Blue Point Healthcare Center

Based on observation, staff interviews and record reviews, it was determined that the facility failed to ensure that it was free of medication error rates of five percent or greater. This was evident during observation of med pass on 2 of the 2 units in the facility during a recertification/complaint survey.The findings includeOn 12/08/25 at 8:20 AM an observation of med pass was conducted on the basement floor with Staff #15, a Registered Nurse (RN). Resident #90's two eye drops Cosopt ophthalmic solution and artificial eye drop were not given, Staff #15 stated that she could not find them and will call pharmacy to bring it stat. On 12/8/25 at 9:52 AM during another med pass observation for Resident #36 with staff #16 a certified medicine aide (CMA), the resident was ordered Visine ophthalmic and Systane ophthalmic eye drops for dry eyes, the CMA could not find the eye drops, she said the facility allows them to use the artificial tear drops as substitutes.Review of the physician's order for Resident #36 did not reveal an order to substitute any of the eye drops with the artificial…

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

Based on observation, staff interview and record reviews, it was determined that the facility failed to 1) appropriately store drugs for Resident #121 and, 2) label drugs and biologicals in accordance with currently accepted professional standards. This was evident for 2 of 2 nursing units observed during the recertification/complaint survey.The findings include1) On 12/02/25 at 1:08 PM Observation of a medicine cup in Resident #121's room with 4 pills were made including an inhaler labelled Symbicort 160 mcg/4.5 mcg, 2 puffs twice a day and an icy hot max pain relief lidocaine cream 2.7 oz bottle. The resident stated it was his Gabapentin and Tylenol and that the inhaler was from the hospital.On 12/02/25 at 1:16 PM Staff #3 a Certified medicine Aide (CMA) was asked about the medication at the bedside. She said the medications should not be left at the bedside and verified the surveyors' findings. In an Interview with the Director of Nursing (DON)/Administrator on 12/03/25 at 9:03 AM. They stated that there is a protocol for medications at the bedside and that Resident #121 can keep…

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

Based on medical record review and interviews, it was determined that the facility failed to provide Dental services. This was evident for 3 (Resident #4, #12, and #8) of 4 residents reviewed for dental services during the recertification/complaint survey. The findings include: 1) During the investigative interview on 12/03/2025 at 9:17 AM with Resident #4, the resident stated my teeth are falling out, and I need dentures. Surveyors observed missing teeth on the top and bottom areas of the resident's mouth. A record review on 12/04/2025 at 8:25 AM noted that Resident #4 had a consult ordered on 10/3/2025 for: Audiology, Dental, Optometry, Ophthalmology and/or Podiatry as needed. 2) During the investigative interview on 12/3/2025 at 8:54 AM, Resident #12 stated, I have been at this facility for a couple years, and I have not seen a dental hygienist or dentist. I am losing my teeth and would like dentures. A record review on 12/04/2025 at 8:35 AM noted that Resident #12 had a consult ordered on 11/29/2023 for: Audiology, Dental, Optometry, Ophthalmology and/or Podiatry as needed. On…

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

Based on observation, interview and record review it was determine that the facility staff failed to 1) follow the facility infection prevention policy to operate on a systematic and organized date-driven method track and trend for in-house infections effective and timely, and 2) maintain/use laundry dryers according to the manufacture's instructions for use. The second one was found to be evident of 3 out of 3 dryers observed during the recertification/complaint survey.The findings include-1) On 12/04/2025 at 08:50 AM, observation and interview of Residents' 2nd floor revealed that Infection isolation signs were up in some of the resident's doors. However, the staff was not sure the reasons why.On 12/04/2025 at 9:49 AM during an interview, The Infection preventionist Staff #19 stated she using infectious diagnosis daily information to format her worksheet. However, she did not follow the facility policy to run a systematic and organized data-driven method to track/ trend the rough data. She could not provide any back-up reports from Regional office in McGeer Criteria either.During…

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

Based on observation, interviews and medical record review, it was determined that the facility failed to assess residents for the ability to self administer medication. This was evident during random observations when medications were found at the bedside of 2 residents (Resident #61 and #62). The findings include: During the tour of the 'C' unit of the facility on 6/25/25 at 8:15 AM, this surveyor and another surveyor completing tour observed a medication cup on a bedside table full of pills. There were no residents observed or staff from the doorway. This surveyor knocked and entered the multiple person room. There were 2 people, an individual in the 'b' bed was awake, 'c' bed asleep and the 'a' bed resident sounded to be in the bathroom. The medication cup of pills was at the 'a' bed. There were 7 pills in the cup, 5 white, 1 pink and 1 brown. This surveyor asked the other surveyor to please go get a nurse to assist. LPN #15 arrived at the room and was asked if she passed the medication or who did. She picked up the medication and stated it was not her. At this time Resident #…

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

Based on medical record review and interview with facility staff, it was determined that the facility staff failed to notify the attending physician when the resident was refusing their medications. This was evident during the review of 1 of 3 residents administered Narcan (Resident #11) The findings include: The medical record for Resident #11 was reviewed on 6/23/25 at 10:51 AM related to a facility reported incident where Resident #11 was administered Narcan secondary to a suspected overdose occurring on 2/3/25. Further review at this time of Resident #11's medical record revealed admission to the facility for a minimal 6-week course of intravenous antibiotics for septic wounds on the leg and abdomen from suspected drug use and related endocarditis (inflammation of the heart due to an infection). Resident #11 was ordered Suboxone as part of his/her substance use disorder treatment. According to his/her medication administration record (MAR), Resident #11 refused 9 doses for the month of January and 5 of 8 doses for February 2025. Surveyor interviewed physician staff #35 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 staff interview; it was determined that the facility failed to protect a resident (Resident #43) from misappropriation of personal funds by failing to provide the resident with way to secure the resident's valuables from theft. This was evident for 1 of 67 residents reviewed during the complaint survey. The findings include: The surveyor reviewed a facility reported incident (MD00217424) sent to the State of Maryland ' s Office of Health Care Quality alleging that Resident #43's money was stolen from his/her room. Medical record review for Resident #43 on 6/24/25 at 1:28 pm revealed the facility documented a change on condition which reported that the resident alleged that his/her money ($110.00) was stolen from the resident's room. On 6/24/25 at 1:40pm, the surveyor reviewed the facility investigation of the reported incident. The investigation contained a concern form dated 4/28/25 which reported that the resident was given a lock box to secure his/her valuables. On 6/25/25 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff 1) failed to provide written notice to the resident and resident representative of the transfer to a local hospital for evaluation on 12/17/24. (Resident # 38). This was evident in 1 of 67 residents reviewed during a complaint survey; and 2) failed to ensure that hospital transfers were documented in the residents' medical records and that appropriate information was communicated to the receiving health care institution. This was evident for 1 (Resident #14) of 67 residents reviewed. Findings include:1) On 6/25/25 at 12:00pm, the surveyor reviewed complaint MD00212839 that was sent to the State of Maryland's Department of Health Care Quality alleging that the facility failed to recognize Resident #38's change in status resulting in the resident's family calling for emergency assistance to have the resident transferred to the local hospital on [DATE]. Review of Resident #38's medical records on 6/25/25 at 12:29pm revealed 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 reviews, the facility failed to have individualized care plans in place for Resident #32, #36, and #37 who have SUD (substance use disorder). This was evident for 3 out of 5 residents reviewed for care planning who had SUD.Findings include:1. On [DATE] at 10:55 AM, a medical record review revealed Resident #37, who had a diagnosis of SUD (Substance Use Disorder) and a BIMS score of 15/15, indicating intact cognition. On [DATE], GNA (Geriatric Nursing Assistant) called the Nurse into the room. The Nurse entered the room and found the resident unresponsive with no respirations and no pulse and no response to any verbal or tactile pain stimuli. A STAT (immediate) Code was called and all life-saving measures were given including CPR (cardiopulmonary resuscitation), Narcan x 4 administered and use of AED (automated external defibrillator) until emergency services staff arrived. Continued review of the record revealed Behavior Health saw resident on [DATE] where he/she described mood as 5/10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, it was determined that the facility 1) failed to intervene when a resident that was admitted with a known history of substance use disorder was showing signs and symptoms of potential use and abuse of those substances. This was evident during the review of 1 of 3 residents administered Narcan (Resident #11); and 2) failed to ensure hospital instructions for surgical wound care were addressed upon the resident's admission to the facility. This was evident for 1 (Resident #14) of 10 residents reviewed for neglect.The findings include:1) Review of the facility reported incident on 6/23/25 at 10:51 AM for Resident #11 revealed that on 2/3/25 Resident #11 was observed on the ground outside appearing non-responsive, two doses of Narcan were administered with a positive response from the resident and s/he became alert and responsive to staff who had gathered to assist. Continued record review revealed that Resident #11 was admitted to the facility post hospitalization 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 a review of medical records, facility reported incidents, Controlled Medication Utilization Record sheets, Medication Administration Record (MAR), and interviews with staff, it was determined that the facility failed to consistently document address residents' pain, ensure prescribed medications had adequate parameters, ensure non-pharmacological interventions were attempted prior to the administration of narcotic pain medication, document assessment of pain and administration of an as-needed (PRN) pain medication on the electronic MAR and further monitor the resident's pain level and efficacy of the medication. This was evident for 3 of 5 residents reviewed for pain Resident #48, #5, #16 The findings include: A review of complaint MD00211655, revealed the following: 1. On 6/27/25 at 8 AM a review of Resident #48's clinical record revealed that the resident's primary physician on 10/25/24 ordered Dilaudid (Hydromorphone) Oral Tablet 4 MG, give 1 tablet by mouth every 6 hours as needed for Pain. This medication is used to help relieve moderate to severe pain. Dilaudid…

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 facility staff it was determined that the facility failed to ensure that a radiology report was timely accessible to the attending physician. This was evident during the review of 1 of 3 fractures (Resident #13)The findings include:Revie of the medical record for Resident #13 on 6/24/25 at 11:17 AM for an injury of unknown origin revealed an x-ray was ordered for this resident on 11/6/24 and completed on 11/6/24 at 2:13 PM. This report was then reported back to the facility on [DATE] at 6:32 PM stating that Resident #13 had a fracture of the right femoral neck and recommended further imaging of the right hip. This report was not responded to or followed up on by the facility attending physician until 11/7/24 at 12:12 PM. The current facility DON was interviewed on 6/24/25 at 1:56 PM and was notified of the findings. There was no further information provided prior to exit regarding the delay in reviewing the x-ray by the attending physician.

Based on record review and interview with staff it was determined the facility staff failed to ensure that the resident's appointed decision maker was provided education and opportunity to consent or decline the COVID-19 vaccine booster on the resident's behalf. This was evident for 1 (#21) of 67 residents reviewed during the complaint survey. The findings include: A complaint reviewed on 6/23/25 at 1:15 PM alleged that Resident #21, a resident who was incapable of making decisions for him/herself received a COVID-19 vaccine booster on 1/16/24 without the consent of his/her guardian. Resident #21's medical record confirmed the resident had a court appointed guardian since 2017. The Resident's immunization record revealed 2 electronic consent forms which indicated 2023-2024 COVID-19 Moderna. One was dated 1/30/24 and the other 4/26/24, both indicated education was provide and Resident Refused. The documentation did not indicate that the resident's court appointed guardian was contacted, provided education and either declined or consented for the resident to receive the vaccine. 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 the review of a recent facility discharge practice and interview with facility staff, it was determined that the facility failed to provide a resident and or their representative (RP) with the proper paper documentation of the facilities bed hold policy. This was evident for 1 of 1 (#1) reviewed for hospitalization during a complaint survey. The findings include: 1. Medical record review for Resident #1 was completed throughout the day on 2/7/24. Resident #1, according to facility and hospital documentation, was hospitalized on [DATE]. A review of the facility discharge transfer form was reviewed with the facility Regional Director of Clinical Operations (RDCO) on 2/7/24 at 1:32 PM. The discharge/transfer form previously had a check off list to show that the bed hold policy was given. However, the form had recently been modified and that area was no longer available on the form. A comprehensive review of the facility documentation failed to reveal documentation that a bed hold notice was provided to the…

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

Based on observations, interviews with facility staff, and record review, it was determined that the facility failed to complete a thorough investigation of an incidents submitted to the state agency. This was evident for 4 (Resident #91, #2, #268, and #270) of 12 facility reported incidents reviewed with allegations of abuse. The findings include: 1. On 10/23/23 at 10:40 AM, the surveyor reviewed facility investigation material regarding MD00183300 (an allegation of resident-to-resident abuse) provided by the Director of Nursing (DON). The investigation only included an eInteract Change in Condition Evaluation that indicated behavioral changes of physical aggression for Resident #91. The investigation did not contain any interviews with residents or facility staff, or any other evidence that could be used to determine if abuse had occurred. On 10/23/23 at 10:44 AM, the survey team interviewed the Director of Nursing (DON), Regional Director of Clinical Operations (RDON) #30, and Corporate Nurse #21 regarding facility investigation material. At the time of the interview, the DON was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews it was determined that the facility failed to implement comprehensive person-centered care plans. This deficient practice was evident in 4 (#97, #101, #102, and #270) of 8 resident records reviewed for comprehensive care plans during the survey. The findings include: 1. On 10/17/23 at 11:03 am a review of Resident #102's care plans revealed a care plan for impaired skin integrity was initiated on 10/13/22. The care plan did not mention the wound care that was being provided. 2. A review of Resident #101's electronic medical record on 10/30/23 at 3:22 pm revealed the resident was admitted to the facility on [DATE] and the Activities care plan was not completed until 10/04/23. 3. On 11/15/23 at 11:02 am A review of Resident #97 care plans revealed the resident did not have a care plan for substance abuse even though the resident had a known substance abuse disorder when admitted . A care plan for substance abuse was initiated on 02/28/23 which was after an overdose. 4. 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 record review and staff interview it was determined that the facility staff failed to update a resident's plan of care after an antibiotic was completed. This occurred for 1 (Resident #95) of 10 residents reviewed for care plans during the annual survey. Findings include: Ertapenem is an antibiotic used to treat infections. A care plan is a federally mandated tool that is based on a resident's assessment and describes the services that the facility will provide to the resident to attain or maintain the resident's physical, mental, and psychosocial well-being. The care plan must be developed and revised after each assessment, including the comprehensive yearly assessment and quarterly assessments, and when the resident displays a change in condition. Review of Resident #95's medical record on 10/27/23 at 2:31pm revealed the resident was admitted to the facility with diagnosis that included Osteomyelitis. Osteomyelitis is inflammation of bone caused by infection, generally in the legs, arms, or spine. Further review of Resident's #95's medical record on 10/27/23 at 2:45pm,…

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 resident family and facility staff, it was determined the facility failed to administer a medication as ordered by the physician. This was evident for 1 of 15 residents (#134) reviewed records. The findings include: Resident #134's family member requested to speak to the survey team on 11/20/23 at 3pm, s/he stated the resident had not been receiving his/her medication for Liver Failure. Review of Resident #134's medical record on 11/20/23 at 4pm revealed a physician order dated 11/10/23 to administer Xifaxan 550mg (milligrams) by mouth for Liver Cirrhosis. Xifaxan is an antibiotic that can help prevent recurrence of certain liver problems. Further review of the medical record revealed a Medication Administration Record (MAR) for November 2023, in which resident #134's Xifaxan was signed off as being administered starting on 11/11/23 at AM. Continued review revealed the nurses coded the MAR a (9) on 11/17/23 (pm), 11/19/23 (pm) and 11/20/23 (am) meaning 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 1.) what the Psychiatric Nurse Practitioner Consultant documented in the resident's progress notes did not accurately reflect what was in residents' medical records (Residents #7 and #35) and 2.) the facility failed to ensure that physicians place orders in the electronic health record (EHR) and follow up on labs for the purpose of assessing and documenting resident conditions and treatments accurately (Resident #61). This was evident for 3 of 114 residents (#7, #35, #61) reviewed during the survey. The findings include: 1. Resident #7's medical record was reviewed on 10/25/23 at 11:30 am. The review revealed resident #7 was admitted to the facility with diagnosis that included Paranoid Schizoaffective and Major Depression. Review of the medical record on 10/25/23 at 12pm revealed resident #7 was seen by Consultant Nurse Practitioner from Counter Point Health Services (Staff #45) on 10/13/23 at that time (Staff # 45) documented that resident was receiving Lexapro 10mg (milligrams) by mouth every day for depression;…

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 interview with facility staff, it was determined that the facility failed to ensure the medication error rate was less than 5% during the medication administration facility task. This was evident for 8 of 26 opportunities for error observed during the medication administration facility task, resulting in an error percentage of 30.77%. The findings include: On 10/25/23 at 6:14 PM, the surveyor observed Certified Medication Aid (CMA) #66 prepare medication for Resident #167. CMA #66 poured two tablets of Colace into a cup, but when questioned by surveyors if this medication was intended for Resident #167, CMA #66 stated it was the wrong medication and instead poured out two tablets of Sennosides-Docusate Sodium oral tablets. Later review of Resident #167's orders confirmed that the resident was ordered Sennosides-Docusate, not Colace. On 10/27/23 at 8:35 AM, the surveyor observed Registered Nurse (RN #22) administer oral medications to Resident #418 including pancrealipase tablets, sodium zirconium cyclosilicate capsules, B complex-C-folic acid…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to properly store and monitor medications and medical supplies and dispose of medications according to professional standards. This was evident in 3 out of 3 medication storage rooms observed during the annual survey. The findings include: 1. During observation rounds on [DATE] at 12:28 PM the following was found in A-B wing medication room: a) 1 tray of tiger top test tubes that expired on [DATE]. b) 2 Lipo filter [NAME] locks that expired on [DATE]. c) 10 blue top test tubes that expired on [DATE]. d) 1 expired straight catheter that expired on [DATE]. e) 2 foley catheters that expired on [DATE] and [DATE]. f) 2 tiger top test tubes with resident's names that had been discharged from facility, were found unused. g) 1 Lift lock safety infusion set that expired on [DATE]. h) There was no thermometer in the refrigerator where the facility stored medications. During an interview on [DATE] at 12:35 PM staff (#14) stated that the nurses monitor temperature of…

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

Based on medical record review and interview with facility staff, it was determined the facility failed to maintain an accurate medical records for a residents. This was evident for 3 of 16 residents (Resident# 2, #97, and #122) reviewed for complaints. The findings include: 1. Review of complaint MD00179418 and Resident # 2's medical record on 11/20/23 at 5:48pm revealed the resident was transferred to hospital on 7/3/22. According to the MAR (Medication Administration Record) the resident was scheduled to receive the following on 7/4/22: A blood Glucose level at 7:30am and 11:30am with sliding scale insulin. Aspirin, Folic Acid, Metoprolol, Thiamine, Zoloft, and Lisinopril (including obtaining a pulse prior to administration) at 9am. Further review of the Medication Administration Record (MAR) revealed the blood sugar level was signed off as being obtained at 7:30am and 11:30am on 7/4/22 and resulted a level of 231 at 7:30am and 155 at 11:30am. According to the MAR the resident received 3 units of insulin at 7:30am and 2 units of insulin at 11:30am on 7/4/22. Continued review of…

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

Based on observation and interviews it was determined that the facility staff failed to provide a dignified existence to a resident evidenced by a resident wearing a soiled jacket multiple times. This deficient practice was evident in 1 (#5) of 4 residents assessed for dignity. The findings include: On 10/18/23 at 10:00 am while on Unit D the surveyor observed Resident #5 in the wheelchair in the hallway with a black jacket on that was heavily soiled. On 10/25/23 at 9:39 am during an interview with Geriatric Nursing Assistant # 51 reported when a family member brings in clothing, the staff ask the family to add the clothing to the inventory sheet; all personal property and belongings are labeled. When a resident's clothes are soiled, the staff try to accumulate a load to be laundered. The soiled items are bagged and labeled then sent to laundry. Personal laundry is not done every day. During an interview with Laundry Assistant #54 on 10/31/23 at 11:09 am he/she stated, the GNA's put the dirty laundry in a bag and place the bag in the bin located on the unit. He/she goes to the unit…

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

Based on record review and interviews it was determined that the facility staff failed to accommodate a resident with a known visual impairment with large print documents for the resident to read. This deficient practice was evident in 1(#101) of 1 resident assessed for visual accommodations during the survey. The findings include: On 10/16/23 at 1:39 pm when the surveyor asked Resident #101 did he/she participate in the Activities offered by the facility, he/she made the surveyor aware that nobody came to talk to him/her about the Activities they have to offer. He/she is unable to read the calendar because he/she needed glasses and can only read large print. On 10/30/23 3:26 pm during an interview with Activities Assistant #24 he/she reported, every month they have a committee meeting, and they find out what activities the residents like. They have basic activities daily which may include the Cafe, worship services, and listening to music. They offer 1:1 Activities with a lot of residents. They have a calendar for Activities, but it is scheduled to change. The calendar goes out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview it was determined the facility staff failed to keep the facility in a comfortable homelike environment. This deficient practice was evidenced on Unit D during the survey. The findings include: On 10/16/23 at 7:50 am during observation rounds on Unit D the surveyor observed multiple maintenance issues on the unit as well as resident dignity concerns. 1. Multiple ceiling tiles located in the main hall were peeling, two of the lights in the hallway were uncovered, and the blinds in rooms [ROOM NUMBER] were damaged. 2. room [ROOM NUMBER] did not have closet doors, personal items were in a crate, trash was on the floor in the closet (cup, paper towel, and straw). Geriatric Nursing Assistant (GNA) #39 confirmed the surveyor's findings. 3. Resident #45's call bell was hanging from a string on the wall. The top-drawer front on the dresser was missing and the resident's belongings were exposed. 4. The call bell system on the unit was not working; Director of Nursing # 13 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 staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#35) of 1 resident reviewed during the annual survey. The findings include: Review of Resident #35's medical record on 10/17/23 at 9:40am and 10/24/23 at 9am revealed on 6/22/23 the resident was transferred to the hospital for an altered mental status. Further review of the medical record failed to reveal that the resident and/or the resident representative was notified in writing of the transfer/discharge of the resident along with the reason for the transfer. During an interview with the Director of Nursing (staff #13) on 10/25/23 at 10:31am, he stated he was unable to locate any documents that the resident and/or the resident representative was notified in writing of the transfer/discharge of the resident along with the reason for the transfer. He stated that a form has now been developed to correct the issue.

Based on medical record review and staff interview it was determined the facility failed to notify the resident and/or the resident representative in writing of the bed-hold policy upon transfer of the resident to an acute care facility. This was evident for 1 resident of 5 residents (Resident # 35) reviewed during the annual Survey. The findings include: Review of the medical record for Resident #35 on 10/24/23 at 10:51am revealed that on 6/22/23 Resident #35 was transferred to an acute care facility for an altered mental status. Medical record documentation revealed that the resident representative was called, however there was no written documentation that the resident and/or the resident representative was notified in writing of the facility bed-hold policy. During an interview with the Director of Nursing (staff #13) on 10/25/23 at 10:31am, he stated he was unable to locate any documents that the resident and/or the resident representative was notified in writing of the bed hold policy. He stated that a form has now been developed to correct the issue.

Based on record review, observation, and interview with facility staff and residents, it was determined that the facility staff failed to: 1) administer medications as ordered by the physician for residents (#30, #95). This was evident for 2 of 5 residents selected for a follow-up medication chart review; and 2) follow professional standards by providing a treatment without a physician's order (Res. #102) and failing to monitor a resident's weight as ordered (Resident #123). This deficient practice was evident in 2 (#102 and #123) of 5 resident records reviewed for standards of practice. The findings include: 1.During observation rounds on 10/17/23 at 10 am, Resident #30 stated s/he does not receive his/her medications on time. Review of the (MAR) Medication Administration Record on 10/23/23 at 1pm revealed the following: 1a. Resident #30 was scheduled to receive Gabapentin 800mg(milligrams) by mouth at 1pm on 10/13/23 for neuropathy pain (nerve pain); according to the Medication Administration Audit Record, the medication was not signed off as being administered until at 2:34pm 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, record review and interviews with facility staff, it was determined that the facility failed to provide activities designed to support the physical, mental, and psychosocial well-being of the resident. This was evident for 2 (Resident #31 and Resident #50) out of 3 residents reviewed for activities. The findings include: 1. On 10/16/23 at 10:59 AM, the surveyor observed Resident #31 in their room and not receiving one-to-one (1-1) activities. In addition, on 10/17/23 between 09:30 and 10:30 AM, and on 10/18/23 between 9:30 and 11:00 AM, surveyors were on Resident #31's unit at the nurse's station with direct view of Resident #31's room; no 1-1 activities were observed with the resident and the resident was not seen being transported to activities during that time. On 10/16/23 at 2:45 PM, Resident #31's medical record was reviewed. The review revealed that Resident #31 was bed bound and entirely dependent on staff for care. The surveyor interviewed the Administrator and Activities Leader #29 (AL #29) on 10/18/23 at 02:00 PM regarding activities at 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and facility investigation documents, and other pertain information it was determined that the facility failed to provide adequate supervision to residents (#508 and #59). This was evident in 2 of 2 residents reviewed for elopement during this survey. The findings Include: 1. Review of Resident #508's medical record revealed the resident was admitted to the facility in February of 2022, with diagnosis that included schizoaffective disorder and ambulatory dysfunction. Review of the Facility Reported Incident MD00179418 on 11/13/23 at 3 pm for Resident #508, revealed on the morning of 6/23/23, at approximately 7:51am it was discovered that Resident # 508 was located outside the facility premises a few houses down from the facility sitting on a neighbor's step. A review of Resident #508's Electronic Medical Record on 11/13/23 at 3:30pm revealed that the resident has a Brief Interview for Mental Status (BIMS) score of 5, which indicates severe cognitive impairment.…

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 with facility staff, it was determined that the facility failed to follow a physician's order. This was evident for 1 (Resident #31) of 3 residents reviewed for urinary catheters. The findings include: A Foley catheter is an invasive urinary drainage device that is inserted into a patient's urethra and remains in place. It can be ordered for several reasons including to facilitate urinary drainage when a patient is retaining urine. However, catheters are associated with an increased risk of urinary tract infection as well as other adverse events and should be used only when clinically indicated and ordered by a physician. On 10/16/23 at 11:00 AM, Resident #31 was observed with a Foley catheter in place. On 10/19/23 at 1:27 PM, record review of Resident #31's electronic health record (EHR) revealed a diagnosis of neurogenic bladder, a physician's order for a Foley catheter, and a physician's order to change the Foley catheter every 4 weeks and as needed. On 10/19/23 at 1:52 PM, review of the resident's medical record revealed no…

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, medical record review and staff interview, it was determined that the facility failed to ensure a physician supervised the care of a resident as evidenced by the physician failing to evaluate if a resident admitted to the facility with a foley catheter still required to have the foley catheter in place. This was evident for 1 (#95) of 2 residents reviewed for foley catheters during the annual survey. The findings include: Observation was made on 10/16/23 at 8:16 am of Resident #95 lying in bed with a foley catheter bag lying on the floor in a covered bag. A Foley catheter is a flexible tube placed in the body which is used to empty the bladder and collect urine in a drainage bag. Review of Resident #95's medical record on 10/17/23 at 11:55 AM revealed the resident was admitted to the facility in September of 2023 from an acute care facility with diagnoses including but not limited to Acute urinary retention and type 2 diabetes mellitus. Review on 10/30/23 at 9am of the hospital Discharge…

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 staff failed to ensure the physician reviewed and addressed irregularities identified by the clinical pharmacist in a timely manner. This was evident for 3 (Resident #74, #83 and #61) of 8 residents reviewed for Unnecessary Medications. The findings include: 1. A review of Resident #74's medical records on 11/3/23 at 12:46pm revealed that Pharmacist Medication Regimen Review was conducted monthly by consultant pharmacist. On 5/9/23 consultant pharmacist recommended as below: This resident has an order for Gabapentin 300mg three times a day. The listed diagnosis is seizure control, but after review of the chart, there is no history of seizures. However, there was no documentation of physician/prescriber response to the pharmacist recommendations to agree, disagree, or other comments. As of 11/3/23 the diagnosis for the Gabapentin continued to read for seizure control. On 11/3/23 at 1:00 pm, the surveyor shared the above concerns with DON. The DON verified the findings. 2. Thyroid-Stimulating Hormone…

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 clearly establish a rationale for the administration of three Blood Coagulation medications for Resident #74. This was evident for 1 of 8 residents reviewed for unnecessary medication. The findings include: Blood Coagulation medications slow down the body's process of making clots. Medical record review on 11/3/23 at 12:46 pm revealed Resident #74 was admitted to the facility with a history of diagnoses that included but were not limited to Cerebral Vascular Accident and Deep Vein Thrombosis. Cerebral Vascular Accident (stroke) is when blood flow to part of your brain is stopped either by a blockage or the rupture of a blood vessel. Deep Vein Thrombosis (DVT)-A blood clot in a deep vein, usually in the legs. Review of the medication orders revealed a physician order dated 9/27/22 to administer the following medications. Aspirin EC Low Dose 81 MG by mouth once a day for Blood coagulation, Plavix 75 MG by mouth once a day for blood coagulation and Eliquis 5 MG by mouth two times a day for…

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

Based on medical record review, observation and staff interview it was determined the facility failed to follow prescribed dietary orders for a resident. This was evident for 1 resident (#99) out of 11 residents reviewed during the annual survey. The findings include the following: Review of Resident #99's medical record on 11/17/2023 at 11:20 AM revealed a Physician order on 10/17/2023 for Resident #99 to be served meals with paper or plastic. During observation rounds on 11/17/2023 at 12:55 PM Resident #99 was noted to be eating lunch using metal silverware. During an interview on 11/17/2023 at 01:15 PM staff (#19) stated he/she was not sure why Resident #99 was served with the metal silverware but would educate staff and counsel staff right away. After surveyor intervention, Resident #99's metal silverware was replaced with plastic silverware. On 11/17/2023 at 1:20 PM a copy of Resident #99's menu ticket that was for lunch served on 11/17/2023 and was used by the Dietary department was given to surveyor by the Director of Nursing. The menu ticket stated that Resident #99 was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility staff failed to discard spoiled perishable food and outdated dry storage items. This deficient practice was discovered during the kitchen tour during the survey. The findings include: On 10/16/23 at 8:03 am, during the initial walk through of the kitchen area, the surveyor observed a box of spoiled cucumbers, oranges with mold, and molded red onions. There was a cart of outdated turkey and cheese, ham & cheese, and salmon & cheese sandwiches. On 10/16/23 at 8:16 am, while checking the dry storage room with Certified Dietary Manager #19 the surveyor observed a bag of expired Marshmallows dated 08/24/22, 2 bags of opened cake mix that were not dated, a gallon of [NAME] Cooking wine dated 10/03/17 and four bags of expired Quick Oats hot cereal dated 09/11/23. During an interview on 11/02/23 at 12:31 pm with CDM #19 he/she reported produce is delivered once a week. He/she goes through the produce regularly to consolidate and inspect it and cucumbers…

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 staff failed to dispose the garbage and refuse properly as evidenced by garbage on the ground and the inability to close the dumpster lid. This deficient practice was discovered during the survey. The findings include: On 10/25/23 at 10:25 am, the surveyor went outside with Certified Dietary Manager #19 to access the area where the dumpsters are in the rear of the facility. The surveyor observed three dumpsters; the dumpster to the far right was overflowing with waste and the lid was unable to close. The surveyor observed waste on the ground between dumpsters number one and two. The waste on the ground was cup lids, gloves, empty juice containers, cartons of milk, and an empty intravenous medication bag with a resident's name on the sticker. On 11/13/23 at 9:38 am during an interview with EVS Director #7 who reported the floor techs have access to the dumpsters and whoever is assigned to take the trash out and the kitchen uses the same dumpsters. They have three pick-ups on a weekly basis. The days are Monday,…

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 failed to correctly store and clean medical equipment to prevent infection. This was evident in 1 out of 4 clean utility rooms observed during the annual survey. The findings include: Intravenous poles are medical devices that are designed to hang bags and tubing containing intravenous fluids or medicines which need to be administered to a resident. During observation rounds on 11/15/23 at 10:23 AM, the clean utility room located on C wing was found to have two dirty Intravenous poles with one partial used Intravenous bag containing clear fluid as well as used Intravenous tubing hanging from one of the Intravenous poles. During an interview on 11/15/23 at 10:40 AM Staff #73 stated that the dirty IV poles should not be stored in this clean location and should be cleaned after each use. After surveyor intervention, the Intravenous poles were disinfected, and the partial used Intravenous bag and tubing was discarded.

Based on observations and interviews with facility staff it was determined the facility failed to ensure that resident rooms were maintained in a homelike manner and kept clean and comfortable. This was found to be evident during observations made of 3 resident rooms observed during the survey. Findings include: An observation was made during the initial tour of the facility on 10/16/23 at 7:35 AM and the following concerns were identified: 1. While touring the 100 hallway two surveyors observed a resident room (# 111) and the closet doors were leaning inside the closet and not attached to hinges. 2. While touring the 200 hallway two surveyors observed a resident room (# 202) that had blinds that needed repair. The Administrator and DON was made aware of the concerns on 10/16/23 at 2:00 PM. 3. Another observation was made on 11/1/23 at 2:27 PM while two surveyors toured the building, of a resident room located on the left side of the 100 hallway, next to the therapy room. There was a large amount of clothes on the floor underneath the bed covering the entire area beneath the bed. An…

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

Based on observations and interviews with facility staff it was determined the facility failed to ensure that resident environment is functional and comfortable, clean and well maintained. This was found to be evident during observations made of 1 exit door and 2 shower rooms observed during the survey. Findings include: 1. An observation was made on 10/16/23 at 7:55 AM while touring the facility. Two surveyors entered the 100 hallway and noted that while walking toward the exit door located straight ahead at the end of the hallway, the area was noted to be cold. Two residents were observed with coats on while in the hallway. One of the residents reported to the surveyors that the hallway is always cold. The exit door had steps that lead directly to a gate located at the bottom of the stairway. Beyond the gate was an adjacent parking lot. During an interview with the DON on 10/16/23 at 2:00 PM he was made aware that a resident reported the hallway being extremely cold and that two residents were observed wearing coats while in the hallway. During a subsequent 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 observation and interview it was determined that the facility failed to provide adequate ventilation in the kitchen as evidenced by condensation dropping from the ceiling when the steamer was used. This deficient practice was discovered during the facility's survey. The findings include: On 10/16/23 at 12:58 pm, the surveyor entered the kitchen with Certified Dietary Manager #19 and observed condensation falling from the ceiling over the steamer and the entry point of the kitchen. The ceiling tile above the steamer was buckled and the ceiling tile near the plate warmer was damaged. On 11/02/23 at 12:31 pm, during an interview with CDM #19 he/she expressed concerns about the ventilation to the maintenance department and was told it was not an issue via the Fire Marshall and the Regional District Manager told him/her it was not an issue but now that they know it's a problem they are going to work on correcting the issue.

Based on medical record review and interview with staff, it was determined the facility staff failed to provide a written notice for emergency transfers to the residents, residents representative and the ombudsman. This was found to be evident for 4 out of 5 (#61, #84, #86, #90) residents reviewed for a facility-initiated transfer during the investigative portion of the survey. The findings include: Review of Resident #90's electronic and paper medical record on 9/09/21 at 8:30 AM revealed that, on 7/15/2021, Resident #90 was transferred to the hospital for a change in medical condition. Further review of Resident #90's medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party, ombudsman and/or resident was notified in writing of the hospital transfer. An interview was conducted with the Social Worker on 9/09/21 (staff #12) at 10:41 AM she/he indicated that she/he was not aware that she must report transfers or discharge to the ombudsman or to notified the resident or resident's responsible…

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 a resident had a complete and accurate Preadmission Screening and Resident Review (PASRR). This was evident for 2 (#61 and #73) out of the 61 residents that were reviewed as part of the survey process. The findings include: The Level I Pre-admission Screening and Resident Review (PASARR) must be completed by either the nursing facility or the referring doctor for every individual who will be admitted to a nursing facility to identify individuals who may have Mental Illness (MI), Intellectual Disability (ID), and/or Related Condition (RC). The nursing facility is responsible for ensuring that a Level I screen is completed for everyone prior to admission. The PASRR determines whether an individual, who has an active diagnosis of Mental Illness (MI) or Intellectual/Developmental Disability (ID/DD), meets the criteria for admission to a nursing facility and may require specialized services. PASARR is required for all persons seeking admission to Medicaid certified nursing…

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 with resident and facility staff and medical record review, it was determined that the facility failed to 1. be able to identify all residents that are identified as smokers in the courtyard, 2. provide a safe smoking environment for residents. 3, complete assessments related to a resident's smoking status and therefore needs related to smoking. This was evident for 4 of 4 (#6, #51, #104 and #112 residents observed and reviewed for safe smoking. The findings include: 1. During an observation of residents smoking in the courtyard on 1/3/2021 at 1:17 PM, 2 residents identified as #6 and #51 were identified as having cigarettes in their own possession. Resident #6 and #51 had entered the courtyard at the same time and remained by the entrance. Resident #6 had a cigarette in his/her mouth, lit and was actively smoking when staff # 20 came up with a cigarette for Resident #51 and lit his/her cigarette. Staff #20 did not question Resident #6 where his/her cigarette came from. Staff #6 was asked if she knew everyone who was out in the courtyard and she…

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

Based on interview residents and staff and medical record review, it was determined that the facility failed to provide residents with needed Social Work services and assistance to attain their highest wellbeing. This was evident during the review of 2 of 61 residents (# 34 and #6 ) reviewed during the annual survey. MOLST Maryland order for Life Sustatining Treatments is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient ' s wishes about medical treatments. The findings include: 1. During the review of the medical record for Resident #34 surveyor noted that a MOLST was on file stating that s/he was a Do not intubate in the event of a code as per the surrogate decision maker. Surrogate paperwork regarding Resident #34 was requested on 9/7/2021 at 1:14 PM. The paperwork was requested again on 9/8/2021 at 8 AM and on 9/8/2021 at 1:14 PM. On 9/9/2021 the facility social work (SW) director/designee stated that there was no paperwork. She further 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.

Based on resident interview and a test tray from the kitchen, it was determined that the facility failed to ensure palatable meals are served. The findings include: 1. Resident #6 was interviewed on 9/1/21 at 10:25 AM. The resident stated, the food sucks. 2. Resident #61 was interviewed on 9/1/21 at 11:17 AM. The resident stated It sucks. I have to order out every day. 3. Resident #86 was interviewed on 8/31/21 at 10:22 AM. The resident said the food was awful. The survey team ordered two test trays: a regular and a lacto-ovo vegetarian. The food trays were received on the unit at 12:22 PM on 9/9/21. The trays were taken by the team at 12:26 PM, the same time the residents were to receive their trays. The team checked the temperatures and tasted the food. The results of the temperature check were: Grilled ham and cheese - the temperature was 118 degrees Fahrenheit (F) cranberry juice - the temperature was 42 degrees F nutritional juice - the temperature was 48 degrees F No double portions on tray as ordered for the resident. Grilled cheese - the temperature was 80 Degrees F Noodles…

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 8/31/21 at 8:30 AM,a tour of the facility's main kitchen was conducted with the Food Service Manager (Staff #58) and the following was observed: 1. In the refrigerator, surveyor identified Italian sausage label with a use by date of 8/22/21. 2. In the refrigerator, surveyor identified ground beef label with a use by date of 8/22/21. 3. In the refrigerator, surveyor identified cherry pie filling with a use by date of 8/21/21. 4. The hand washing sink in the kitchen had a buildup of debride in the sink and drain. 5. The sugar container had the scoop inside. 6. The trash can by the hand sink was dirty with black marks and food debris. 7. An empty rice container was observed with debris of rice and brown/ orange and yellow spots…

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 pertinent facility documents and interview with facility staff, it was determined that the facility failed to have an updated facility assessment that included information relevant to the services provided and the needs of the residents. The findings include: Initial review of the facility assessment on 9/8/2021 at 7:55 AM revealed a title page identifying the 'Facility Assessment Tool for Blue Point 11/2019 through 10/2020. However, after further review of the assessment, the data in the assessment was for October 1, 2016- September 30, 2017. This was brought to the attention of the DON on 9/8/2021. Staff #22, the Rehab manager was interviewed on 9/8/2021 at 11:17 AM regarding the identified therapy vendor in the facility assessment. He stated that, as of 2019, the identified therapy vendor in the assessment changed and there was a new therapy vendor in place. Additionally at that time, the facility DON, and staff #7, the Regional Clinical director of operations were interviewed and confirmed that the laboratory and X-ray services that were identified in the…

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

Based on facility staff roster and staff interview, it was determined that the facility had a bed capacity of 135 and did not employ a qualified social worker from March 2021 to the present on a full-time basis. This deficient practice was found during an annual survey and has the potential to affect all residents. The findings include: Interview with the social work director (staff #12) on 9/2/2021 at 10:00 AM revealed that the facility social worker department only employed the director and an assistant. Staff #12 stated that none of the social worker staff, including him/herself, had the educational credentials as a qualified social worker. Staff #12 further stated that the facility had a contract with a qualified social worker that reviewed the social work documents/records monthly by telephone. On 9/2/2021 at 11:30 AM, the surveyor interviewed the Administrator and the Director of Nursing regarding the contract with the social worker consultant. The Administrator stated that the social worker consultant was employed by the facility since September 2020. The Administrator also…

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

Based on observation, interviews, and policy review, it was determined that the facility staff failed to adhere to appropriate standard and transmission based precautions to help prevent the spread of infection. This was found to be true for 1 (LPN#16) of 2 licensed staff members observed on one unit in the facility during the Medication Administration Observation conducted during the survey. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. Findings include: On 5/4/2021, The Maryland Department of Health (MDH) Secretary issued an amended Directive and Order Regarding Nursing Home Matters. The 5/4/21 Directive and Order, finding it necessary for the prevention and control of 2019 Novel Coronavirus (SARS-CoV-2 or 2019-NCoV or COVID-19), and for the protection of the health and safety of patients, staff, and other individuals in Maryland, hereby authorize and order the following actions for the prevention and control of this infectious and contagious disease under the Governor's Declaration of Catastrophic Health Emergency. 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 tour of the facility, observation, and interview with facility staff, it was determined that the facility did not have a designated location that would accomodate all residents for dining. The findings include: During tour of the facility on 9/9/2021 at 11:45 AM during the observation of lunch, it was determined that there was no designated location where all residents could dine outside of their rooms if they chose. The facility Administrator was interviewed on 9/9/2021 at 12:10 PM. The surveyor raised the concern that the facility was not able to provide a location for all residents to dine outside their rooms if they chose. She stated that the facility was in the process of remodeling. There was a small room on each floor where residents could dine outside of their rooms, however, it was not large enough to accomodate all residents living on the floor. The Administrator further verbalized concern related to COVID-19 and having a communal dining room; however, the facility was not in outbreak status and secondary to the current community positivity rate <5% 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 observation and staff interview, it was determined that the facility failed to ensure that the facility maintained an adequate amount of potable emergency water available. This was evident during the facilities annual survey. The findings include: Potable water on hand is calculated at 1 gallon per resident (total bed capacity) x 3 days. The total bed capacity was 135 at 3 gallons which would be a total of 405 gallons needed on hand. On 9/2/21 at 11:45 PM, the facility's emergency water storage was observed to have 240 gallons of potable water on hand; 165 gallons short of 1 gallon per resident per day for 3 days. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 9/14/21.

Based on observation and staff interview, it was determined that the facility staff failed to ensure that a handrail was secured to the wall. This was evident for 1 resident area observed during the survey. This deficient practice has the potential to affect all residents, staff, and visitors on the unit. The findings include: On 08/31/21 at 09:08 AM during a tour of the facility, it was observed the handrail was misisng outside of elevator #1 to the left . The wall was noted with holes where the handrail was once secured. On 9/7/21 at 11 AM, during a tour of the facility, it was noted that the wall outside of elevator #1 was covered with 8 x 10 paper signs covering where the handrail was once secured. On 9/7/21 at 1 PM, an interview with the Regional Director of Clinical Operations was made aware of these findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, it was determined that the facility staff failed to ensure that residents received at least two showers each week as requested and that the facility failed to provide the opportunity for residents to participate in resident council meetings. This was evident for 1(#39) out of 4 residents reviewed for choices as part of the survey process and was found to be true for 9 (# 27, #26, #86, #24 #72, #76, #32, #68, and #31) of 61 residents observed for resident council and grievance process during an annual survey. The findings include: Resident #39 was interviewed on 8/31/21 at 10:43 AM. The resident stated that he/she does not get weekly showers. Resident would like showers every week but has only received one in the past month. A review of the clinical record on 9/13/21 revealed that, during the past 30 days, the resident received a shower on 8/21/21. The resident received bed baths on 8/18, 8/25, 8/28, 9/1, 9/4, 9/8, and 9/11. The Director of…

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

Based on observation and interview, it was determined that the facility staff failed to display the results of the most recent annual recertification survey and plan of correction in a place readily accessible to residents, family members and legal representatives of residents. This was evident for 1 of 1 survey results book posted in the facility. The findings include: Surveyor observation of the lobby on 8/31/21 and 9/1/21 revealed no evidence of the state inspection results in an open and readily accessible area for residents, staff, and visitors to review and a tour the facility did not reveal any signs posted that indicatedwhere the state survey results were located. The surveyor asked the receptionist (staff #15) where the state inspection results were, and the receptionist presented a white binder that was located behind the desk of the receptionist which contained the results of the survey inspections. It is the expectation that the results of survey inspections (both complaint and annual) be placed in an open, easily accessible location and labeled so that interested…

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 failed to ensure that a resident admitted with a history of abuse of a vulnerable individual had their whereabouts and interactions monitored. This was evident for 1 (Resident #6).out of 61 residents reviewed as part of the survey process. The findings include: A review of Resident #6's clinical record on 9/8/21 revealed that the resident was admitted with a history of abuse of a vulnerable individual. The resident had a psychological consult on 6/4/21 and there was no mention of the abuse. The nurse assigned to the resident (Staff #8) was interviewed on 9/8/21 at 10:17 AM. Staff #8 said the resident does leave the room and usually goes to the courtyard to sit and/or smoke. Resident #6 did not go down to the lower level of the facility to the best of their knowledge. The resident did not have a behavioral monitoring program, nor were staff expected to observe the resident's whereabouts. The social worker (Staff #12) was interviewed on 9/8/21 at 10:31 AM. She said Resident #6 was a laid back…

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

Based on observation, medical record review and interview, it was determined that the facility failed to provide a comprehensive care plan that included smoking interventions. This was found to be true for 2 of 61 residents (#95 and #104) reviewed for care plan accuracy during an annual survey. Care Plan - This term refers to a document which is the written plan of how a long-term care facility will provide care. This plan is based on resident health assessments, preferences, and goals. The findings include: 1. On 8/31/2021 at 1:30 PM, Resident #95 was observed during the facility scheduled smoking time. Resident #95 had an excessive amount of cigarette ash on his/her clothing and wheelchair. Another resident was assisting the resident #95 with holding the cigarette to his/her mouth. Review of resident #95's medical records on 9/1/2021 at 7:10 AM revealed that the resident hadn't received a smoking assessment since admission, 7/15/2021. On 9/2/2021 at 9:54 AM, interview with the rehabilitation manager (Staff # 22) revealed that resident #95 had a weakness on the right side, but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to update Resident # 104's care plan to address actual skin impairment (pressure ulcers). This was evident for 1 of 2 residents reviewed for pressure ulcer/ injury. A Pressure Ulcer is any lesion caused by unrelieved pressure that damages the underlying tissue(s). Although friction & shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. Pressure (decubitus) ulcer stages are as follows: Stage I - Intact skin that is red or discolored. Stage II - A partial-thickness loss of skin involving the outer and inner layers of the skin Stage III- the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone. Stage IV- the pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may…

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 discharge plans were made for residents that were given thirty-day discharge notices. This was evident for 2 (#61 and #86) out of 61 residents reviewed as part of the survey process. The findings include: 1. A review of Resident #61's clinical record revealed that the resident was given a thirty-day discharge notice on 5/14/20. There was no discharge plan to determine what support the resident would need. The Administrator was interviewed on 9/13/20 at 7:33 AM. She was notified of the lack of a discharge plan. 2. A review of Resident #86's clinical record on 9/13/21 revealed the resident was given a thirty-day discharge notice on 2/12/20. There was no discharge plan to determine what support the resident would need. The Administrator was interviewed on 9/13/20 at 7:33 AM. She was notified of the lack of a discharge plan. No further evidence was presented to the team prior to exit.

Based on resident interview, staff interview, observation, and clinical record review it was determined that the facility staff failed to ensure a resident's activities of daily living (ADL) was carried out (Resident #39). This was evident for 1 out of the 61 residents reviewed as part of the survey process. The findings include: Resident #39 was observed to have long fingernails on both hands on 8/31/21 at 10:57 AM. On 9/10/21 at 9:24 AM the resident's fingernails were observed to be long. The resident was asked if long fingernails were a preference or did, they need to be cut. Resident expressed a desire to have the nails cut. The Director of Nursing was interviewed on 9/10/21at 10:57 AM. He was informed of the findings.

Based on medical record review and interview with facility staff, it was determined the facility failed to; 1) to perform a preventive physician order for turning and repositioning for (Resident # 104), and 2) consistently obtain weights for the resident as ordered by the physician. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Morbid Obesity. Morbid (Severe) Obesity is an abnormal or excessive fat accumulation that presents a health risk. During a facility tour on 8/31/21 at 6:50 AM on Unit A, the surveyor observed resident # 104 lying flat on his/her back in bed, with face upward, while (GNA #3) provided bedside care to the resident. GNA #3 after completing the task, was observed walking out of the resident's room, leaving the resident lying flat on his/her back. At 09:42 AM, the surveyor performed a second observation, during which the resident # 104 was noted lying flat on his/her back, facing upward. Further observation at 11:04 AM found 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 interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure a resident who had the need for new glasses received new glasses or was seen by an audiologist for routine services. This was evident for 1 out of 4 residents reviewed for communication and sensory issues. The findings include: Resident #61 was interviewed on 9/1/21 at 10:58 AM. Resident stated that glasses were ordered two years ago but have not been delivered. Resident #61 also said that it has been more than two years since the last hearing exam. A review of Resident #61's clinical record revealed that the resident had two eye exams: 11/21/18 and 1/21/20. Both of the exams recommended that glasses be obtained. The Director of Nursing (DON) was interviewed on 9/13/21 at 2:01 PM. The information regarding the need for glasses and the lack of an audiological exam was shared with the DON. No evidence of glasses being purchased or that audiological exams were obtained were presented to the team prior to exit.

Based on surveyor observation, review of the medical record and an interview with facility staff it was determined the facility staff failed to ensure that the oxygen tubing and humidification bottles were date labeled to ensure timely replacement to minimize risk of infections. This was evident for 1 of 2 residents observed (resident #75). Findings include: 09/01/2021 11:42 AM Resident #75 was observed lying in bed on his right side looking towards the doorway. Surveyor observed that the O2 meter on the concentrator was set at 3.5 liters/minute. The label on the humidifier bottle that was connected to the oxygen tubing was label with the date of 08.24.2021. 09/01/2021 11:43 AM the resident stated that sometimes he changes his own tubing and humidifier bottle because the staff forget. Also, during an interview the resident he stated that he had using oxygen for two years. On 09/0202021 at 08:02 AM the surveyor observed that Resident #75's oxygen humidifier bottle had not been changed and the tubing to the humidifier was labeled with the date of 08.24.2021. On 09/02/2021 at 8:47 AM…

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

Based on multiple observations, interviews with resident and staff and medical record review, it was determined that the facility failed to monitor the administration of a resident receiving a nicotine patch and cessation of smoking. This was evident for 1 of 2 (#51) residents reviewed observed during smoking times identified with nicotine patches. The findings include: On 9/3/2021 at 1:20 PM, Resident #51 was observed outside smoking. S/he was noted with his/her own cigarettes and lighter in addition to receiving a cigarette from the activities staff #20, who was in the courtyard to monitor residents. At 1:39 PM on 9/3/2021, this observation was reported to the DON. On 9/7/2021 LPN staff #8, was interviewed at 9:17 AM. She showed the surveyor his /her documentation on the medication administration record that Resident #51's nicotine patch was administered this morning. At 9:30 AM on 9/7/2021, Resident #51 was observed going outside to the courtyard during the smoking break. Resident #51 was observed smoking and was asked if s/he would show me his/her left shoulder and s/he…

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 a resident was free of unnecessary medications (#79). This was evident for 1 out of 1 resident reviewed for unnecessary medications. Medical record reviewed for Resident #79 revealed on 7/28/2021 the physician ordered: clonazepam Give 0.5 mg by mouth at bedtime for Anxiety (Clonazepam is a benzodiazepine medication for the treatment of panic disorder). Anxiety is a nervous disorder characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior or panic attacks and can be displayed by various behaviors or verbalizations; Trazodone HCl Tablet 50 MG Give 1 tablet by mouth at bedtime for Depression with Insomnia was also ordered by the physician (Trazodone is a psychotropic medication used to treat depression). Medical record reviewed on 9/3/21 at 1 PM, revealed the facility staff failed to clearly identify target symptoms for the administration of psychotropic and anxiety medications and establish a plan for the ongoing monitoring…

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 medication administration observation, medical record review, and staff interview, It was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 3 (#72, # 84, and # 85) of 7 residents observed during 36 medication administration opportunities resulted in an error rate of 11.11%. Findings included: The surveyor observed medication administration on [DATE] and noted that LPN # 16 carried out her med pass for Resident # 72 at 0832 AM on [DATE]. Resident #72 missed the Vita D 2000mg Cholecalciferone dose due at 0900 as the medication was not located in two of two medication carts and was considered a missed dose. 2. The surveyor observed LPN # 16 performingmed pass at 09:19 AM on [DATE] for Resident #84. The resident did not receive the I-vite Multivitamin tablet due at 0900 as the medication was not located in two of two medication carts checked by staff # 16, therefore a missed dose occurred due to the unavailability of the medication. 3. LPN #16 performed the…

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

Based on observation, interviews, and medical record review, it was determined that the facility failed to provide dental services within a reasonable time frame following a physician's dental consult request. This was found to be evident for 1 out of 3 residents (Resident #104) reviewed for dental. The findings include: During the interview on 8/31/21 at 10:23 AM, Resident #104 stated that his/her lower-middle tooth was broken and painful. The resident stated that s/he has been on pain medication for the toothache for a while, but the pain had worsened. The surveyor observed that the resident's lower-middle tooth was visibly broken. The resident stated that s/he had requested multiple times to be seen by a dentist, but had not been seen. On 9/1/21 at 12:42 PM, a review of the Resident # 104's physician's order revealed a dental consult ordered on 6/22/21 at 1:44 PM for a dental appointment for toothache. Further review of physician orders revealed a dental consult ordered on 7/28/21 at 4:44 PM for a dental appointment for toothache. During the interview on 09/07/21 01:19 PM 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 interview, it was determined the facility staff failed to maintain a medical record in the most accurate form for a resident (# 113 and 52). This was evident for 2(# 113 and 52) of 61 residents reviewed in the survey process. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Resident #113 was discharged from the facility on 6/15/2021. On 8/19/2021, 2 months after discharge, a comprehensive skin and wound evaluation was completed for Resident #39 and the information was recorded in the medical record for Resident #113. The inaccurate medical record assessment was confirmed with the Director of Nursing on 9/3/21 at 11:42 AM. 2. On 9/8/2021 at 12:50 PM, Resident #52 explained that s/he was unable to receive billing records from the facility when requested. Resident #52 was unsure if…

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.