall and the wall was cracked around the pipe. The floor was cracked and broken at the joint at the entry to the bathroom. On 04/29/25 at 11:42 AM, interviews and observations were conducted with the Administrator, Maintenance Director, and Account Manager of the Healthcare Services Group (AMHSG) were conducted to review the concerns. The Maintenance Director said the facility performed some repairs and contracted out other repair work when necessary. The…

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

Based on medical record review and interview it was determined that the facility staff failed to implement a patient centered care plans for dental care and integumentary care. This deficient practice was evidenced in 3 (#25, #37, #112) of five resident records reviewed for dental and integumentary care during the recertification survey. The findings include: On 04/25/25 at 1:41 PM a review of Resident #37 electronic medical record revealed the resident did not have a care plan for dental care. On 04/28/25 at 9:21 AM a review of Resident #25 electronic medical record (EMR) revealed the resident did not have a care plan for dental care. On 04/30/25 at 11:39 AM a review of Resident #112 EMR revealed a care plan for integumentary care was not initiated although the resident is ordered to receive a skin treatment twice a day for his/her skin condition. On 04/30/25 at 11:56 AM during an interview with the Director of Nursing (DON) the surveyor asked, should Resident's #25 & #37 have a care plan for poor dentition and should Resident #112 have an integumentary care plan? The DON…

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, medical record reviews, and interviews it was determined that the facility staff: 1) failed to clarify a physician's order, failed to monitor a resident for extrapyramidal side effects who was prescribed psychotropic medication, failed to ensure a resident received their therapeutic treatment for a skin condition, and 2) failed to follow through on laboratory monitoring recommendations. This was found evident of 3 (Resident #72, #112, and #126) out of 6 Residents reviewed for medication regimen review. The findings include: 1) During observation rounds on 04/24/24 at 11:03 AM the surveyor observed Resident #112 skin was extremely dry and scaly. A review of the resident's electronic medical record revealed the resident was diagnosed with Atopic Dermatitis. On 04/29/25 at 9:42 AM a review of Resident #112 treatment administration record (TAR) revealed the resident was ordered to receive a dermatologic cream to their skin twice a day. Further review of the order revealed the physician failed to indicate where the cream should be applied. At 1:40 PM the surveyor…

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 medication record review and interviews it was determined that the facility staff failed to act upon a pharmacy recommendation to add a dosage to a supplement prescribed to a resident. The deficient practice was evidenced in 1 (#127) of 2 pharmacy recommendations reviewed during the recertification survey. The findings include: On 04/28/25 at 10:38 AM a review of the pharmacist recommendations revealed there was a recommendation dated 02/19/25 in which the nursing staff failed to act upon. During an interview with the Director of Nursing (DON) at 12:25 PM the surveyor asked what the process is for addressing pharmacy recommendations. The DON verbalized the recommendations are received via email and the unit managers print the reviews and give them to the physicians. After they review the recommendations, the management team checks to see if there is a new order to be carried out. The form is signed and given to Medical Records to file. On 04/30/25 at 9:36 AM review of the pharmacy review dated 02/19/25 revealed Cyanocobalamin did not have strength. There are multiple doses…

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 resident's family and staff interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 of 1 (101) residents reviewed during the survey process. The findings include: In an interview with Resident #101's son on 4/24/2025 at 12:00 PM, revealed that Resident #101 stated they don't give showers I get a bed bath every day. I would like a shower. The son stated that the resident had asked their spouse to take them to the shower, but the spouse was physically unable to do so and instead gave the resident a sponge bath. The Resident's son reported that both the water and the washcloth that had been used were black with dirt. The complainant also reported that the Resident had stated that they were itchy from lack of washing. Review of Resident #101's most recent MDS revealed that s/he is totally dependent for bathing requiring extensive assistance for all Activities of Daily Living (ADL). The Minimum Data Set…

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

Based on review of facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 4 (#31, #7, #26, #33) residents of 19 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 2/13/25 at 2:00 PM facility reported incident MD00182916 was reviewed and revealed that Resident #31 was discharged to the hospital on 7/25/22 due to abnormal blood work. On 8/26/22 the facility was made aware by a hospital social worker that Resident #31 alleged verbal abuse by nurses at the facility and physical abuse by the geriatric nursing assistants at the facility. According to the facility's documentation an investigation was initiated. Review of the investigative packet that was given to the surveyor by the Nursing Home Administrator (NHA) revealed an initial and 5 day email confirmation that an investigation was done, however there was no investigation included in the paperwork. On 2/13/25 at 2:23 PM an interview was conducted with the NHA.…

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 (#12, #23, #7, #21) of 42 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.Review of Resident #12's medical record on 2/13/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include cerebral infarction. Cerebral infarction, also known as an ischemic stroke, is a condition where blood flow to the brain is interrupted, causing brain cells to die. Further review of Resident #12's medical record revealed a nurse's note on 7/3/24 at 10:15 AM that stated, Resident left…

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 it was determined that the facility staff failed to immediately inform the resident representative of the residents' transfer to the hospital. This was evident for 1 (#16) of 42 residents reviewed during the complaint survey. The findings include: Resident #16's medical record was reviewed on 2/18/25 at 9:33 AM. A change in Condition progress note dated 1/21/24 at 00:15 (12:15 AM) indicated that Resident #16 was found lying on the floor. Upon assessment the resident had no apparent injuries however his/her oxygen saturation (SpO2) was 75% (Normal SpO2 is between 95%-100%). A respiratory assessment revealed diminished lung sounds and grunting-like breathing. The physician was notified and ordered oxygen administration and if there was no improvement, send to the emergency room (ER) for further evaluation. The note indicated that the resident's representative was made aware. It did not identify the time of the notification. Another progress note at 1:00 AM on 1/21/24 indicated that the resident's oxygen saturation improved to 85%, and 911 was…

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

Based on review of facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were reported timely to the appropriate agencies. This was evident for 2 (#26, #27) residents of 42 residents reviewed during a complaint survey. The findings include: 1) On 2/20/25 at 11:49 AM a review of facility reported incident MD00186485 alleged that on 12/6/22 Resident #26 alleged that a geriatric nursing assistant (GNA) had abused the resident during care early on 12/6/22. Review of the facility reported incident was blurred as to the actual time, with it either being at 3:00 AM or 8:00 AM, which was confirmed by the NHA. Review of the email confirmation that was submitted to OHCQ documented that the initial report was not filed until 12/6/22 at 5:25 PM, which was not within 2 hours of suspected abuse. There was no email confirmation as to when the final report was submitted to the Office of Healthcare Quality (OHCQ). On 2/20/25 at 12:05 PM an interview was conducted with the NHA. The NHA confirmed the report was not…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#10, #14) of 42 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 2/14/25 at 12:25 PM Resident #10's medical record was reviewed and revealed Resident #10 was admitted to Hospice services on 11/9/24. Review of the quarterly MDS with an assessment reference date of 2/10/25, Section O, failed to capture that the resident received Hospice services. On 2/20/25 at 12:55 PM an interview was conducted with the MDS coordinator who confirmed 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, observation and staff interview, it was determined the facility staff failed to revise a resident's care plan. This was evident for 1 (#10) of 42 residents reviewed during a complaint survey. The findings include: On 2/14/25 at 12:25 PM facility reported incident MD00209375 was reviewed and revealed Resident #10 alleged that on 9/1/24 GNA #23 hurt Resident #10's arm. Review of the facility investigation documented that Resident #10 had a history of banging his/her arm on the side rail. The investigation documented that padding had been placed on the side rail to prevent further injury and that the issue had been care planned. On 2/19/25 at 11:30 AM observation was made of Resident #10 lying in bed having a dressing change by hospice staff. There was a quarter bed rail up on the right side of the bed with a yellow foam noodle on the top of the bed rail. Review of the care plan, has potential for skin tear, failed to have the intervention of padding the side rail. Review of the care plan, has skin tears to right lower arm and has a behavior problem r/t banging…

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 a recapitulation of the resident's stay was completed following a resident's discharge from the facility. This was evident for 1 (Resident #23) of 42 residents reviewed during a complaint survey. The findings include: On 2/14/25 at 10:42 AM a record review was conducted for Resident #23. Resident #23 was admitted to the facility in July 2017 for physical and occupational therapy following an amputation of the right leg above the knee. On 1/20/23 a care plan note documented, Family and patient in agreement that they desire the matter of social work addressing alternative nursing home locations. Patient will look to pursue further the Alf [assisted living facility] after that patient is located within another nursing home facility. On 4/28/23 social services documented a Maryland Discharge Instructs for Resident #23 for a discharge of 5/1/23 to an assisted living facility. It was completed by the…

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

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 provide showers twice weekly to a resident (Resident #17). This was evident for 1 of 42 residents reviewed during a complaint survey. The findings include: Review of Resident #17's medical record on 2/14/25 for a concern related not receiving showers from October 2023 until January 2024 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include dementia. Dementia is a general term for a decline in mental abilities that impacts a person's daily life. It's caused by brain damage that destroys nerve cells. Further review of Resident #17's medical record revealed the facility staff assessed the Resident on 11/7/23 to need supervision and/or touching assistance for showering and bathing. Review of Resident #17's care plans revealed a care plan entitled: Resident has an ADL (Activities of Daily Living) Self Care Performance Deficit related to dementia initiated on 10/26/23 that included an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers for a resident (Resident #1). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). Review of Resident #1's medical record on 2/14/25 revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure a resident's drug regimen was free from an unnecessary drug (Resident #6 and #15). This was evident for 2 of 42 residents reviewed during a complaint survey. The findings include: 1. Review of Resident #15's medical record on 2/14/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include hypertension. Hypertension, also known as high blood pressure, is a condition where the blood pressure in the arteries is consistently elevated above normal levels. Review of Resident #15's physician orders revealed on 4/1/24 the Resident was ordered Metoprolol 25 mg one time a day for high blood pressure, hold if blood pressure is less than 110 or heart rate less than 60. Review of Resident #15 April 2024 Medication Administration Record revealed from 4/1 through 4/14/24 the Resident was administered Metoprolol 2 times outside of the parameters: a) on 4/8/24 at 6:00 PM when the Resident's heart rate was 59 and b) 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 schedule a follow up appointment with a consultant for a resident (Resident #15). This was evident for 1 of 42 residents reviewed during a complaint survey. The findings include: Review of Resident #15's medical record on 2/14/25 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include hydronephrosis. Hydronephrosis is a condition where urine backs up into the kidney, causing it to swell. Review of a nurse's note on 3/31/24 at 11:37 PM stated the Resident had a Foley in place. A Foley catheter is a thin, flexible tube inserted into the bladder to drain urine. Review of the Resident's hospital Discharge summary dated [DATE] revealed the Resident's plan: 1. Will need outpatient urology follow up for moderate right hydronephrosis, referral for urology appointment has been made. 2. Foley catheter currently in place, will need voiding trial. Further review of Resident #15's medical record revealed a nurse's 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.

Based on record review and staff interview, it was determined that facility staff failed to properly maintain the mandatory testing frequency for staff to help prevent the spread of COVID-19. This was found to be true for all employees tested during the week of November 17, 2020. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The findings include: A review of intake # MD00160661 conducted on August 3, 2021 at 8:30 a.m. revealed a concern about the facility failing to maintain the mandatory COVID-19 testing frequency outlined in the Amended Directive and Order Regarding Nursing Home Matters document (MDH 2020-11-17-02) effective November 17, 2020. MDH 2020-11-17-02 which stated to increase mandatory COVID-19 testing to twice a week for nursing home employees and once a week for nursing home residents. A review of facility COVID-19 testing records for facility staff and residents for the month of November 2020 conducted on August 3, 2021 at 10:30 am revealed facility staff were not tested twice a week as ordered by MDH…

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 it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of insects. This was evident for the ground floor conference room and the back staircase. The findings include: On 7/29/2021 at 8:18 AM room [ROOM NUMBER] was observed with live gnats flying in the room. On 8/3/2021 at 10:43 AM, a live gnat was observed in the ground floor conference room that the survey team was working from. At 10:45 AM observation of the employee entrance/ground floor exit/outdoor smoking section revealed the presence of multiple gnats just outside the facility door. A nonfunctional Ecolab bug trap was observed inside the door to the stairwell among 3 live gnats. On 8/4/2021 at 10:25 AM a house fly and a gnat were observed inside the ground floor conference room. The Administrator and Director of Nursing were made aware of these findings on 8/4/2021 during the exit conference.

Based on surveyor observation and interview with staff it was determined the facility staff failed to ensure that residents call bells were within reach. This was evident for 2 (#27 and #74) of 60 residents observed during the initial resident sample observations. The findings include: On 7/22/2021 at 10:18 A.M. Resident #74 and Resident #27's call bells were observed on the floor where the residents could not reach them. Staff #5 was made aware of the call bell issues at this time. The Administrator and Director of Nursing were made aware of these findings on 8/4/2021 during the survey exit conference.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and resident interview it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficiency has the potential to affect multiple residents. The findings include: On 7/22/2021 at 10:34 AM during an initial tour of the facility, Resident #31's bathroom was observed with no soap or paper towels. On 7/27/2021 at 1:10 PM room [ROOM NUMBER]'s window was observed with 4 missing pieces of the vertical blinds. Resident #89 stated that they had to hang a blanket over the broken blinds to prevent the sun from waking them up in the morning. On 8/3/2021 at 9:33 AM the facility's rear elevator, registration # BC4264, was observed with dust buildup on the ceiling vent. At 9:43 AM the air intake vent on the side of the building facing the main parking lot was observed in disrepair and protruding from the wall allowing for possible pest entry. The Administrator and Director of Nursing were made aware of these findings on 8/4/2021 during the…

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

Based on clinical record review, observation, staff interview and review of an abuse investigation it was determined that nursing staff failed to ensure that residents were free of abuse. This was evident for 1 (#59) out of 3 residents reviewed for abuse. The findings are: A review of the facility investigation into a reported incident of staff to resident abuse revealed that Resident #59 was being assisted in bed by Nurse #14 on 1/1/21 at 7:30 PM. GNA #15 was assisting Resident #59's roommate and had the privacy curtain closed. She heard Nurse #14 talking loudly and very mean to Resident #59 because the resident got out of bed again. GNA #15 wrote that she continued with the task. When Nurse #14 became louder and started cursing she looked around the curtain. Nurse #14 was struggling to get the resident into the bed. Nurse #14 asked for her assistance, and she helped the resident back into bed. GNA #15 wrote that she called the (now former) Director of Nursing (DON) (Staff #16) to report the incident. A follow up interview with GNA #15 revealed that Nurse #14 was saying Get the…

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

Based on medical record review and staff interview, it was determined that facility staff failed to update a resident's care plan after a change in status. This was evident in 1 (resident #31) of 60 residents reviewed during a survey. The findings include: Review of Resident #31's medical records on July 29, 2021 at 7:01A.M. revealed that on February 25, 2021, the resident attempted to escape from their assigned floor several times during the day. Resident #31's escape attempts caused the facility to complete a risk assessment on February 25, 2021 at 3:48 P.M. which assessed the resident as being at risk of attempting to escape from the facility in the future. Further review of Resident #31's medical records on July 29, 2021 at 9:20 A.M. revealed that a medical order for a Wanderguard was issued on February 25, 2021. A Wanderguard is a device used to monitor the location of a resident who was assessed as being at risk of escaping from the facility. A Wanderguard will make an alarm sound if the resident is close to elevators, steps, or doors that lead from the floor or unit to which…

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

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure that resident clinical records were maintained in a complete and accurate manner. This was evident for 2 (#34 and #55) out of 60 resident clinical records reviewed. The findings are: 1) A review of Resident #34's clinical record revealed that the resident had a Preadmission Screening and Resident Review (PASRR) completed on 2/26/19. The resident's PASRR was to be reviewed by the state agency for determination of additional services and care related to mental illness. Further review revealed that the state agency reviewed the resident's PASRR for Intellectual Disability (ID) and determined that the PASRR would not be the subject of review because the resident did not have a diagnosis of ID. The facility social worker failed to thoroughly review this inaccurate determination and resubmit it for a corrected review. 2) A review of Resident #55's clinical record revealed that a PASRR was completed on 6/7/17. The state agency determined that additional services and/or a directed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined that the facility staff failed to ensure hand rails were secured firmly to the wall. This was evident for 1 resident floor observed during the survey. This deficient practice has the potential to affect all residents, staff, and visitors on the unit. The findings include: On 8/4/2021 at 09:21 AM during a tour of the facility, the handrail outside room [ROOM NUMBER] was observed to be loose and not securely affixed to the walls. It was also observed at this time that the handrail end caps were missing on the handrails outside of room [ROOM NUMBER] and the Spa/shower room. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 8/4/2021.

Based on observation, record review, staff and resident interviews it was determined that the facility staff failed to provide residents with the most dignified existance (#53, #112, #121). This was evident for 3 of 48 residents selected for review during the survey process. The findings include: Based on observation of lunch in the second-floor dining room it was determined the facility staff failed to provide residents with the most dignified existence by not all residents being served lunch at the same time while seated at the same table, failing to offer or provide clothing protectors and failed to provide Resident #53 with the most dignified existence. This was evident for 2 of 17 residents in the dining room for lunch. 1 A. The facility staff failed to provide lunch to all residents seated at the same table in a timely manner. Observation of lunch in the 2nd floor dining room on 8/27/18 at 12:12 PM revealed resident #117 was served lunch. The resident was seated at a table with 7 other residents. The facility staff continued to serve lunch to the other residents at the table.…

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

Based on medical record review and interview, it was determined the facility staff failed to administer a medication to Resident #19 per the standard of practice and physicians' order. This was evident for 1 of 48 residents selected for review during the survey process. The findings include: Medical record review for Resident #19 revealed on 3/7/18 the physician ordered: Levemir 30 units at hour of sleep. Levemir is a long-acting injectable insulin that can be used for long-term management of diabetes. Insulin is a hormone that is naturally produced in the body by the pancreas. It helps convert the glucose (sugar) in the bloodstream into energy. This energy is then distributed to cells throughout the body. On 5/30/18 the physician ordered: finger stick 2 times a day, morning and night, call physician if below 60 or above 400. Finger sticks are a way of testing the concentration of glucose in the blood. Particularly important in diabetes management, a blood glucose test is typically performed by piercing the skin (typically, on the finger) to draw blood, then applying the blood to a…

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

Based on medical record review and interview, it was determined the Antibiotic Stewardship Program committee failed to conduct meetings as least quarterly. The findings include: Medical record review for Resident #100 revealed on 12/30/17 the physician ordered: Ceftriaxone Sodium Solution 1 gram intravenously every 24 hours for urinary tract infection (UTI) for 5 Days. A UTI is an infection involving any part of the urinary system. Ceftriaxone, sold under the trade name Rocephin, is an antibiotic useful for the treatment of several bacterial infections. An intravenous is a thin, soft, plastic tube called a catheter that is inserted through the skin and into a vein and is used to give medicines and fluids. On 1/03/2018, the physician ordered: Ertapenem Sodium Solution, 1 gram intravenously one time a day for UTI until 1/11/2018 (8 days). Ertapenem injection is used to treat certain serious infections such as urinary tract infections that are caused by bacteria. It works by killing bacteria. On 4/16/2018, the physician ordered: Meropenem Solution, use 1 gram intravenously two times 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 interview, it was determined the facility staff failed to provide residents with reasonable accommodations. This was evident for 2 of 5 residents observed during medication pass. The findings include: Observation of Resident #54's room during medication pass on 8/29/18 at 8:15 AM revealed the resident's sheet was worn through to the point of being able to see the mattress. Observation of Resident #110 on 8/29/18 at 9:00 AM revealed the resident in bed and the sheet was noted to be worn through and the mattress seen. Interview with the Director of Nursing on 8/31/18 at 2:00 PM confirmed the facility staff failed to provide Residents #54 and #110 with reasonable accommodations using bed sheets worn through so the mattress can be seen.

Based on medical record review and interview, it was determined the facility staff failed to notify the physician of the results of a urine culture in a timely manner for Resident (#100). This was evident for 1 of 48 residents selected for review during the survey process. The findings include: Medical record review for Resident #100 revealed on 7/17/18 the physician ordered: Urine culture. Further record review revealed the facility staff obtained the urinalysis as ordered. Urine culture is a simple test that can provide many useful pieces of information about various diseases and conditions. Urine can be evaluated by its physical appearance (color, cloudiness, odor, clarity) it can also be analyzed based on its chemical and molecular properties, including microscopic assessment. Urine culture and sensitivity (C&S) a microscopic study of the urine performed to determine the presence of pathogenic bacteria in patients with suspected urinary tract infection. Review of the medical record revealed the urinalysis results were in the facility on 7/18/18; however, it is not uncommon 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 clinical record review, observation, and staff interview it was determined that the facility staff failed to ensure clinical records were completed in an accurate manner (#81). This was true for 1 out of the 48 residents selected for review during the annual survey process. The findings are: A review of Resident #81's clinical record revealed that the resident's physician wrote an order on 5/9/18 for the resident to have a helmet on while out of bed. The resident was observed on 8/29/18 at 1:56 PM to be without a helmet on while in the third-floor dining room. The resident was observed again on 8/29/18 from 2:28 PM to 2:31 PM to not have the helmet on while in the third-floor dining room. Two staff members were present in the room. One of whom exited upon my arrival. The resident was observed without the helmet on while in the third-floor dining room on 8/30/18 at 7:54 AM. The resident was observed without the helmet on while in the third-floor dining room on 8/30/18 at 11:18 AM. The resident was observed without the helmet on while in the third-floor dining room on 8/31/18…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined the facility staff failed to maintain the room of Resident #55 in a home like environment. This was evident for 1 of 48 residents selected for review during the survey process. The findings include: Surveyor observation of Resident #55's room on 8/28/18 at 7:50 AM and 12:40 PM and 8/29/18 at 7:35 AM and 11:06 AM revealed Resident #55 had a 3-drawer dresser used for the resident's clothes. Further observation at that time revealed the top drawer of the dresser missing. It was further observed 2 drawers in place and the residents clothing placed in the top area that did not contain a drawer. Interview with the Director of Nursing on 8/31/18 at 2:00 PM confirmed the facility staff failed to maintain the environment for Resident #55 home like. During the initial tour of the facility on August 27, 2018 the survey team observed the following evidence of unattended maintenance and/or housekeeping concerns: The findings include: 1. A tour of the environment of care…

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

Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that the resident, resident's representative and the Ombudsman were notified in writing of the resident's transfer and the rationale for the transfer to an acute care facility. This was evident for 3 of 48 (#2; #64; #88) residents reviewed during the investigative portion of the survey. The finding includes: 1. Review of the medical record for Resident #2 was conducted on 8/28/18 at 9:03 AM. Review of the nurse's notes revealed that resident #2 was transferred to the hospital on 8/1/18 and 7/21/18 via 911. Review of the medical record revealed Physician orders for transfer to the hospital. Further review failed to disclose evidence that Resident #2, their representative or the Ombudsman had been provided with a written notification or the rationale for the transfer. Interview with the Director of Nursing on 8/28/18 at 1:30 PM confirmed that written notifications to residents, their representatives and the Ombudsman were not sent out for this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, it was determined the facility staff failed to reassess a resident (#48) following a significant change in condition related to a significant weight loss. This was evident for 1 of 48 residents selected for review during the survey process. The MDS (Minimum Data Set) is a federally-mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. MDS assessments are completed upon admission, quarterly and for any significant change in condition. Categories of MDS are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, it was determined the facility staff failed to conduct a thorough and comprehensive assessment prior to initiating a care plan for Resident #110. This was evident for 1 of 48 residents selected for review during the survey process. The findings include: Medical record review revealed Resident #110 was admitted to the facility on [DATE]. Medical record review revealed on 7/10/17 the facility staff initiated a care plan: resident has a behavior problem (Pica, eating nonfood items). An intervention on that care plan: keep items that resident can easily pick up and put in his/her mouth such as gloves out of reach. The care plan is a written document that is used and altered constantly. The care plan covers essentials of care - nutrition, mobility, sleeping, positioning, oral care and personal hygiene, falls prevention, psychological needs, recording of clinical signs, communication and information, and sexuality. An individual care plan is prepared for each…

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

Based on clinical record review and staff interview it was determined that the facility staff failed to revise resident's care plans as needed (#31 and #81). This was true for 2 out of the 48 residents selected for review during the annual survey process. The findings include: 1. A review of Resident #31's clinical record revealed that the resident has a care plan to address Restorative Care/Functional maintenance with Splinting and PROM [Passive Range of Motion]. One of the interventions is Apply splints to bilateral hands. Keep on for up to 8 hours as tolerated. Skin check every 2 hours and PRN. The Director of Therapy was interviewed on 8/29/18 at 1:09 PM. He stated that the resident was discharged on 5/8/18 and it was recommended that the resident continue to wear left hand splint according to schedule (5 hours). A review of a facility form entitled Screening Form completed on 8/28/18 noted that per nursing report, pt [patient] removes the splint and therefore, it is difficult to maintain donning schedule. Change in RNP [Restorative Nursing Program]? Y/N (Y was circled).…

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

Based on observation and interview, it was determined the facility staff failed to place Resident # 63 in a position conducive to eating. This was evident for 1 of 17 residents observed during lunch in the second-floor dining room. The findings include: Observation of dining on 8/28/18 at 12:17 PM revealed Resident #63 positioned in a recliner chair. The recliner positioned Resident #63 in a backward tilt instead of an upright position. The facility staff served Resident #63 lunch; however, failed to re-position the resident in the recliner in a more suitable position to eat. It was further noted the resident attempting to eat lunch and dropping food on his/herself. Interview with the Director of Nursing on 8/31/18 at 2:00 PM confirmed the facility staff failed to provide a position for Resident #63 conducive to eating.

Based on observation and interview, it was determined the facility staff failed to assist residents eating lunch in the second-floor dining room. This was evident for 2 of 17 residents observed during dining observation. The findings include: Observation of dining in the 2nd floor dining room on 8/27/18 at 12:12 PM revealed the facility staff failed to assist residents while eating lunch. Observation of lunch at that time revealed Residents #23 and #78 sitting next to each other eating. It was noted Resident #78 had a carton of milk and juice on the lunch tray. It was further noted; the containers were not opened for the resident. It was further revealed, Resident # 78 handed the carton of milk and juice to Resident #23 who opened a container of juice and milk for Resident #78 and handed the milk and juice back to Resident #78. Interview with the Director of Nursing on 8/31/18 at 2:00 PM confirmed the facility staff failed to assist Resident #78 by failing to open cartons of milk and juice.

Based on observation, medical record review and interview it was determined the facility staff failed to provide grooming and personal hygiene services (Resident #80). This is evident for 1 of 48 residents selected for review during the investigation stage of the survey process. The findings include: Observation of Resident #80 on 8/27/18 at 9:30 AM revealed the Resident to be unshaven and have elongated fingernails. Interview with the Resident at that time revealed the Resident would like to be shaven and have his fingernails trimmed. Further observation of the Resident on 8/28/18 at 12:15 PM, 8/29/18 at 10:42 AM and 8/30/18 at 7:39 AM revealed the Resident remains unshaven with elongated fingernails. Review of Resident #80's medical record revealed the Resident is dependent on the facility staff for his care, comfort and safety. The facility staff conducted a quarterly MDS assessment on 7/27/18 and coded the Resident in Section G Functional Status as a one person physical assist for personal hygiene. Interview with the Director of Nursing on 8/30/18 at 8:10 AM confirmed the…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to follow Physician's orders as written for residents (#42; #55; #57). This was evident for 3 of 48 residents selected for review during the survey process. The findings include: 1. Based on medical record review, observation and interview, it was determined the facility staff failed to elevate the heels off of the bed for Resident (#55). Medical record review for Resident #55 revealed on 7/15/17 the physician ordered: float heels while in bed. When a resident must spend prolonged periods of time in bed, the risk for pressure ulcers to form increases. There are, however, several methods that, when employed properly, can greatly reduce those chances. A pillow (or a soft piece of foam) can be an effective tool in reducing pressure, when placed between parts of a patient's body that press against each other or against the mattress. When it comes to wound care, the term float the heels means that a resident's heels should be positioned in such a way as to remove all contact between the…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain an ophthalmology consultation as recommended by the ophthalmologist for Resident #53. This was evident for 1 of 48 residents selected for review during the survey process. The findings include: Medical record review for Resident #53 revealed the resident had an ophthalmology consultation on 10/24/17. Ophthalmology is the branch of medicine that deals with the anatomy, physiology and diseases of the eye. Review of that consultation revealed the resident was to return to the ophthalmology clinic in 6 months- 4/18. Further record review revealed the facility staff failed to obtain that consultation. Interview with the Director of Nursing on 8/31/18 at 2:00 PM confirmed the facility staff failed to obtain the follow up ophthalmology consultation for Resident #53. Based on medical record review and interview it was determined the facility staff failed to follow up and ensure ophthalmology services were obtained for Resident # 86. This is evident for 2 of 48 residents selected for review…

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

Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers for residents with pressure ulcers (Residents #80 and #86). This was evident for 2 out of 48 residents selected for review during the investigation stage of the survey process. 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 (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). The findings include: 1. Review of Resident #80's medical record…

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

Based on medical record review, observation and interview it was determined the facility staff failed to ensure a resident received proper foot care and treatment (Resident #86). This was evident for 1of 48 residents selected for review during the survey process. The findings include: Review of Resident #86's medical record revealed the Resident was last seen by the podiatrist on 2/26/18 for the care of elongated, thickened toenails bilaterally and a callous on the side of the left foot. Podiatrists are health care professionals who have been trained to prevent, diagnose, treat and rehabilitate abnormal conditions of the feet and lower limbs. They can also treat and alleviate day-to-day foot problems, including: toenail problems, such as thickened, fungal or ingrown toenails. corns and calluses. Review of the Podiatrist's progress note reveals the Podiatrist documented RTC (return to clinic) in 2 to 3 months. Further review of the medical record revealed Resident #86 has not been seen by the Podiatrist since 2/26/18. Observation of Resident #86 on 8/29/18 at 10:39 AM with facility…

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

Based on record review, observation and interview, it was determined the facility staff failed to apply fall mats as ordered and failed to place the bed in low position for Resident #55; in addition failed to prevent Resident #110 from taking food off the lunch delivery cart and eating it. This was evident for 2 of 48 residents selected for review during the survey process. The findings include: 1 A. The facility staff failed to place a fall mat next the resident's bed as ordered. Medical record review for Resident #55 revealed on 1/8/18 the physician ordered: floor mat at bedside, remove mat when resident is not in bed. Bedside fall mats are safety features that are placed on the floor at the side of the bed. Fall mats are made from high-impact foam and are designed to help prevent injury from potential falls. Surveyor observation of Resident #55's room on 8/27/18 at 12:00 PM, 8/28/18 at 12:40 PM and 8/29/18 at 7:35 AM revealed the resident in bed; however, the facility staff failed to place a fall mat next to the bed as ordered. The fall mat was observed folded and placed against…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain weights as ordered for Resident (#110). This was evident for 1 of 48 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #110 revealed on 5/25/18 the physician ordered: weigh 3 times a week due to weight gain, every day shift every Monday, Wednesday and Friday. Observation of medical record revealed the facility staff failed to obtain weights on 6/8/18 and 6/15/18 (Fridays) as ordered by the physician. Interview with the Director of Nursing on 8/31/18 at 2:00 PM confirmed the facility staff failed to obtain weights as ordered on Resident #110. Based on record review, observation and interview, it was determined the facility staff failed to monitor a resident consumption of nutritional juice drink three times a day. (Resident #42)). This was evident for 1 of 48 residents selected for review during the investigation stage of the survey process. The findings include: Medical record review for Resident # 42 revealed 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, observation and interview, it was determined the facility staff failed to notify the Physician following a resident's (#48) significant weight loss and change in condition. This was evident for 1 of 48 residents selected for review during the survey process. The findings include: Medical record review revealed that Resident #48 was admitted to the facility on [DATE] with diagnoses including but not limited to Malnutrition; Adult Failure to thrive and Major Depressive Disorder. A Physicians order dated 4/10/18 for Weight on admission, next day and weekly x 4 weeks, then monthly. Following a change in condition on 5/19/18 Resident #48 was admitted to the hospital, returning to the facility on 6/21/18 with a G-tube which was placed due to Malnutrition and weight loss. A gastrostomy tube (also called a G-tube) is a tube inserted through the abdomen that delivers nutrition directly to the stomach and is one way of providing nutrients and calories for someone who is unable to take…

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

Based on medical record review and interview, it was determined the consultant pharmacist failed to identify and bring to the facility staff's attention Resident #19 not receiving Levemir as ordered by the physician. This was evident for 1 of 48 residents selected for review during the survey process. The findings include: Medical record review for Resident #19 revealed on 3/7/18 the physician ordered: Levemir 30 units at hour of sleep. Levemir is a long-acting injectable insulin that can be used for long-term management of diabetes. Insulin is a hormone that is naturally produced in the body by the pancreas. It helps convert the glucose (sugar) in the bloodstream into energy. This energy is then distributed to cells throughout the body. On 5/30/18 the physician ordered: finger stick 2 times a day, morning and night, call physician if below 60 or above 400. Finger sticks are a way of testing the concentration of glucose in the blood. Particularly important in diabetes management, a blood glucose test is typically performed by piercing the skin (typically, on the finger) to draw…

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

Based on medical record review and interview, it was determined the facility staff failed to ensure Resident #100 was free from unnecessary medications. This was evident for 1 out of 48 residents selected for review during the survey process. The findings include: Medical record review for Resident #100 revealed on 7/17/18 the physician ordered: Urine culture. Further record review revealed the facility staff obtained the urinalysis as ordered. Urinalysis is a simple test and can provide many useful information about various diseases and conditions. Urine can be evaluated by its physical appearance (color, cloudiness, odor, clarity), also referred to as a macroscopic analysis. It can be also analyzed based on its chemical and molecular properties, including microscopic assessment. Urine culture and sensitivity (C&S) a microscopic study of the urine culture performed to determine the presence of pathogenic bacteria in patients with suspected urinary tract infection. The results of the C+S will guide the physician to determine if antibiotics are needed and which medication would be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined that the facility staff failed to ensure resident medications were properly secured. This was true for 1 out of the 3 nursing units. Findings include: This surveyor observed the medication cart for the first-floor unit to be unlocked and unattended on [DATE] at 12:10 PM. Drawers filled with medications which could be opened and pose a risk to any resident opening the drawers. The Certified Medication Aid (CMA) was observed in a resident's room at the bedside administering medications. This surveyor was standing by the medication cart when the CMA returned. CMA was interviewed, and the findings were explained to her. Based on observation and staff interview it was determined the facility staff failed to dispose of expired medical supplies on 1 of 3 nursing units observed. Observation was made on [DATE] at 9:15 AM of a bag with 25 blue top blood collection tubes with an expiration date of [DATE]; 1 Blood culture bottle with an expiration date of [DATE] and…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood work as ordered by the physician for Resident (#53). This was evident for 1 of 48 residents selected for review during the survey process. The findings include: Medical record review for Resident #53 revealed on 6/22/18 the physician ordered: CBC, CMP, Mg, P, BNP, FLP, TSH and free T4. A complete blood count (CBC) is a test that measures the cells that make up the blood: red blood cells, white blood cells, and platelets. The comprehensive metabolic panel (CMP) is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working. Magnesium testing may be ordered as a follow up to chronically low blood levels of calcium and potassium. It also may be ordered when a person has symptoms that may be due to a magnesium deficiency, such as muscle weakness, twitching, cramping, confusion, cardiac arrhythmias, and seizures. Phosphorus is a mineral the body needs to build…

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 upon resident interview, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine and emergency dental care. This was evident for 2 of 48 residents (#57 and #64) selected for review during the survey process. The findings include: 1. During interview with Resident #57 on 8/27/18 at 12:21 PM, he/she stated he/she would like to be seen by the dentist. Observation of the Resident at that time revealed the Resident has missing teeth, broken teeth and decayed teeth with blackened roots. Review of Resident #57's medical record revealed the Resident was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment was completed on 10/13/17 and the facility staff coded the Resident in Section L Oral/Dental Status as Obvious or likely cavity or broken natural teeth. The facility staff also documented in a MDS note at that time, Missing several teeth, remaining are broken and decayed. On 7/10/18 the facility staff documented 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.

Based on observation and staff interview it was determined that the facility staff failed to properly maintain the temperature of the first-floor resident nourishment refrigerator. This was evident during the review of the Medication Storage room. The findings include: Observation was made on 8/31/18 at 12:38:PM of the Resident Nourishment refrigerator found to be at 24 degrees with a frozen ½ gallon of milk labeled with a resident's name and a bag with 4 frozen plums. The unit manager was present and made aware of this concern. According to the Center for Disease Control the refrigerator should be maintained between 35- 46 degrees. In an interview with the Director of Nursing on 8/31/18 at 12:55 PM she was made aware of this concern.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility staff failed to maintain a medical record in the most complete and accurate form (Resident #80). This was evident for 1 of 48 residents selected for review during the investigation stage of the survey process. The findings include: Review of Resident #80's medical record revealed the Resident was admitted to the facility on [DATE] and has a physician order on 7/22/17 for weekly weights. Further review of the Resident's medical record revealed the facility staff has not obtained weekly weights since 8/9/17. Interview with the Director of Nursing on 8/30/18 at 8:13 AM revealed the Resident should be on monthly weights and the order is incorrect. Interview with the Director of Nursing on 8/30/18 at 8:13 AM confirmed the facility staff failed to maintain an accurate medical record.