Autumn Lake Healthcare At Perring Parkway

Based on observation and interview it was determined the facility failed to ensure dignity was maintained for Resident #24. This was evident for 1 out of 1 Resident (#24) reviewed for dignity during the facility's recertification survey. The findings include: During the surveyor's initial tour of the facility on 11/24/2025 at 8:08AM Resident #24 was observed sitting in their wheelchair in the resident hallway outside of their room with bare feet on the hallway floor and multiple orange stains were observed on the t-shirt they were wearing. On 11/25/2025 at 8:50AM the surveyor observed Resident #24 sitting in their wheelchair in the resident hallway outside of their room wearing the same t-shirt with the same stains on it which was observed by the surveyor the day prior. On 11/25/2025 at 9:05AM the surveyor requested and performed a dual surveyor observation with the facility's Administrator of Resident #24. At this time Resident #24 was observed from the hallway laying in their bed exposed with no clothing on from the waist down. At this time, the surveyor shared the concern with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that the facility failed to ensure a resident's right to formulate an Advanced Directive and maintain accurate documentation within their medical record. This was evident for 4 (Resident #2, #5, #64, and #57) out of 6 residents reviewed for Advanced Directives during the survey.The findings include: Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. It is a legal document outlining future healthcare wishes and appointing a healthcare agent. Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. It is a state specific medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview with staff, it was determined that the facility failed to ensure the baseline care plan was thoroughly completed and included the resident -specific initial goals based on admission orders needed to properly care for the resident immediately upon their admission. This was evident for 1(Resident #99) out of 4 residents reviewed for care planning during the annual survey.The findings include: The facility must develop and implement a baseline care plan for each resident that includes the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury with the instructions needed to provide effective and person-centered care of the resident and meet professional standards of quality care.On 11/24/2025 at 8:36AM, during a tour of Station 1, the Surveyor observed Resident #99 in their room lying awake in bed. 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 record review and interview with staff, it was determined that the facility failed to ensure residents and/or resident representatives were offered the opportunity to participate in their care planning process by holding timely quarterly care plan meetings. This was evident for 2 (Resident #31 and Resident #57) out of 4 residents reviewed for care planning during the annual survey. The findings include:A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs.On 11/25/2025 at 10:20AM, 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 observation, record review, and interviews, it was determined that the facility failed to ensure a resident was offered the opportunity to participate in facility sponsored group activities. This was evident for 1 (Resident #54) out of 2 residents reviewed for activities during the annual survey.The findings include:On 11/24/2025 at 12:00PM, during an interview conducted with the resident representative, the Surveyor was informed that Resident #54 was provided with coloring activities in their room but has not observed facility staff offer to take the resident to group activities or observed the resident at group activities. The resident representative stated that that would be nice for the resident to get out of their room and go to group activities because they would really enjoy it. The resident uses a wheelchair and would need staff assistance with transportation around the facility.On 11/25/2025 at 12:30PM, during a review of Resident #54's electronic medical record, the Surveyor discovered that…

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

Based on observation, interview and record review it was determined the facility failed to ensure a resident's dry skin condition was identified and failed to ensure they received intervention to address the condition. This was evident for 1 out of 1 Resident (#24) reviewed for skin conditions during the facility's recertification survey. The findings include: During the surveyor's initial tour on 11/24/2025 at 8:08 AM Resident #24 was observed in their wheelchair in the hallway with no socks or shoes and the surveyor noted the resident's lower extremities appeared to have very dry skin with visible flaking present. On 11/24/2025 at 11:37AM the surveyor observed Resident #24 laying in their bed and noted they continued to have very dry visibly flaky skin on both lower extremities. Review of Resident #24's medical record by the surveyor on 11/25/2025 at 9:41AM revealed there was no documentation present for the Resident's dry flaky skin on their lower extremities having been identified or addressed. Review of Resident #24's diagnoses revealed they had a diagnosis of lymphedema. 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 record review and interview with the resident and the staff, it was determined that the facility failed to ensure a resident receives proper treatment and scheduled follow-up appointments to maintain vision. This was evident for 1 resident (Resident #57) reviewed for vision services during the annual survey.The findings include:On 11/24/2025 at 11:30AM, during an interview with Resident #57, the Surveyor was informed that Resident #57 had cataract surgery on the right eye and was supposed to have cataract surgery on the left eye, but the facility never scheduled the surgery.On 11/24/2025 at 1:26PM, a review of Resident #57's electronic medical record revealed an eye care group note dated 4/22/2024 with a completed assessment that included Cataract, mixed; Bothersome; Both eyes; VA stable, but patient is not satisfied with level of vision and a plan in which Cataract surgery recommended; ophthalmology consult; Follow-up: 4-5 months; Referral: Ophthalmology consult; Please schedule an appointment 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.

Based on observation, interview, and record review it was determined the facility failed to ensure consistent incontinence care was provided. This was evident for 1 out of 1 Resident (#4) reviewed for bowel and bladder incontinence during the facility's recertification survey. The findings include: During the surveyor's initial tour of the facility on 11/24/25 at 8:05AM Resident #4 was observed in their bed wearing a visibly wet, yellow incontinence care product. Review of Resident #4's medical record by the surveyor on 11/24/2025 at 10:42AM revealed Resident was documented consistently by various nursing staff on the Task Documentation Survey Report throughout the month of November 2025 as having total dependence upon staff for toileting needs for incontinence of bowel and bladder. Surveyor review on 12/01/2025 at 11:31AM of Resident #4's incontinence care documentation in the medical record revealed that incontinence care was documented as being provided on the following dates and times: 11/28/25 at 12:35AM and 7:34PM, 11/29/25 at 1:05AM, 9:08AM, and 7:09PM, 11/30/25 at 1:53PM,…

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, interview and record review it was determined the facility failed to: 1.) ensure respiratory tubing and the humidification saline bottle was dated and timed in accordance with professional standards and ensure a respiratory nebulizer machine, face mask, tubing and saline bottle was stored off of the floor's surface. This was evident for 2 out of 2 Residents (#98, #10) reviewed for respiratory during the facility's recertification survey. The findings include:1.) On 11/24/2025 at 8:09AM the surveyor observed Resident #98 wearing their nasal cannula oxygen tubing which had no label indicating date or time of when it was placed or would expire. On 11/24/2025 at 8:09AM the surveyor observed Resident #98's humidification bottle for their oxygen with no labeling indicating date or time of when it was placed or when it would expire.On 11/24/2025 at 8:09AM the surveyor observed Resident #98's nebulizer machine and face mask directly laying on the floor's surface next to their bed. On 11/24/2025 at 8:10AM the surveyor requested a dual observation of the concerns with…

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

Based on observation and interviews with staff, it was determined that the facility failed to ensure an appropriate storage method was implemented for medications awaiting final disposition consistent with standards of practice. This was evident for an observation in 1 medication room (Station 2) out of 2 medication rooms observed during the annual survey. The findings include:Disposition is the process of returning and/or destroying unused medications. On 11/26/2025 at 7:49AM, an observation of the medication room on Station 2 revealed a medication bottle of levetiracetam oral solution for Resident #79 and a white paper bag with a ONETOUCH Ultra 2 device, strips, and lancets for Resident #100. On 11/26/2025 at 9:45AM, a review of Resident #79's electronic medical record revealed that levetiracetam oral solution was discontinued on 11/20/2025. A review of Resident #100's electronic medical record revealed that the resident was discharged on 10/14/2025. On 11/26/2025 at 10:53AM, the Surveyor conducted an interview with Unit Manager #17 in Station 2's medication room. 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 record review and interviews with the resident and staff, it was determined that the facility failed to assist the resident in obtaining routine dental care. This was evident for 1 resident (Resident #57) reviewed during the annual survey.The findings include:On 11/24/2025 at 11:30AM, during an interview with Resident #57, the Surveyor was informed that the resident has not been examined by a dentist in a long time and has been requesting to see a dentist for routine services related to existing dentition and general oral hygiene.During a review of Resident #57's electronic medical record on 11/24/2025 at 1:30PM, the Surveyor discovered a dental consult note dated 2/16/2024, which was the last documentation of dental services provided to the resident. Further review failed to reveal documentation of any scheduled routine appointments.On 11/26/2025 at 1:20PM during an interview conducted with Registered Nurse (RN) #21, the Surveyor was informed that Resident #57 had requested to see the dentist.On 11/26/2025 at 2:00PM, an interview with the Director of Nursing (DON) revealed…

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

Based on observations, interviews and resident medical record review it was determined the facility failed to provide a diet that meets the residents special dietary needs and taking consideration of the resident's preferences. This was evident for 1(Resident #8) out of 6 residents reviewed and observed during the annual survey. The findings include the following: During observational rounds and interview on 11/242025 at 8:45 AM Resident #8 stated, I am not allergic to beef and on my meal ticket it says I am allergic to beef. I was also supposed to get bacon and Oatmeal Cereal for breakfast but there is no bacon on my plate and there is no Oatmeal Cereal. We never get drinks with our meals, and I want my coffee with my breakfast. They bring it too late, not at all and I am either done with my food or if I wait for them to bring it to me, my food is cold. Resident #8 meal tray was found to have scrambled eggs, 2 sausage patties, 1 piece of white toast with no juice, no coffee, no tea, and no Oatmeal Cereal. Resident #8 meal ticket dated 11/24/2025 Breakfast that was present 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 observations, review of facility documentation and interviews and it was determined the facility failed to follow the menu for residents' meals. This was evident for 2 (Resident #8 and #58) out of 6 residents reviewed during the survey.The findings include the following: During observational rounds and interview on 11/242025 at 8:45 AM Resident #8 stated, I was also supposed to get bacon and Oatmeal Cereal for breakfast but there is no bacon on my plate and there is no Oatmeal Cereal. We never get drinks with our meals, and I want my coffee with my breakfast. They bring it too late, not at all and I am either done with my food or if I wait for them to bring it to me, my food is cold. Resident #8's meal tray was found to have scrambled eggs, 2 sausage patties, 1 piece of white toast with no juice, no coffee, no tea, and no Oatmeal Cereal. Resident #8 meal ticket dated 11/24/2025 for Breakfast, that was present on his/her meal tray, stated that resident was to receive 4 slices of bacon, 12 oz of Oatmeal Cereal, 12 oz of Coffee or Hot tea, 8 oz of Orange Juice. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to 1.) ensure a resident admitted with severe cognitive impairment had two physician certifications completed and in the medical record, and failed to ensure the MOLST form reflected surrogacy as the basis of the orders and failed to ensure physician documentation of advanced directives and the molst form being reviewed was present in the medical record, and 2.) failed to ensure accuracy of a documented indication for use of a medication in a medical order. This was evident for: 1.) 1 out of 5 Residents (#10) reviewed for advanced directives, and 2.) 1 out of 1 Resident (#24) reviewed for skin conditions during the facility's recertification survey. The findings include: Based on interview and record review it was determined the facility failed to ensure medical records were complete and accurately documented for residents. This was evident for 1 out of 5 residents (Resident #10) reviewed for advanced directives, and 1 out of 1 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 observation and interview, it was determined that the facility failed to ensure tube feeding equipment was properly dated to prevent potential infection control risks. This deficient practice was evident for 1 (Resident #9) of 1 resident reviewed for tube feeding.The findings include:On 11/24/2025 at 10:27 AM, Resident #9 was observed to be using a tube feeding that was not dated. Staff #10, who was assigned to Resident #9, was located and confirmed that the tubing and nutrition bottle were undated. Staff #10 stated it was the responsibility of the nurse to ensure the tube feeding equipment was dated. On 11/25/2025 at 10:48 AM, the Director of Nursing was made aware of the findings.

Based on medical record review and staff interview it was determined the facility failed to develop, implement, and update a person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for 4 residents (#32, #80, #76, #14) out of 15 residents reviewed during the survey. The findings include the following: 1) Review of Resident #32's medical record on 12/15/2023 at 2:00 PM revealed a revised care plan dated 11/08/2023 with a focus for Resident (#32) being at risk for changes related to resident's current psychological diagnoses. The care plan further states under Interventions/Tasks, for staff to administer medications as ordered and to observe for side effects but there was no resident centered or specific side effects that staff should be monitoring resident for noted on the care plan related to antipsychotic medications. Further review of Resident #32's medical record revealed a Pharmacy Consultation Report dated 11/08/2023 that Resident (#32) receives Quetiapine, an antipsychotic medication, and should 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.

Based on medical record review and staff interview it was determined the facility failed to ensure that residents were free from unnecessary drugs due to inadequate monitoring. This was evident for 5 residents (#32, #14, #70, #18, #44) out of 13 residents reviewed during the annual survey. The findings include the following: 1) Review of resident (#32)'s medical record on 12/13/2023 at 10:44 AM revealed a Pharmacy Consultation Report dated 11/08/2023 that resident (#32) receives Quetiapine, an antipsychotic medication, and the resident should be monitored for involuntary movements including tardive dyskinesia as well as the facility interdisciplinary team ensures on-going monitoring for effectiveness and potential irreversible consequences (e.g., uncontrolled movements). Further review of the medical record failed to reveal evidence that the facility performed an Abnormal Involuntary Movement Scale (AIMS) test to resident (#32) at time of admission. Review of facility policy, Use of Psychotropic Medication on 12/13/2023 at 11:15 AM stated that residents who receive an antipsychotic…

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 resident electronic medical record and interviews with facility staff it was determined the facility failed to provide the resident and/or responsible party a written copy of the hospital transfer summary. This was found to be evident during the facility's Medicare/Medicaid survey. The findings include: Resident # 43 was admitted to the facility with the following but not limited diagnosis: Dementia. Review of the resident electronic medical record on 12/12/23 at 9:23 AM revealed that on 8/19/23 Resident # 43 was sent to the hospital. On November 4, 2023, Resident #43 had a fall, and was assessed to have no injury at the time of the fall. The next day on 11/5/23 the resident complained of pain and an order was given to send the resident out to the hospital for evaluation. The survey team requested a copy of the transfer summary form that was sent to the family regarding the resident hospitalizations. An interview was conducted with the DON on 12/19/23 at 1:00 PM and she stated that she was unable to provide a transfer summary form that was sent to 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 clinical record review and staff interview it was determined that the facility staff failed to ensure its residents had a complete and accurate Preadmission Screening and Record Review (PASRR). This was evident for 1 out 45 of residents (Resident #47) in the survey sample. The findings are: The PASRR level 1 screening is federally mandated and must be completed for all applicants to nursing facilities which participate in the Maryland Medical Assistance Program regardless of an applicant's payment source. The purpose of the screening is to help ensure that residents are not inappropriately placed in nursing homes for long term care. The program assists in the placement and provision of services for individuals with severe mental illness and/or intellectual disability. A review of Resident #47's medical record on 12/18/23 at 11:15 AM revealed the resident had a PASRR which was done in the hospital on 2/23/23. Review of Section C.1 Serious Mental Illness Diagnosis. Does the individual have a major mental disorder? If yes, list the diagnosis. The item was left blank and the…

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

Based on medical record review and staff interview it was determined the facility failed to provide the resident and their representative with a written summary of the baseline care plan within 48 hours of the resident's admission. This was evident for 1 resident (#32) out of 8 residents reviewed during the annual survey. The findings include: Review of Resident #32's medical record on 12/14/2023 at 11:20 AM revealed that there was no written summary of Resident #32's baseline care plan given to the resident #32's representative within 48 hours of admission. During an interview on 12/14/2023 at 11:45 AM the Director of Nursing stated that there are no care plans given out and the facility does not provide written summaries of care plans to residents or their representatives. During an interview on 12/15/2023 at 09:25 AM staff member (#9) stated the facility does not provide any form of summaries of care plans to residents or their representatives, but the facility will be doing this moving forward.

Based on medical record review and interviews it was determined the facility staff failed to update a resident's care plan who had a wound and a resident with a history of falls. This was evident in 3 (#84, #36, #70) residents out of 8 resident records reviewed for updated care plans during the survey. The findings include: 1) On 12/20/23 at 10:41 am a review of Resident #84's electronic medical record (EMR) revealed the resident was receiving wound care to the surgical site located to the right stump. Further review of the resident's care plan revealed the resident's care plan was not updated to include the ordered wound care. Also, the care plan indicated that the resident was at risk for an alteration in skin integrity and the resident's skin would remain intact. On 12/20/23 at 12:30 pm during an interview with Director of Nursing (DON) #2, he/she stated, the unit managers complete the care plans and update the care plans. The care plans should be updated when there are changes and quarterly. DON #2 stated, the care plan should have been updated to reflect the resident's wound…

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 resident medical record and interviews with the facility staff it was determined the facility failed to properly assess a resident for bedrails. This was found to be evident for 1(Resident # 14) of 7 residents reviewed for accidents during the facility's survey. The findings include: Resident #14 was admitted to the facility with the following but not limited diagnoses: Parkinson's Disease, Alzheimer's Disease, Dementia, and Anxiety Disorder. Review of the facility's matrix (used to identify pertinent care categories for residents) on 12/11/23 at 4:05 PM revealed the resident had a fall with major injury (MI). Review of the resident 11/7/23's Annual Minimum Data Set (MDS) Assessment, (a federally mandated assessment tool used by nursing staff to gather information on each resident's strengths and needs) revealed Section J1900: Number of falls since admission/entry or reentry: A-No Injury =Two or more B-Injury (except major) = None C- Major Injury = None An interview was conducted with the DON and Administrator on 12/14/23 at 10:30 AM and she stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to ensure the physician and nurse practitioners accurately assessed a resident's medications (Resident #91) and wound dressing instructions (Residents #94). This was found to be evident for 2 out of 45 residents reviewed during an the survey. The findings include: 1. On 12/22/23 at 7am a review of Resident #91's medical record revealed the resident was admitted in the facility in July 2023 with diagnosis including but not limited type 2 diabetes mellitus. Review of the discharge summary from the hospital included instructions to continue HumuLIN R U-500 KwikPen Subcutaneous Solution Pen-injector 500 UNIT/ML (Insulin Regular) Inject 80 unit subcutaneously three times a day before meals for DM. Humulin® (HUE-mu-[NAME]) R U-500 (500 units/mL) is for adults and children who need more than 200 units of insulin in a day to control high blood sugar for their diabetes mellitus. It is more concentrated than Humulin R U-100. It has 5…

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 interviews, medical record reviews, and observations the facility failed to provide pharmaceutical services that assured accurate dispensing and administering of medications to meets the needs of each resident. This was evident for 1 of 1 resident (Resident # 287) reviewed during the survey. The findings include: On 12/12/23 at 08:15 AM the surveyor initiated a medication administration observation with LPN #11. During the observation the surveyor was informed by LPN #11 that the Aspart insulin pen for Resident #287 was not present in the medication cart. LPN #11 checked the medication room behind the nurses' station and then called the pharmacy to request Resident # 287's insulin pen as well. A review of the order summary report on 12/1/23 at 08:40 AM revealed that Resident #287 was prescribed on 12/9/23 and the order instructed the clinical staff to administer the Aspart insulin on 12/10/23 at 07:00 AM. The prescriber also ordered that the Aspart injection solution 100 units/ml be administered subcutaneously at 07:00AM, 11:00AM, and at 5 PM before meals. On 12/12/23 at…

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

Based on medical record review and staff interview it was determined the facility pharmacist failed to identify and report irregularities in resident (#70's) drug regimen to the Physician, facility's Medical Director and/or the Director of nursing. This was evident for 1of 5 residents reviewed for unnecessary medications. The findings include: Review of the medical record for Resident #70 on 12/13/23 at 2:21pm revealed the resident was admitted to the facility with diagnoses that included Anxiety, Depression, and insomnia. A review of the physician orders on 12/13/23 at 3pm revealed the resident is receiving the following: Trazodone HCl Oral Tablet 50 MG (milligrams)by mouth at bedtime for insomnia. (Trazadone is an antidepressant medicine. It's used to treat depression, anxiety, or insomnia.) Melatonin 3 MG by mouth one time a day at 6pm for insomnia. (Melatonin is a hormone that may provide some relief from insomnia.) Sertraline HCl (Zoloft) Oral Tablet 100 MG once a day for depression. (Sertraline is used to treat depression, anxiety disorder.) Pharmacy reviews dated 9/5/23,…

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, record review, and interviews it was determined that the facility failed to ensure the medication error rate was less than 5%. This was evident for 2 of 25 opportunities for medication errors with an error percentage of 7.14% observed during the medication administration facility task performed. The findings included: On 12/12/23 at 08:15 AM the surveyor initiated a medication administration observation with LPN #11. During the observation the surveyor was informed by LPN #11 that the Aspart insulin pen for Resident #287 was not present in the medication cart. LPN #11 checked the medication room behind the nurses' station and then called the pharmacy to request Resident # 287's insulin pen as well. A review of the prescriber order summary report on 12/12/23 at 08:40 AM was completed by the surveyor. The medical record review revealed that Resident #287's prescriber wrote on 12/9/23 that the resident was to receive Aspart insulin beginning on 12/10/23 at 07:00 AM. The prescriber also ordered that the Aspart injection solution 100 units/ml be administered…

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 administer prescribed mediation to residents. This was found to be evident for 2 out of 45 (Resident #94, #287) reviewed during the annual survey. The findings include: 1. An investigation of complaint MD00175452 revealed that Resident #94 was not receiving an antibiotic because they were not available for 3 days. A medical record review on 12/20/23 at 11:00 AM, revealed that Resident #94 was admitted to the facility on [DATE], from an acute care facility with a diagnosis of osteomyelitis right ankle and foot. Further record review revealed a physician order on 2/18/22: Meropenem-Sodium Chloride Intravenous Solution Reconstituted 1 GM/50ML (Meropenem & Sodium Chloride) every 8 hours for wound infection. Review of the Medication Administration Record (MAR) for February 2023 and Nursing Progress notes, revealed that the medication was not available on 2/18, 2/19, and 2/20/22. On 12/18/23 at 7:53 AM, an interview with…

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

Based on medical record review and staff interview it was determined the facility failed to accurately maintain resident face sheet/Emergency Data sheet with diagnoses that reflected his/her condition. This was evident for 1 resident (#32) out of 8 residents reviewed during the survey. The findings include the following: Review of resident (#32)'s medical record on 12/13/2023 at 12:29 PM revealed a progress note written by a nurse practitioner that resident (#32) had a diagnosis of Anxiety. The diagnosis Anxiety was not found on resident (#32)'s face sheet/Emergency Data sheet/Resident Information Sheet. During an interview on 12/13/2023 at 01:15 PM the Director of Nursing stated she was not sure why resident (#32) did not have the diagnosis Anxiety in the system, but it should be added.

Based on observations and interviews of the residents and facility staff it was determined the facility failed to ensure that the resident's call system was functioning properly. This was found to be evident for 1 of multiple resident rooms observed during the facility's survey. The findings include, An observation was made on 12/11/23 at 11:28 AM while on the unit. The resident in bed by the window (A Bed) Resident # 46 called out for help. Two surveyors entered the resident room and checked to see if the resident call light was working. The resident stated that s/he had been pressing the button, but it was not working. One surveyor remained at the resident bedside and tested the resident call light while the other surveyor stood at the resident doorway entrance and observed that the dome light above the door did not light up. The two surveyors then walked to the nurse station to alert staff # 6 of the concern that the resident call light did not light up. Staff # 6 immediately went into the resident room to check the call light and upon pressing the light, it lit up on the wall…

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 the facility staff failed to notify the physican of a heart rate below the set parameter as ordered for Resident (#68), failed to notify the physician of a weight gain for Resident (#234) and failed to notify the Power of Attorney (POA)/or emergency contact of changes in condition for Resident (#68 and #233) and the facility staff failed to notify a resident's physician of a positive ultrasound result timely manner for Resident (#21). This was evident for 4 of 4 residents selected for change in condition investigation during the annual survey process and 4 of 39 residents selected for review during the annual survey process. The findings include: A power of attorney (POA) is a written authorization to represent or act on another's behalf in private affairs, business, or some other legal matter. A Power of Attorney form allows the resident to appoint another person to act on their behalf should they ever require someone to make short- or long-term decisions for the resident. The Emergency Contact is the person you would like…

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

Based on review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization. This was evident for 3 (#38, #58, #59) of 8 residents reviewed for Hospitalization during an annual recertification survey and 3 of 39 residents selected for review during the annual survey process. The findings include: 1. Review of the medical record for Resident #38 revealed the resident was transferred to an acute care facility on 6/22/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. 2. Review of the medical record for Resident #58 revealed the resident was transferred to an acute care facility on 11/30/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. 3. 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 staff interview and employee record review (Staff #8), it was determined that the facility failed to complete the required performance review of a geriatric nursing assistant at least once every 12 months in 1 employee record reviewed during this survey. The findings included: Performance appraisals are completed at least every 12 months to identify in-service education needed for each geriatric nursing assistant. Interview with the Director of Nursing on 1-31-19 at 9:00 AM confirmed a performance appraisal had not been completed for Staff #8 for 2 years, 2017 and 2018. This surveyor interviewed the Nurse educator on 2/5/19 at 9:25 AM. She said competency trainings were stopped in November of 2018 secondary to her being sick, but they will resume in March of 2019. The education files of four geriatric nursing assistants (GNA's) were reviewed to verify that competencies were reviewed on an annual basis. Staff #5 was hired on 3/25/85 but did not have an annual performance review in 2018. Staff #6 was hired on 11/24/15 but did not have an annual performance review in 2018.…

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 of facility staff, it was determined that food service employees failed to ensure that sanitary practices were followed, equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 1/29/19 at 9:01 AM, an initial tour of the facility kitchen with the food service manager was conducted. The following observations were made: 1) Condiments a two large containers of red liquid were unlabeled in the walk in refrigerator. 2) Crumbs and food debris were observed along kitchen floor between and behind appliances. 3) Accumulated food debris and dust was observed along the tops of protruding electrical outlet boxes and window sills throughout the kitchen suggesting they had not been cleaned or even wiped in some time. On 1/31/19 at 12:48 PM, another walkthrough of the facility kitchen was conducted. The following observations were made: 1) Crumbs were observed on the floor between appliances and under counters as…

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 Resident #16 with the most dignified existence. This was evident for 1 of 2 residents investigated for dignity during the survey process and 1 of 39 residents selected for review during the annual survey process. The findings include: Surveyor observation of Resident #16's breakfast on 2/5/19 revealed the breakfast was in the resident's room and on the over bed table at 8:37 AM. Further observations revealed the facility staff failed to provide Resident #16 with breakfast until 9:05 AM (at least 28 minutes of sitting in Resident #16's room) and failed to re-heat the food for Resident #16. Interview with the Director of Nursing on 2/5/19 at 1:00 PM confirmed the facility staff failed to provide Resident #16 with the most dignified existence. See F 692

Based on observation and interview, the facility staff failed to honor residents (# #58, #283, #183) menu choices and shower requests. This was evident for 3 of 3 residents reviewed for choices during the annual survey and 2 of 39 residents reviewed during the annual survey. The findings include: 1. Interview with Resident #58's family member on 1/29/19 at 11:15 AM revealed Resident #58's food dislikes had been recorded but staff were not honoring his/her dislikes. The meal tickets stated dislikes: cheese, chicken, potatoes, turkey, deluxe macaroni and cheese and white bread. On 1/30/19 at lunch Resident #58 was served chicken with staff ignoring the dislikes listed on the meal ticket. Although the food choices were submitted to the Dietary Manager and written on the meal ticket, Resident #58's food choices had not been honored. On 1/30/19 at 12:15 PM Unit Manager #6 confirmed Resident #58's food choices were not honored. 2. On 1/21/19 Resident #283 requested the alternative meal choice for dinner. Geriatric Nursing Assistant #8(GNA) wrote when he/she went to obtain the alternative…

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 resident complaint, reviews of a medical record and staff interview, it was determined that the facility staff failed to 1. take steps to protect a resident's property from becoming lost, and 2. maintain a current list of a resident's belongings. This was evident for 1 (Resident #183) of 1 resident reviewed for personal property during an annual recertification survey 1 of 39 residents selected for review during the annual survey and the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The findings include: 1. The facility staff failed to 1. take steps to protect a resident's property from becoming lost, and 2. maintain a current list of a resident's belongings In an interview with Resident #183 on 1/29/19 at 10:18 AM, Resident #183 stated that s/he was missing sweaters and new pants. Resident #183 stated that s/he did notify the facility laundry people of the missing items a couple months ago. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative and the facility failed to provide and resident and the resident's family member with written notification regarding an emergent transfer to the hospital Resident (#183). This was found to be evident for 4 out of 8 residents reviewed for a facility-initiated transfer during the investigative portion of the survey and 4 of 39 residents selected for review during the annual survey. The findings include: 1. A medical record review for Resident # 38 was conducted on 1/30/19. Review of the physician order written on 6/22/18 revealed that Resident # 38 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the…

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

Based on resident complaint, reviews of a medical record and staff interview, it was determined the facility staff failed to initiate a care plan to address a resident's behaviors of wandering into other resident rooms. This was evident for 1 (Resident #40) of 4 residents reviewed for accidents during an annual recertification. The findings include: During an interview with Resident #49 on 1/29/19 at 12:36 PM, Resident #49 indicated Resident #40 wanders into his/her room occasionally and Resident #40 has startled Resident #49 in the past. Reviews of Resident #40's medical record on 2/1/19 failed to reveal any care plan to address Resident #40's wandering behaviors. In an interview with the nursing unit manager on 2/1/19 at 1:49 PM, the nursing unit manager stated that the nursing staff had not initiated a care plan to address Resident #40's wandering throughout the facility in his/her wheelchair.

Based on medical record review, observation and staff interview, it was determined the facility staff failed to provide services to Resident #334 as stated in the care plan. This was evident for 1 of 3 residents reviewed for care plans during the annual survey process. The findings include: Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. Medical record review for Resident #334 revealed the facility staff initiated a care plan on 1/14/19 which stated: Resident is at risk for falls related to history of falls. (It was also noted in the medical record Resident #334 had falls on 1/9, 1/11, 1/15, 1/27 and 2/1 2019). An intervention on the care plan was: bed in low position. Surveyor observation of the…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to ensure the dose of a medication was as accurate as possible. This was evident for 1 of 6 residents observed for medication pass and 1 of 33 opportunities for error. The findings include: Medical record review for Resident #49 revealed on 11/29/18 the physician ordered: Iron Sulfate 325 milligrams-7.4 cubic centimeters (cc) via PEG tube every day as a supplement. This medication is an iron supplement used to treat or prevent low blood levels of iron (e.g., for anemia). Iron is an important mineral that the body needs to produce red blood cells and keep you in good health. Percutaneous endoscopic gastrostomy (PEG) is a medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate, medications and fluids as needed. Observation of medication pass on 2/1/19 at 8:15 AM revealed facility staff nurse #13 used a medication cup to measure the 7.4 cc of medication 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 clinical record review, staff interview, and observation it was determined that the facility staff failed to ensure an order for the use of a hand splint was followed (#22) and the facility staff failed to apply a heel protective device for Resident (#183). This was true for 2 out of the 6 residents reviewed for Range of Motion during the annual survey process. The evidence is as follows: 1. A review of Resident #22's clinical record revealed that the primary physician wrote an order on 4/5/18 to Don right hand orthotic 9AM, remove at 3PM. This surveyor observed on 2/1/19 at 1:59 PM the resident laying in bed with right hand below the bed sheets. I asked the unit manager to lift the sheets so that the hand could be observed. When he lifted the sheet, it was observed that the hand splint was not on the resident. The unit manager said he would put the hand splint on the resident. He looked on the night stand and could not find it. He looked inside the nightstand's drawer and could not find it there either. He then went to the dresser and searched the first drawer. He found it…

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 that the facility staff failed to follow a written physician order to prevent loss of range of motion (Resident #51). This is evident for 1 of 4 resident's reviewed for limited range of motion. The findings include: On 1-31-19 at 12:30 PM with Unit Manager #6 it was confirmed that physician ordered bilateral orthotic hand splints (that were to be placed by 10:00 AM after light range of motion exercise and removed by 2:00 PM) had not been placed on Resident #51 who is totally dependent on the facility staff for all care. It was also confirmed that on Resident #51's left hand the middle finger had a nail that was 1/2 inch over the nail bed and pressing into the palm making an indention. The orthotic splints are to maintain the current range of motion in the hands and the nails are to be kept trimmed to prevent skin breakdown. The facility failed to consistently apply ordered hand splints which are to prevent decrease in current range of motion in the hands and maintain fingernails.

Based on medical record review, observations, and staff interviews it was determined that facility staff failed to ensure a resident was free from accident hazards. This is evident for 2 out of 2 residents selected for reveiw of accidents during the survey and 2 (#54 and #67) out of 39 residents reviewed during the investigative stage of the survey. The findings include: 1. The facility staff failed to ensure a resident was free from accident hazards. On 1/30/2019 a review of the medical record for Resident #54 revealed a Change in Condition dated 1/12/19 which stated the resident had burns and blisters on both inner thighs from being burnt by hot soup during lunch. A Progress Note from 1/14/2019 stated Patient spilled hot soup on his/her leg over the weekend and a blister developed. Further review of the medical record revealed a care plan Resident/Patient requires assistance/is dependent for ADL care in eating related to: Paralysis/Weakness affecting left side. Activities of Daily Living are activities performed by individuals on a daily basis that would be necessary 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 record review, observation and interview, it was determined the facility staff failed to provide Resident #16 with the most provisions to provide for optimal nutrition. This was evident for 1 of 12 residents selected for review of nutrition and 1 of 39 resident selected for review during the annual survey. The findings include: 1 A. The facility staff failed to get Resident #16 out of bed for all meals as ordered. Medical record review for Resident #16 revealed on 10/12/18 the physician ordered: out of bed for meals. Surveyor observation of the resident on 2/5/19 at 8:37 AM revealed the resident in bed. The resident's breakfast tray was noted to be sitting on the over-bed table as the surveyor entered the room and the facility staff failed to give Resident #16 the tray in a timely manner. At 9:05 AM, it was noted the facility staff gave Resident #16 breakfast: however, the facility staff failed to get the resident out of bed as ordered. It was noted the resident was in bed and the breakfast tray was placed on the over-bed table in front of Resident #16. 1 B. The facility…

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

Based on record review, observation and interview, it was determined the facility staff failed to have emergency equipment a manual ventilation bag (Ambu) at the bedside for Resident #334 in accordance with the standard of practice. This was evident for 1 of 1 resident selected for review of respiratory care/tracheotomy during the annual survey process. The findings include: Surveyor observation of Resident #334 on 1/2/19 at 10:00 AM revealed the resident lying in his/her bed with a tracheostomy tube connected to a tracheostomy mask with oxygen. A tracheotomy, or tracheostomy, is a surgical procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea. A check of equipment needs for resident's #344 respiratory care failed to reveal a manual ventilation bag (Ambu) and trach adapter to deliver lifesaving oxygen to the resident if needed. An Ambu bag is a manual resuscitator or self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not…

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

Based on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication for Resident (#16). This was evident for 1 of 4 residents selected for pain assessment and 1 of 39 residents selected for review during the annual survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. Medical record review for Resident #16 revealed on 11/23/18 the physician ordered: Oxycodone-Acetaminophen, 5 milligrams (mgs)/325 mgs by mouth every 4 hours as needed for pain 6-10. Oxycodone is 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 Certified Registered Nurse Practitioner failed to determine the significance and need of an ordered laboratory blood test for Resident #67. This was evident for 1 of 39 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #67 revealed on 10/4/18 the Certified Registered Nurse Practitioner (CRNP) ordered: Eliquis 2.5 milligrams by mouth every day for DVT prophylaxis. Deep vein thrombosis, or DVT, is a blood clot that forms in a vein deep in the body. Eliquis belongs to the group of medications called anticoagulants. Anticoagulants prevent harmful blood clots from forming in the blood vessels. They do this by reducing the ability of the blood to clot. Further record review revealed on 10/4/18 the CRNP ordered: INR tonight for results in the morning. The INR, or international normalized ratio measures the time for the blood to clot. It is used to monitor blood-thinning medicines, which are also known as anticoagulants. Because of this, people taking…

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 maintain a medication error rate below 5%. Based on observation of medication pass on 2/1/19 the facility staff failed to administer medications to Resident (#49) resulting in an error rate of 6.06%. This was evident of 2 of 33 opportunities for error and 1 of 6 residents observed during medication pass. The findings include: 2 A. The facility staff failed to ensure medications were available for Resident #49. Medical record review for Resident #49 revealed on 10/30/18 the physician ordered: Keppra 500 milligram (mgs) via PEG tube 2 times a day for seizures. Keppra is a medication used to control seizures. Seizures are symptoms of a brain problem. They happen because of sudden, abnormal electrical activity in the brain. Percutaneous endoscopic gastrostomy (PEG) is a medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate, medications and fluids as needed.…

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 ensure medications were thoroughly labeled with residents' name. This was evident for 1of 5 medication carts observed during the annual survey process. The findings include: Observation of medication pass on 2/1/19 at 8:15 AM revealed a bottle of liquid Potassium Chloride in the bottom draw of the medication cart. Potassium chloride is a mineral supplement used to treat or prevent low levels of potassium in the blood. Potassium is essential for the function of the heart, muscles, kidneys, nerves, and digestive system. Further observation of the medication cart revealed the bottle of Potassium Chloride had no name on the bottle to determine which resident it was to be administered to. Interview with the Director of Nursing on 2/5/19 at 1:00 PM confirmed the facility staff failed to ensure medications were thoroughly labeled with residents' name.

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 for Resident # 38. This was evident for 1 of 4 residents selected for review of dental during the survey process. The findings include: 1. An interview was conducted with Resident # 38 on 1/29/2019 at 11:4 5 AM. When asked if the resident was experiencing any dental or oral issues the resident responded I have missing teeth and tooth pain. I told them I wanted to see a dentist. Review of Resident #38's medical record revealed the Resident was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment was completed on 9/13/18 and the facility staff coded the Resident in Section L Oral/Dental Status as mouth or facial discomfort and reports difficulty chewing. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information…

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.

2. The facility staff failed to maintain complete and accurate medical records. On 1/30/2019 at 12:16 PM a copy of Resident #54's Care Plan was obtained from the Director of Nursing (DON). 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. Review of the Care Plan revealed that the copy presented to surveyors by the DON was inconsistent with the Care Plan stored digitally within Point Click Care (PCC). PCC is a software program used by facilities to digitally manage resident records, medications and care plans. It is commonly used as a reference by employees when providing care to residents. The physical copy of Resident #54's Care Plan given to surveyors had two focuses, Resident is at risk for injury or complications related to the use of anticoagulation therapy and Resident has actual skin disruption related to blister formation that were not present in PCC and thus not available to staff using PCC to reference Resident #54's Care Plan. Inaccurate records place the resident at…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to provide the most effective infection control practices while administering medications to Resident (#52) and facility staff failed to reduce the risk of cross contamination and spread of infections by not washing hands after direct patient care for Resident # 334. This was evident for 1 of 6 residents observed for medication pass and 1 out of 33 opportunities for error (Resident #52) and 1 out of 2 residents reviewed for a facility-initiated transfer during the investigative portion of the survey. The findings include: 1. The facility staff failed to provide the most effective infection control practices while administering medications to Resident # 52. Medical record for Resident #52 revealed on 8/21/18 the physician ordered: Systane .3-.4%, 1 drop both eyes for dry eyes. Systane is used to relieve burning, irritation, and discomfort caused by dry eyes. Observation of medication pass on 2/1/19 at 9:00 AM revealed facility staff nurse # 13 obtained toilet tissue from 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 observation and interview of facility staff, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This deficient practice has the potential to affect all residents. The findings include: 1. On 1/29/19 at 9:32 AM a mobile cart used for serving coffee was observed in the hallway outside room [ROOM NUMBER]. A container filled with single use creamers was observed inside the cart. Both the container itself and the creamers were soiled with dried coffee spills. The cart had dried, sticky stains from spilled juice and had crumbs stuck to its surface. 2. On 1/30/19 at 1:25 PM a meal cart was observed exiting the elevator on the first floor. The cart had brown stains on the white exterior and dried food crumbs stuck to the bottom edge. The exterior covering was broken with holes and chipped corners. 3. On 1/31/19 at 8:23 AM a meal cart was observed exiting the elevator on the second floor. The cart was visibly soiled…

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.