Carroll Park Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record reviews and staff interviews, it was determined that the facility failed to complete a comprehensive assessment within 14 days of a significant change in the resident's condition. This was evident for 1 (Resident #11) of 6 residents reviewed for Minimum Data Set( MDS) assessments during the facility's recertification/ complaint survey. The findings include:The Minimum Data Set is a federally mandated, standardized assessment tool used in skilled nursing facilities to comprehensively assess a resident's clinical and functional status. The Minimum Data Set is used to develop individualized care plans, monitor quality of care, and determine Medicare reimbursement.On 05/11/2026 at 10:55 AM, during the facility tour, the surveyor observed Resident #11's bed in the lowest position. During an interview with the resident, he/she stated that he/she had experienced a fall some time ago.On 05/13/2026 at 11:02 AM, review of Resident #11's electronic health record showed a nursing progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that facility staff failed to accurately code the resident's status on the Minimum Data Set assessment. This deficient practice was identified for 2 (Resident #100 and #2) out of 6 residents reviewed for Minimum Data Set assessments.The MDS is a federally mandated, comprehensive, standardized clinical assessment tool of all residents in Medicare/Medicaid nursing homes that evaluates functional capabilities and health needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care that they need. The findings include: (1) On [DATE] at 9:49 AM, during the review of complaint 2977960, it was noted in Resident #100's electronic health record that he/she was readmitted to the facility on [DATE] and transferred to the hospital via Emergency Medical Services (EMS) on [DATE]. On [DATE] at 11:31 AM, review of progress notes in Resident #100's electronic health record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, it was determined that the facility failed to implement a care plan with interventions regarding Resident #66's indwelling catheter. This was evident for 1 (Resident #66) out of 1 residents reviewed for urinary catheter. The findings include: On 05/11/2026 at 9:15 AM, during screening Resident #66 was observed to have an indwelling foley catheter. Resident #66 stated that he/she utilizes a foley catheter all the time and his/her foley catheter was changed during his/her recent hospitalization. On 5/12/26 at 12:48 PM, during a review of Resident #66's EMR (electronic medical record) the surveyor noted that Resident #66 was diagnosed with paraplegia and neurogenic bladder requiring chronic catheterization. Review of Resident #66's most recent hospitalization discharge summary documented that Resident #66 was transferred from the facility on 5/2/26 to the hospital, where Resident #66 was diagnosed with acute pyelonephritis (bacterial infection of the kidney),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to provide care in accordance with the standards of practice, when Resident #28 was documented to not have a stool for 8 days (from 05/03/2026 to 05/10/2026) and no PRN bowel protocol medications were ordered or administered nor were abdominal assessments documented in the progress notes as per facility policy. This was evident for 1 (Resident #28) out of 18 residents reviewed for quality of care. The findings include: Facility's Bowel Management Protocol Policy and Procedure: Purpose- To establish a standardized bowel management protocol to prevent constipation, fecal impaction, avoidable hospital transfers, discomfort, and bowel-related complications. Policy- Residents shall receive individualized bowel management based on assessment findings, diagnosis, medications, risk factors, providers orders, and clinical condition. Nursing staff shall proactively monitor bowel function and intervene timely.High risk residents; includes 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 record review and interview, it was determined that the facility failed to have the provider respond to Medication Regimen Review recommendations in a timely manner. This was evident for 3 (Resident #2, #8 and #63) out of 5 residents reviewed for unnecessary medications.Facility 's Medication Regimen Review (MRR) Policy and Procedure. It is the policy of this facility that each resident's medication regimen shall be reviewed by a qualified consultant pharmacist at least monthly, and more frequently as clinically indicated, to identify medication irregularities, unnecessary medications, adverse outcomes, monitoring deficiencies, and opportunities for optimization.POLICY STANDARDS: 1. Every resident shall receive a monthly medication regimen review. 2 Medication irregularities shall be promptly reported. 3. Provider responses shall be documented. 4. Recommendations shall be tracked through resolution. (reviewed November 2025) The findings include: (1) On 5/11/2026 at 1:38 PM, record review revealed that…

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

Based on record review and observation, it was determined that the facility did not ensure that enhanced barrier precautions were maintained while Resident #28 received wound care on 05/12/2026. This was evident for 1 (Resident #28) out of 2 residents reviewed for pressure ulcers. The findings include: Facility's Enhanced Barrier Precautions (EBP) Policy and Procedure. Enhanced Barrier Precautions are intended to reduce transmission of multidrug- resistant organisms through the appropriate use of gowns and gloves during high-contact resident care activities for residents at increased risk of transmission. Multidrug-Resistant Organisms (MDRO): Organisms resistant to multiple antimicrobial agents, including but not limited to: MRSA, VRE, ESBL-producing organisms, CRE, Candida auris and other organisms identified by public health authorities. High-Contact resident care activities requiring gown and gloves- Staff shall wear gown and gloves during the following care activities for qualifying residents: dressing assistance, bathing or showering. wound care. (reviewed November 2025) 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 interviews it was determined that the facility failed to ensure a resident was free of abuse. This was evident for 1(Resident # 3) out of 1 resident reviewed for abuse during the complaint survey The Findings include:Record review was conducted on 3/2/26 at 10:30 AM for a facility reported incident # 2735744. The record review revealed that GNA # 5 and Resident # 3 got into an argument regarding clothes on 2/4/26. During an interview conducted on 03/2/26 at approximately 10:45 AM, the Director of Nursing (DON) reported that on 2/4/26 Resident # 3 threw his/her IPAD and snack tray at GNA # 5. The GNA caught the snack tray and slammed the tray down on top of Resident # 3's hand which was laying on the nurses desk. Resident # 3 sustained a broken fingernail. GNA #5 was sent home pending investigation and GNA #5 was later terminated. Her name was sent to the Maryland Board of Nursing. The DON was notified 2/4/26 at 5:45PM and administrator was notified on 2/4 26 at 5:35 PM. Resident #3 was assessed head to toe with no injuries except for a broken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to store and process linens to prevent the spread of infection This was evident for 1 out of 1 observation made in the facility's laundry room. The findings include: On 11/25/2025 at 1:06 PM, an observation upon entering the laundry room hallway (which is a common hallway used by staff) revealed the door to the clean laundry room from the common hallway was propped open all the way, with a large fan in the doorway, which was on and faced the inside of the room (blowing air from the common hallway into the clean room). There were staff actively folding clean linen. Further observation at the same time revealed clean laundry (consisting of towels, reusable bed pads, comforters, sheets, resident gowns, and blankets) which was folded and stacked on an entire linen cart full (which was not covered). There was also clean linen folded and stacked on top of the linen cart across the width of the cart and approximately 3 layers high (all of the linen being exposed). In addition, in the same clean laundry room…

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

Based on interviews and medical record review it was determined that the facility failed to honor the resident's preferences of getting showers. This was evident for 1 (Resident #84) of 1 resident reviewed for choices during the survey. The Findings Include: On 11/20/2025 at 12:33 PM, Resident #84 expressed a concern that they had not received a shower since being moved to the second floor in early November. The resident stated that they have only been provided with bed baths and that a physical shower has not been done. On 1/21/2025 at 11:07 AM, review of the resident's Annual MDS from 2/3/2025, under section F- Preferences, revealed that during an interview with the resident for daily/activity preferences it is very important that the resident is able to choose how they are bathed. On 11/21/2025 at 11:36 AM, review of the second floor shower logs failed to reveal shower forms filled out for the resident in the month of November. On 11/21/2025 at 11:50 PM, in an interview with Staff #8, Geriatric Nursing Assistant (GNA), she stated that when a resident gets a shower the expectation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff failed to ensure an advance directive was on file for a resident. This deficient practice was evident for 1 (#75) of 4 residents review for advance directive during the annual survey.The findings include: On 11/20/2025 at 1:43 PM, during an interview with the Director of Social Services (SW) #3, she stated that she began working at the facility October 2025. When asked about the process for newly admitted residents regarding advance directives, she explained that a resident should have an advance directive either prior to admission, at the time of admission, or be offered the paperwork during the care plan meeting. When questioned about Resident #75's advance directive, she stated she would follow up with her team to obtain the information. On 11/21/25 at 8:27 AM, a review of Resident #75's medical record revealed a social service assessment dated [DATE], in which the social worker documented that the resident has an advance directive…

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

Based on record review and interviews, it was determined that the facility staff failed to provide evidence that a level 1 preadmission screening and resident review (PASARR) was completed prior to admission, or at the time of admission for a resident with a mental disability. This deficient practice was evident for one resident (#47) reviewed for PASARR during the annual survey. The findings include: The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders, intellectual disabilities and related conditions. This initial screening is referred to as Level I Identification of individuals with MD or ID and is completed prior to admission to a nursing facility. The purpose of the Level I pre-admission screening is to identify individuals who have or may have MD/ID or a related condition, who would then require PASARR Level II evaluation and determination prior to admission to the facility.On 11/20/2025 on 11:33 AM, during a review of Resident #47's medical records, the documents indicate that the resident…

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

Based on interviews and record reviews, it was determined that facility staff failed to ensure the resident's discharge planning needs were addressed and failed to follow up on the resident's request for discharge. This deficient practice was evident for one (#52) resident reviewed for discharge planning during the annual survey.The findings include:On 11/19/25 at 7:46 AM, during an interview with Resident #52, the resident expressed concerns about their discharge plans and stated that they had not participated in a care plan meeting in quite some time.Review of Resident #52s medical record on 11/19/2025 at 11:36 AM revealed a care plan conference note dated 07/31/25. The social worker documented that the care plan meeting was held with the resident and interdisciplinary team. During the meeting, the resident inquired about possibly being discharged at some point. The social worker noted that they would look into the waiver program for the resident.Further review of the records revealed a social services progress note dated 09/30/25, which failed to show any evidence that the social…

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

Based on record review and interviews it was determined that the facility failed to conduct quarterly care plan meetings. This was evident for 2 (Resident #3 and Resident #52) out of 3 residents reviewed for care planning. The findings include: Care plan meetings are scheduled quarterly (every 3 months) discussions where the healthcare team and the resident or resident representative review the resident's current condition, discuss goals, and update the care plan to ensure it meets the residents needs. These meetings help everyone stay on the same track, address concerns, and coordinate appropriate, effective care. 1) On 11/19/25 at 7:46 AM, during an interview with Resident #52, the resident expressed concerns about their discharge plans and stated that they had not participated in a care plan meeting in quite some time. Review of Resident #52s medical record on 11/19/2025 at 11:36 AM revealed a care plan conference note dated 07/31/25. The social worker documented that the care plan meeting was held with the resident and interdisciplinary team. During the meeting, the resident…

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

Based on observations, record reviews, and interviews, it was determined that the facility failed to maintain professional standards of practice by 1) ensuring a resident with congestive heart failure (CHF) had their weights adequately monitored, and 2) maintaining correct medication administration documentation. This deficient practice was evident for 1 (#75) of 1 resident reviewed for professional standards of practice and 2 (Resident #22 and #18) out of 6 residents observed for medication administration during the annual survey.The findings include: 1) On 11/19/2025 at 12:51 PM, a review of Resident #75s medical record showed that the resident was admitted in June 2025 with multiple diagnosis including CHF. Further review of the Treatment Administration Record (TAR) revealed an order initiated on 06/10/2025 for weekly weights every Wednesday. The record revealed that staff signed off that weights were obtained, but the weight section was marked with an x, indicating no weight was recorded on 10/01/2025, 10/08/2025, 10/15/2025, 10/22/2025, 11/05/2025, and 11/12/2025. A new weight…

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

Based on interview and medical record reviews, it was determined that the facility failed to provide treatment/services to maintain vision. This was evident for 1 (Resident #2) of 2 residents reviewed for vision during the survey. The Findings Include: On 11/19/2025 at 8:24 AM, during an interview with Resident #2, they stated that they had itchy scratchy eyes. They stated that they had not seen an eye doctor. On 11/21/2025 at 8:31 AM, a review of the resident's medical records revealed that on 6/6/2025 an order was placed for ophthalmology consult for decreased vision, on 9/4/2025 an order for an ophthalmology consult for an eye evaluation, and on 10/10/2025 there was an order placed for an ophthalmology consult. On 11/21/2025 at 9:12 AM, the medical provider visit notes were reviewed. The physician note on 5/28/25 stated that the resident requested to be seen by an ophthalmologist. The provider stated that an order would be placed. Physicians note from 9/4/25 stated that the resident was seen per nursing request related to seasonal allergies with itchy watery eyes and that…

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

Based on observations and record review, it was determined the facility failed to maintain an effective pest control program. This had the potential to affect all residents. The findings include: On 5/12/25 at 6:25 AM, An observation was made in the facility lobby, hallway, and conference room. 1 large black and brown insect was observed in the conference room, 1 large black and brown insect was observed in the hallway of the 1st floor, 1 large black and brown insect was observed on the hallway of the 4th floor, and 1 large black and brown insect was observed in the Lobby. On 5/12/25 at 7:00 AM, the facilities pest control logs were reviewed. Based on log documentation, multiple roach sighting. 12/5/24- 12/11/24 and treated on 12/13/24. Multiple roach sightings were reported on 12/15/24 through 12/20/24 and treated on 12/27/24. A roach sighting was reported on 12/30/24 and treated on 1/10/25. On 5/12/25 07:20 AM, a review of Facility Reported Incident #MD00204936 from 4/23/24 was conducted. A report was made to the Office of Health Care Quality of a Bedbug sighting in the Lobby 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 failed to maintain records of investigation documentation. This was evident for 2 (Resident #38 and #53) out of 10 residents reviewed for facility reported incidents. The findings include 1.) On 5/7/25 at 2:19 PM, Facility Reported Incident #MD00206207 was reviewed. It was reported that Resident #53 alleged that $70 was stolen from their possession. On 5/8/25 at 1:00 PM, the facilities investigation of Resident #53's money was reviewed. The investigation file contained only the initial and follow-up self-reports that were submitted to the Office of Health Care Quality. On 5/8/25 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). When asked if the investigation file provided was the complete investigation for Resident #53's incident, the DON stated, Yes, that is all we have. When asked if they were able to provide any statements, interviews, in-services, or education from this investigation, the DON stated that what was in the file is all they had. The surveyor requested 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 review of facility investigation and interview with facility staff, it was determined that the facility failed to ensure that a resident remained free of abuse. This was evident for 1 (MD00216920) of 46 Facility Reported Incidents (FRIs) reviewed during an annual survey. The findings include: On 05/13/25 at 9:37 AM, review of facility documentation provided by the facility for MD00216920 revealed that in the early morning of 4/21/25, Resident #23 alleged Geriatric Nursing Assistant (Staff #36) was providing care to them, and Resident #23 told Staff #36 to stop and leave the room. Staff #36 continued to provide care despite the resident's request to stop. On 05/13/25 at 9:39 AM, further review of MD00216920, revealed a written statement from Geriatric Nursing Assistant (Staff #37) stating she was present during the incident. Staff #37 indicated in their written statement that Resident #23 told Staff #36 to stop and get out, but that Staff #36 continued to provide care. Further review of the facility documentation for MD00216920 at the same time revealed that Resident #23's…

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

Based on review of records and interviews, it was determined that the facility failed to implement its abuse policy. This was evident for 1 (Resident #61) of 5 residents reviewed for abuse allegations. The findings include: On 5/12/2025 at 10:56 AM, a review of the facility reported incident (MD00199361) was conducted. The review revealed an allegation of physical abuse towards Resident #61 on 11/9/2023 at 3:30 am. The alleged perpetrator was Staff #19, date of hire 8/22/23. On 5/12/2025 at 11:26 AM, an interview with Resident #61 was conducted. When asked about the incident, Resident #61 stated that s/he called the police that day and that the police officer had told him/her that Staff #19 was working on another unit. On 5/12/2025 at 1:26 PM, facility was asked to provide Staff #19's Timecard for 11/9/23. On 5/13/2025 at 10:37 AM, the requested timecard was received. Review of this document indicated that Staff #19 clocked in at 11:10 pm on 11/8/23 and clocked out at 7:08 am on 11/9/23. On 5/13/2025 at 10:47 AM, a brief interview with the Human Resource Director was conducted. 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 record review and staff interviews, the facility failed to report (1.) unusual occurrences, (2.) allegations of abuse in the required timeframe and (3.) allegations of abuse to a law enforcement agency. This was evident for 3 (Resident #58, #59 and #90) out of 10 residents reviewed for facility reported incidents. The findings include: 1.) On 5/09/25 at 10:11 AM, a review of Facility Reported Incident #MD00216808 was conducted. The incident report states that on 4/13/25. Resident #58 was found lethargic and difficult to be aroused, was placed on 3 liters of Oxygen via nasal canula, and given 2 doses of Narcan. Resident #58 was then sent out to the ER. Resident #58 tested negative for all medications except Methadone which s/he was taking at the time. On 5/9/25 at 10:31 AM, a review of Resident #58's progress notes and the facilities investigation documentation was conducted. Based on progress notes the incident happened at 8:35 AM on 4/13/25. Upon further investigation the initial report was submitted to the OHCQ at 12:30 PM on 4/17/25. The final report was submitted 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 observation, interviews, and record reviews, it was determined that facility staff failed to 1) ensure the resident's nutritional status was accurately assessed, documented, and up to date in accordance with healthcare standard of care guidelines and 2) provide services that meet professional standards by not following written physician orders. This deficient practice was evident for 2 residents (#13 and #67) reviewed during the annual survey. Based on record reviews, observations, and interviews, it was determined that facility failed to provide services that meet professional standards by not following written physician orders. This was found to be evident for Resident #67 during the annual survey. The findings include: During the initial tour of residents on the 4th floor on 05/07/25 at 7:48 AM, the surveyor entered room [ROOM NUMBER] and observed Resident #13 sleeping in bed. The resident appeared malnourished with signs of cachexia (wasting syndrome). Review of the resident's electronic medical…

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

Based on interviews, observations and record reviews, it was determined that facility staff failed to ensure that wound care treatment was completed as ordered by the physician. This deficient practice was evident for 1 (#13) of 5 residents reviewed for physician orders during the annual survey. The findings include: During an interview with Resident #13 on 5/9/25 at 12:30 PM, the resident reports that wound dressing changes are scheduled for every Tuesday, Thursday, and Saturday, however, the dressing change for Thursday 5/8/25 was not done. An observation of Resident #13's left arm revealed that the last dressing change occurred on Tuesday 5/6/25 which is outside the ordered treatment schedule. On 05/09/25 at 1:30 PM, during a record review for Resident #13's treatment administration records (TAR) reveal an order to cleanse and dress wound located on the left forearm every evening shift every other day. Further review of the TAR reviewed that that last recorded wound dressing change was documented on 05/06/25. There was no documentation indicating why the change was not completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, it was determined that facility staff failed to ensure that geriatric nursing assistant (GNA) maintained an active certification. This deficient practice was evident in 1 out of 7 GNA employee files reviewed during the annual survey. The findings include: On [DATE] at 2:30 PM, during an interview with the Administrator, the surveyor requested the employment file for GNA #40. On [DATE] at 9:30 AM, during an interview with the Human Resource Director #10, the surveyor again requested for the employee file for GNA #40. During a review of the employee file, the surveyor identified that the GNA's certification had expired on [DATE]. On [DATE] at 2:30 PM, the surveyor informed the Administrator that GNA #40's certification expired. The Administrator stated that the employee was not working that day and would follow up with the HR Director #10 regarding the status of the GNA's license. On [DATE] at 7:53 AM, the Administrator confirmed that the GNA's certification is…

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

Based on record reviews and interviews, it was determined that facility staff failed to ensure that annual performance reviews were conducted for all geriatric nursing assistant (GNA). This deficient practice was evident in 7 out of 7 GNA's annual performance reviewed during the annual survey. The findings include: On 05/08/25 at 10:42AM, the surveyor requested the complete GNA employee files for GNA's, 23, #24, #25, #26, #27, and #28. The surveyor informed the Human Resource (HR) Director #10 that each file should also include the employee's annual performance review. A review of the employee files on 05/09/25 at 7:58 AM for GNA's #23, #24, #25, #26, #27, and #28 revealed that the requested annual performance review were not included in the submitted files. On 05/09/25 at 2:30 PM, the surveyor informed the Administrator of the requested GNA employee files and the missing annual performance reviews. The Administrator stated that the HR Director #10 would locate the requested files. The surveyor requested an additional GNA employee file for GNA # 40. On 05/12/25 at 9:30 AM, during 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 record review and staff interview, it was determined the facility staff documented inaccurate data in the resident's chart. This was evident in 1 out of 6 resident's reviewed in the recertification survey. The findings include: On 5/13/25 at 8:02 AM, a review of Complaints #MD00199200 and #MD00200378 was conducted. Both complaints alleged the facility provided a lack of Quality of Care leading to Resident #94's transfer to hospital requiring critical care. On 5/13/25 at 8:35 AM, a review of Resident #94's records was conducted. A progress note on 11/6/23 at 8:50 AM indicated the resident was going to be sent out to the ER at the family's request. A progress note on 11/6/23 at 9:36 PM indicated that the resident was out of the facility. Review of the resident's blood pressure indicated the resident's blood pressure on 11/6/2023 at 8:31 AM was documented as 85/63 mmHg. On 11/7/23 at 5:06 AM, the resident's blood pressure was documented as 129/75 mmHg. On 5/13/25 at 10:23 AM, an interview with the Director of Nursing (DON) was conducted. When asked about how Resident 94's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility's staff failed to ensure a sanitary and safe interior environment. This was evident for 1 (Resident#4) out of 8 residents reviewed for sanitary and safe environment. The findings include: Observation, on 09/28/23 at 12:31 PM the bathroom in room [ROOM NUMBER] found a pile of used paper towels under the sink, one ceiling tile that was off the ceiling track, and divided curtains between 2 beds that were torn. In addition, the inside of the bathroom door at the bottom had wood missing across the whole door. On 10/02/23 at 10:13 AM an interview was conducted with the Maintenance Director (Staff #7) and Housekeeping (Staff #4), both stated they were making their daily rounds in residents' rooms; however, they were not aware of the above-described findings. On 10/03/23 at 8:54 AM the surveyor observed the bathroom with the loose ceiling tile, the torn curtains and the damaged bathroom door which were left in the same condition. Staff #7 was…

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

Based on observation and interview with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: During the initial tour of the kitchen conducted on 09/27/2023 at 7:58 AM, the Surveyor and cook #93 observed 3 bags of bread opened and undated on the bread rack. Further observations revealed 2 boxes of sausage opened and undated, 2 personal beverages (fruit punch and lemonade) opened and undated and 1 personal pan pizza undated and unlabeled on the top shelf in the walk-in freezer. In an interview conducted on 09/27/2023 at 8:08 AM, the cook #93 confirmed the facility's food storage policy is to securely close packages/bags once opened and to label the package/bag with an open date and use by date with the date format of month, day and year. During a continued tour of the kitchen, the Surveyor and cook #93 observed a black substance inside the far back top 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and medical record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that resources were used effectively to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by 1. Failure to ensure substantial compliance with regulations that were identified as deficient 2. Failure to implement plans of correction resulting in an immediate jeopardy for the safety of residents who required supervision while smoking by failing to adequately supervise those residents, 3. Failure to implement plans of correction related to residents ' behavioral health by failing to identify, monitor and prevent the additional occurrences of substance abuse, 4. Failure to provide oversight and monitoring of the maintenance and pest control plan of correction for the facility and the kitchen resulting in repeated citations of a non-homelike…

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

Based on Interviews, observation, and record review, it was determined that the facility staff failed to ensure that resident rooms were free from mice. This was evident for 2 residents (#23 and #16) of 140 residents reviewed during the recertification survey. The findings include: On 09/28/2023 at 2:16 PM, during an interview with Resident #23 he/she said that he/she has seen 2 mice at a time-every night and sometimes during the day. On 09/29/2023 at 9:30 AM, a mouse was observed running across the floor in Resident #16's room. Resident #16 pointed out that the mouse will climb up cords near the head of his/her bed. These findings were brought to the attention of the Nursing Home Administrator. A review of service reports dated 06/01/2023 to 09/14/2023 from Orkin, the company that the facility contracts with for pest control, revealed that mice had been identified as an issue months before the start of the recertification survey. The service reports had comments that the logbooks at the nurses' stations were checked but there were no requests made by staff. On 9/15/2023 a service…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facilitate care plan meetings for residents. This was evident for 5 residents, (#59, #159, #463, #465 and #467) of 5 residents reviewed for care planning. The findings include: During an interview conducted on 09/27/23 at 10:06 AM, Resident #59's Personal Representative (PR) stated that there have only been 2 care plan meetings held since Resident #59 was admitted to the facility on [DATE]. Resident #59's PR further stated that she does not know who the current Director of Nursing or Social Worker is and has not been contacted about care plan meetings for Resident #59. On 09/27/23 at 10:37 AM, a review of Resident # 59's medical record revealed no evidence that a care plan meeting was conducted. During an interview conducted on 09/28/23 at 07:50 AM, Resident #463 stated that he/she did not participate in the care plan meeting and only knows about his physical therapy (PT) treatment. On 09/28/23 at 8:37 AM, a review of Resident…

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

Based on interviews and record review it was determined that the facility failed to inform residents of their right to formulate advanced directives. This was found evident for 5 out of 7 (Resident #55, #22, #15, #67, and #27) residents reviewed for advanced directives during an annual and complaint survey. The findings include: 1. On 10/3/23 at 11:32 AM, the surveyor conducted a medical record review for Resident #55. The review revealed that Resident #55's initial admission to the facility was in January of 2022 and the most recent admission was in April of 2023. Further review of the medical record revealed that Resident #55 had no advanced directive in his/her medical record and no documentation that he/she was offered to create one. On 10/3/23 at 1:28 PM, the surveyor conducted an interview with the Social Service Director Staff #14. During this interview Staff #14 stated, if a resident comes into the facility and does not have an advanced directive, she does not ask them if they would like to formulate one. Staff #14 further stated, only if a resident requests to formulate 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 clinical record review, review of facility abuse investigations, and staff interview it was determined that the facility staff failed to ensure allegations of abuse were reported to the state agency. This was evident for 3 (#150, #22, and #90) out of 30 residents reviewed for abuse. The findings are: 1. A review of intake MD00188656 was started on 10/20/23 at 11:11 AM. A review of the nursing progress notes dated 1/31/23 at 2:59 PM revealed that Resident #150 alleged that someone struck him/her really hard in the face during the middle of the night and returned later to kiss him/her on the cheek. The resident later alleged a dog tried to bite him/her. A review of the facility investigation revealed that a nurse (Staff #21) was informed on 1/31/23 of the allegation by the resident. Staff #21 said she observed no signs or symptoms of injury. She said she then told the unit manager (Staff #86) the same day. Further review revealed that the incident was not reported to the state agency until 2/5/23. This surveyor interviewed the Administrator on 10/20/23 at 10:54 AM. The…

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

Based on clinical record review, review of facility investigations, and staff interview it was determined that the facility staff failed to ensure allegations of abuse are thoroughly investigated and accurately reported with inclusion of details such as but not limited to reported injury and witness statements. This was evident for 12 (#119, #161, #165, #365, #374, #22, #42, #115, #63, #369, #70, and #128) out of 30 residents reviewed for abuse. The findings include: 1. A review of Resident #119's clinical record on 10/12/23 revealed that the resident had an incident on 5/3/22 at 11:30 AM. A review of the facility's investigation revealed that the facility reported the incident to the state survey agency but failed to include that the resident suffered an injury. This surveyor interviewed the Administrator on 10/18/23 at 10:20 AM. He was informed that the incident was reported but the facility failed to mention that the resident suffered an alleged injury as a result of the incident. Explained to the Administrator that an alleged injury is an important detail to include in all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, and staff interview, it was determined that the facility failed to ensure a care plan was developed for a resident who was an active smoker upon the completion of resident's comprehensive assessment at admission and failed to review, to revise a resident's care plan after a quarterly assessment, to ensure that care plan meetings took place in a timely manner, to ensure a Power of Attorney (POA) was invited to a care plan meeting. This was evident for 6 (Resident #109, #10, #371, #33, #39, and #67) of 12 residents reviewed for care plan timing and revision. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. This helps to evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview with staff, it was determined that the facility failed to ensure that 1) prescribed medications are correctly transcribed and administered, 2) insulin sliding scale parameters were included on the medication order for a resident receiving insulin, 3) report changes in baseline conditions and health concerns verbalized by residents. and 4) to create a new medication order in the resident's electronic record, once the order had been changed, and facility staff administered narcotics with conflicting orders. This was evident for 1) 2 (Resident # 39 and #46) of 6 residents investigated during the medication administration and investigative portion of the survey, 2) 1 (Resident #39) of 6 observed during the medication administration task portion of the survey, 3) 3 out of 3 monthly Dialysis Communication Logs reviewed during the survey, and 4) 1 Resident (#93) identified in 2 out of 3 narcotic binders reviewed during medication storage observations. The findings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, review of complaint intakes, observation, and staff interview it was determined that the facility staff failed to ensure residents received quality care regarding, but not limited to, medication administration, catheter care, conduct and document accurate nursing assessment, promptly identify and intervene for an acute change in a resident's condition and to provide an emergency medication (Glucagon) timely to a resident (Resident #108) with a finger stick result of 41mg/dl. This was evident for 10 (#121, #161, #364, #381, #63, #16, #517, #162, #131, and #108) out of 140 residents in the survey sample for the annual recertification and complaint survey. The findings include: 1. A review of Resident #121's clinical record on 10/30/23 as part of the investigation into intake #00191930 revealed the resident had a follow up Angiogram (a scan that shows blood flow through circulatory system) scheduled for 1/23/23 at a hospital. The resident was unable to go to the appointment because…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review, observation, and staff interview it was determined that the facility staff failed to appropriately administer pain medications as ordered. This was evident for 3 (#15, #63, and #517) residents out of 11 residents reviewed for pain management. The findings include: 1. A review of Resident #15's clinical record on 10/5/23 revealed the resident was prescribed Oxycodone 7.5 mg every 4 hours as needed for pain. A review of July 2023's Medication Administration Record (MAR) revealed the resident rated their pain as a 0 on a 0 to 10 scale on July 24, 2023, at 5:25 AM. The resident received a dose of pain medication to treat the presumed absence of pain. A review of August 2023's MAR revealed the resident rated their pain as a 0 at 2:56 AM and 7:19 AM but still received the Oxycodone. A review of September 2023's MAR revealed the resident rated their pain as a 0 at 1:55 AM on 9/20/23 and at 6:25 PM on 9/21/23. The Director of Nursing (DON) was interviewed on 10/5/23 at 12:25 PM. 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 record reviews, and staff interviews it was determined that the facility staff failed to put a system in place to ensure that prescribed medications are correctly transcribed and administered. This was evident for 1 (Resident # 46) of 1 residents reviewed for medication administration concerns during the survey. The findings include: Polyneuropathy is a condition in which a person's peripheral nerves are damaged. It affects the nerves in your skin, muscles, and organs. When these nerves are damaged, they can't send regular signals back to your brain. A review of the medical record to investigate intake # MD00196805 was conducted on 10/25/2023 at 10:15 AM. revealed Resident # 46 was admitted to the facility with diagnosis that included Polyneuropathy, nerve pain, and kidney failure requiring dialysis. A review of the resident's Medication Administration Record (MAR) on 11/2/23 at 08:00 AM revealed an admission order dated 06/22/23 for Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth one time a day every Mon, Wed, and Fri for nerve pain; To be given after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility failed to ensure: 1) appropriate temperature was maintained for the medication refrigerator and 2) expired medications were properly disposed of and 3) narcotic medications were adequately wasted, and 4) to maintain a safe and effective system for securing medications and treatments in designated carts on the nursing unit. This was found to be evident in 2 out of 3 medication storage rooms observed in the facility and 2 of 3 medication carts observed out of 6 medication carts in the facility. The findings include: 1. On 10/05/2023 at 8:16 AM the surveyor and Unit Coordinator, Staff #21, conducted an observation of the 4th floor medication storage room located behind the nurses station. The surveyors found the refrigerator's thermometer located inside of the refrigerator, on the top shelf of the door, with a temperature reading of 52 degrees Fahrenheit. The medication refrigerator log stated a minimum temperature of 36 degrees Fahrenheit 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of a complaint, review of administrative documents and record review, it was determined that the facility failed to keep accurate resident records in accordance with professional standards, to accurately display residents' names outside of their rooms, and to ensure that when the nursing staff destroy Schedule II medication, the administrative records were accurate. This was evident of 5 out of 140 (Resident #22, #8, #79, #64, #517, and #162) residents reviewed for accuracy of documentation on annual and complaint survey. The findings include: 1. On 9/28/23 at 11:45 AM, the surveyor conducted an interview with Resident #22. During this interview Resident #22 stated he/she did not have any teeth but also indicated he/she did not have any trouble eating with the lack of teeth. The surveyor observed Resident #22 confirmed that he/she did not have any teeth. On 10/4/23 at 11:44 AM, the surveyor interviewed Speech Therapist Staff #36. During this interview Staff #36 confirmed…

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

Based on interviews, and review of employee records, it was determined that the facility failed to have a qualified, full-time Social Worker employed to oversee the social service duties. This was found evident during 5 months in 2022. The findings include: On 10/13/23 at 1:47 PM, the surveyor reviewed staff records from the human resource department. The review revealed that Social Service Director Staff #95 was employed as the facility's Social Service Director from 9/3/21-3/4/22. Staff #95 has a bachelor's degree in social work and was licensed in the State of Maryland as a Social Worker. The next Social Service Director hired by the facility was Staff #96. Staff #96 did not have a bachelor's degree. Further review revealed that Staff #96 stopped working as the Social Service Director on 5/1/22. The next Social Service Director the facility hired was Social Service Director Staff #14 and was hired on 9/6/22. The review of the records revealed that there was no qualified social worker employed at the facility from 3/5/22-9/5/22. On 11/16/23 at 1:47 PM, the surveyor conducted an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility failed to; 1) keep a sanitary environment. This was found evident on 1 out of 3 floors observed and 2) failed to keep a functional and comfortable environment for 2 of 2 (Resident #84 and #59) random rooms observed on an annual and complaint survey. The findings include: 1.) On 10/5/23 at 11:41 AM, the surveyor observed a partially-eaten food tray labeled breakfast in room [ROOM NUMBER]. No residents were in the room and the tray was left on the resident's bedside table. Next the surveyor observed a food tray located on top of a storage bin where personal protective equipment (PPE) and isolation equipment was stored. This bin was out in the hallway between room [ROOM NUMBER] and 210. On closer observation the tray was labeled breakfast and food had been eaten off the tray. A fly was noted flying over the tray. On 10/5/23 at 11:44 AM, the surveyor interviewed Geriatric Nursing Assistant (GNA) Staff #99. During this interview…

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

Based on interview and observation, the facility failed to provide a bariatric bedside commode for a resident's use. This was evident for 1 (# 417) out of 2 residents reviewed for accommodation of needs. The findings include: On 09/28/23 at 9:30 AM, during interview Resident # 417 stated that s/he was not able to go to the bathroom because the bedside commode the facility provided was not big enough to fit her/his body. S/he is unable to use the bathroom because the toilet is too low, and s/he can't get back up. The resident stated that s/he asked for a bariatric bedside commode a few times, but had not received one yet. The surveyor observed a standard sized bedside commode at the bedside. No assistive devices were present in the bathroom. During an interview with GNA # 35 on 09/28/23 at 10:56 AM, the surveyor asked for the process for obtaining bariatric equipment. The response was maintenance supplies the bed and physical therapy supplies the commode. When asked if it was hard to get the equipment she replied no, we just ask. On 09/28/23 at 10:58 AM, LPN # 21 stated, the process…

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

Based on interview and record review, it was determined that the facility failed to honor the resident's right to participate in family events outside the facility. This was evident for 1 (Resident #46) out of 1 resident reviewed for resident rights. The findings include: On 10/13/23 at 09:50 AM during an interview, Resident#46 stated that he/she requested a Leave of Absence (LOA) on two different occasions: 8/25/23 & 9/5/23, however, only the first one was approved for 8/25/23 from 7:00 AM until 11:00 AM. Resident #46 followed the facility policy and filled out both requests 4 days prior to the requested leave. He/she remembered making the requests to staff at the third-floor nurse's station. An interview was conducted on 10/13/23 at 11:32 AM with the Unit Manager (Staff #3) who confirmed that he received both of Resident # 46's LOA requests. He stated that LOA requests were normally approved by him unless there was a medical risk concern, then it was forwarded to the physician for review. Furthermore, due to facility applied the Leave of Absence policy under therapeutic Bed Hold…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of a closed record, a staff interview, it was determined that a resident was not given an admission contract. This was evident for 1 (Resident #141) of 112 intakes reviewed during an annual certification survey. The findings include: Review of complaint MD00175504 on 11/02/23 revealed an allegation Resident #141 had been admitted to the facility for over a month without an admission contract. A review of Resident #141's closed medical record on 11/02/23 failed to reveal any documentation Resident #141 had received an admission contract. Resident #141 was admitted to the facility on [DATE]. Resident #141 was transferred to another long-term care facility on 02/18/22 per her wishes. In an interview with the facility, on 11/20/23 at 11:50 AM, the administrator stated that he was unable to locate a completed admission contract for Resident #141 after being admitted to the facility and couldn't answer why the contract had not been issued.

Based on reviews of a facility reported incident and staff interview, it was determined that a staff member removed money from a resident's account without the resident's permission. This was evident for 1 of 112 intakes reviewed during an annual recertification survey. The findings include: Review of facility reported incident MD00184909 on 11/01/23 revealed details that staff member #87 was asked by Resident #144 to go buy him some cigarettes on 10/22/22. In addition to buying the smoking materials, staff member #87 also withdrew $40 dollars cash. Review of staff member #87's written statement, dated 11/03/22, staff member #87 admitted that Resident #144 had not given her permission to remove an additional $40 cash from the debit card account on 10/21/22. Review of Resident #144's written statement, Resident #144 stated that he had not given staff member #87 permission to withdraw an extra $40 cash from his account. Resident #144's statement also indicated that Resident #144 confronted staff member #87 on 10/21/22 about the $40 removed from the account. Resident #144 informed the…

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

Based on clinical record review, review of a complaint, and staff interview it was determined that the facility failed to ensure proper planning on an issued 30 day discharge. The findings were evident for 1 (#165) out of the 140 residents that were part of the survey sample. The findings are: A review of Resident #165's clinical record on 10/19/23 to investigate intake #MD00175238 revealed that on 8/3/22 a meeting was held with the Ombudsman, the resident, and the resident's spouse. The resident had been caught smoking in an inappropriate place with the potential of harm to self and to others. The resident and spouse had been warned before but the resident is impulsive without regard to safety of self or others. The spouse understood why a 30-day involuntary discharge was issued secondary to facility not being able to accommodate the resident's need to smoke. Resident requested a facility with more opportunities for smoking. Spouse will call other facilities near home and facility said they would call facilities in the city. Spouse agreed to the discharge. Further review revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, it was determined the facility failed to: 1) provide written notice with the reason for transfer to a resident and 2) failed to notify the Ombudsman of residents that transferred timely. This was found evident of 2 of 7 (Resident #22 & #517) Residents reviewed for hospitalization during an annual and complaint survey. The finding include: 1. On 9/28/23 at 11:52 AM, the surveyor conducted an interview with Resident #22. During the interview Resident #22 stated he/she had recently been transferred to the hospital. On 10/2/23 at 1:43 PM, the surveyor reviewed Resident #22's medical record. The review revealed that Resident #22 was transferred to a hospital related to an unwitnessed fall. Further review of the record revealed that Resident #22 had no documentation that a written notice was given to him/her informing him/her of the reason for transfer. On 10/5/22 at 2:15 PM, the surveyor interviewed the Nursing Home Administrator (NHA). During the interview the NHA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to implement a process to ensure that residents and resident representatives were made aware of the facilities bed hold policy upon transfer to the hospital. This was found to be evident for 2 (Resident #517 and #22) of 7 residents reviewed for hospitalizations during the investigative portion of the survey. The findings include: A Bed Hold is the act of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. It should be provided to all facility residents regardless of payment source. Bed Hold policy should be disclosed in the admission packet during initial admission to the facility and it should be disclosed to resident and, if applicable, resident representatives at the time of transfer; if emergency transfer, within 24 hours. 1. On 9/28/2023 at 8:33 AM, during record review, surveyors discovered Resident #517, was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to accurately assess a resident for antipsychotic medications and to accurately document an assessment. This was found to be evident for 2 (# 92 and #115) out of 8 residents reviewed for Minimum Data Set (MDS) accuracy. The findings include: According to CMS, the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. 1. During a record review on 10/02/23 at 09:09 AM, the surveyor reviewed Resident # 92's Quarterly MDS dated [DATE] coded by former MDS Coordinator #84. For Section I, Active Diagnoses, Section I5900 Bipolar Disorder was coded and in section N0410 Antipsychotic medication was coded, however, Section N0450 A, Antipsychotic Medication Review was scored as not indicated. Therefore, Section N0450 B…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview with staff, it was determined that the facility failed to develop and implement a baseline care plan for a resident, requiring hemodialysis treatments and experiencing recurrent hypoglycemic episodes, that meets the professional standards of quality care. This was evident for 1 (Resident #517) of 13 residents investigated for care planning. The findings include: The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety. Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that are most likely to occur right after admission. Hemodialysis is a treatment, using a dialysis machine, to filter wastes and water…

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

Based on record review and interview it was determined that the facility failed to create a comprehensive care plan. This was found evident for 2 out of 13 (Resident #78 and #8) reviewed for care planning during an annual and complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1. On 10/03/23 at 12:31 PM, the surveyor reviewed Resident #78's medical record. The review revealed that Resident #78 was admitted to the facility in early January of 2023 with a medial history of, post-traumatic stress disorder, and adjustment disorder with mixed anxiety and depressed mood. On 11/17/23 at 12:01 PM the surveyor interviewed Regional Director of Clinical Operations Staff #39. During this interview the surveyor discussed concerns that Resident #78's psychological/psychiatry services may have been missed. Staff #39 stated she would look into the concern. On 11/20/23 at 10:14 AM, the surveyor reviewed psych progress notes in the electronic medical record.…

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

Based on clinical record review, resident interview, and staff interview it was determined that the facility staff failed to ensure residents' discharge goals are evaluated and planned. This was evident for 3 (#71, #165, #46) of the 7 residents reviewed for the discharge process. The findings include: 1. A review of Resident #71's clinical record on 10/31/23 as part of the investigation for intakes #MD00181160, #MD00183249, and #MD00190405 revealed that on 11/18/21 the Social Worker met with the resident to discuss progress in the facility as well as plans for discharge. The resident expressed a desire to return to the assisted living facility the resident occupied prior to admission to the nursing home. The Social Worker wrote This writer will follow up with this resident as needed. On 4/17/23 at 4:12 PM the Social Worker (Staff #14) wrote a social services progress note. The note says, Resident's son has been visiting and care plan meeting is scheduled for 4/20/23 to discuss discharge plans. The resident again expressed a desire to return to the community as expressed 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 observation, interview, and record review, it was determined that the facility staff failed to provide necessary activities of daily living (ADL) care based on the resident's level of daily living needs. This was evident for 1 (Resident # 8) out of 6 residents reviewed for Activities of Daily Living (ADL) level of care. The findings include: Activities of Daily Living is a term used in healthcare to refer to people's daily self-care activities. Health professionals often use a person's ability or inability to perform ADLs as a measurement of their functional status. On 09/28/23 at 11:20 AM an interview was conducted with Resident #8 after surveyor observed 2 Geriatric Nursing Assistant (GNA) staff #60 and staff #61 exited his/her room after the call light was turned off. Resident #8 stated he/she needed assistant to get up and asked for ADLs assistant, however, he/she was told that Nobody gets up before 12 noon. Surveyor observed for another 22 minutes outside of the room, staff did not return to provide ADLs assistance to get him/her up. Geriatric Nursing Assistant (GNA)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, it was determined that the facility failed to provide on-going personalized activities for the residents. This was evident for 3 (Resident #4, #59, and #23) out of 5 residents reviewed for personalized activities. The findings include: 1. Observation, on 09/28/23 at 12:20 PM, found that Resident#4 was lying in bed and did not respond to the surveyor but kept looking to the left side of the window. Review, on 09/28/23 at 12:31 PM Resident #4's care plan indicated that group activities were not meaningful, based on his/her low cognitive baseline after a stroke and several chronic disease processes. The care plan included to offer one-to-one room visitations, alight with his/her previous interests of music and reading. Review of activity staff's documentation from the month of March to September 2023 revealed no one-to-one activity documentation was found. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review, it was determined that the facility failed to provide appropriate oxygen therapy equipment. This was found to be evident for 1 (# 416) out of 1 resident observed on oxygen therapy. The findings include: During an observation on [DATE] at 08:05 AM, the surveyor observed Resident # 416's oxygen cart did not have a handle and the tubing was dated [DATE]. On [DATE] 08:40 AM, the surveyor observed that Resident # 416's oxygen cart did not have a handle and the oxygen tubing was dated [DATE]. Resident # 416 told the surveyor that the tank was empty and without a handle the tank was slippery when trying to move it. During an interview on [DATE] at 08:48 AM, the surveyor asked LPN # 21 the process for changing the oxygen tubing. She replied that the tubing should be changed and labeled every night by the night shift and that Resident # 416 uses oxygen as needed. The surveyor told her Resident # 416 stated that the tank was empty. She replied she would check the tank,…

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

Based on record review and interview it was determined that the facility failed to develop and implement a process to determine if residents with a history of trauma received the appropriate trauma informed care. This was evident for 1 (#568) of 1 resident reviewed for trauma informed care. The findings include: A medical record review for Resident #568 on 2/28/24 at 9:17 AM revealed the Attending Physician's notes for a visit on 12/31/23 that documented the resident had a history of post-traumatic stress disorder. Further review revealed no evidence that an assessment or care plan had been completed to ensure the resident received trauma informed care. An interview with Social Services Staff #24 on 3/1/24 at 10:34 AM revealed she was unaware of a trauma screen being conducted on residents at the facility. An interview with the Director of Nursing (DON) on 3/4/24 at 3:47 PM revealed that the facility had no process in place to screen residents for a history of trauma in order to develop and implement a plan of care addressing the trauma.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews with staff, and review of medical records, it was determined that the facility failed to appropriately treat a resident diagnosed with a mental disorder. This was evident of 2 of 4 residents (Resident #115 & #78) reviewed for mental health services during the annual survey. The findings include: The surveyor reviewed Resident #115's medical records on [DATE] at 2:03 PM. The review revealed that Resident #115 was admitted to the facility in early January of 2022 and had a past medical history of schizophrenia. Further review of the record revealed a progress note from Psychiatrist Staff #54 (a physician that specializes in mental health) on [DATE]. The progress notes stated that Staff #54 was asked to see Resident #115 due to agitation, depression and to evaluate medications. In the note Staff #54 recommended beginning Prolixin 2.5mg in the morning and 5mg before bed for schizophrenia. On [DATE] at 11:45 AM, the surveyor reviewed a progress note written on [DATE] by Resident #115's primary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review and staff interview it was determined that the facility failed to ensure social work assisted a resident with their needs. This was evident for 1 (#385) out of 140 residents in the survey sample. The findings are: A review of Resident #385's clinical record as part of the investigation into intake #MD00180949 was started on 10/12/23. The resident was admitted on [DATE] and discharged on 11/19/22. Review revealed that there were two social work notes in the clinical record, one on 3/23/22 and the other on 8/2/22. The Nurse Practitioner wrote a progress note on 8/16/22 at 9:31 AM stating that the resident wanted to be discharged home. The resident denied any medical complaints and believed discharge was appropriate. There were no social work notes or evaluations found in the clinical record even after the resident requested to be discharged home. The Social Services Director (Staff #14) was interviewed by survey team members on 10/13/23 at 10:43 AM. She said she started working at…

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

Based on review of medical records, medication monitoring/control records and interview with staff, it was determined the facility failed to implement a system to consistently and accurately reconcile controlled medications. This was evident for 2 out of 6 narcotic log binders reviewed during the recertification survey. The findings include: On 10/12/2023 at 11:30 AM surveyors and Staff #25 reviewed the 1st of 2 narcotic binders on the unit which revealed a medication monitoring/control record for Resident #27. The record showed a medication order written by Physician, Staff #50, that read, {medication} 5 mg (milligram) tablet, Give one tablet by mouth every 12 hours as needed for pain. During review of Resident #27's medication monitoring/control record, Staff #25 and the surveyor identified a missing staff signature from the administration of one 5 mg tablet of {medication} on 10/7/2023 at 1:00 AM. Review of the 2nd of the two narcotic log binders on the 3rd floor in the presence of Staff #25, revealed a medication/control record for Resident #63. The record showed a medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview and observation, the facility failed to prescribe a therapeutic diet for a resident. This was based on 1 (# 124) out of 1 resident reviewed for correct dietary orders. The findings include: On 10/18/2023 at 9:55 AM, the surveyor reviewed a complaint dated 9/27/21 on behalf of Resident #124. The complainant alleged the family had to have food delivered because the facility did not serve the resident a therapeutic diet. Although the resident was admitted on [DATE], according to the record review, the facility did not initiate a cardiac diet until 9/28/21 after Resident #124 requested a dietary consult. The surveyor's review of the Nursing admission Assessment on 10/19/2023 at 8:11 AM, dietary requirements read: Cardiac Consistent Carb Diabetic for Resident #124. During an interview on 10/19/2023 at 8:25 AM with the Regional Director of Clinical Operations (RDCO), the surveyor asked what the process was for ordering a therapeutic diet. She stated the admitting nurse sends an order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to maintain the outdoor garbage storage area in a manner to prevent the harborage and feeding of pests. The findings include: During an outside tour of the facility on 10/04/23 at 11:10 AM, the Surveyor and DM #94 observed debris scattered around the dumpster area. The debris included a peanut butter and jelly sandwich and disposable cups and food containers. The garbage bin close to the basement exit door was full to the top with trash items. In an interview conducted on 10/04/2023 at 11:17 AM, DM #94 confirmed that the expectation for trash disposable was that all trash is to be contained inside of the dumpster to avoid the potential of attracting rodents and stated that scattered debris and all other trash would be disposed of immediately.

Based on record review and interview, the facility failed to initiate a Quality Assurance and Performance Improvement (QAPI) plan. This was evident for 1 out of 1 QAPI plan reviewed during the annual survey. The findings include: The Centers for Medicare and Medicaid Services (CMS), defines Quality Assurance (QA) and Performance Improvement (PI) as a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem-solving. On 11/8/23 at 09:15 AM, the surveyor reviewed the 2023 Quality Assurance and Performance Improvement (QAPI) Plan. Under the Vision, Mission, Purpose and Guiding Principles statements, the facility had the examples that were provided on the template. For the section titled QAPI Goals the Example Goals are listed with [include date here], not a facility-initiated goal date. In the Communications section the examples from the template were listed. The Establishment of the QAPI Plan section read, This plan was established on [insert date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interviews, it was determined that the facility failed to ensure that clean linen was protected from contamination, to ensure isolation carts contained Personal Protective Equipment (PPE), and to maintain effective infection prevention practices. This was evident for 1 (3rd floor) of 3 floors observed for the handling of linens, for 7 out of 7 isolation carts observed, and for 1 of 3 random observations during an annual and complaint survey. The findings include: 1. On 09/28/2023 at 8:11 AM, an interview was conducted with Staff #2, a Geriatric Nursing Assistant. She said that the door to the 3rd floor linen cabinet was broken. She stated It gets contaminated. Residents reach in there with their dirty hands and then we have to touch the linens. At 8:15 AM the Surveyor observed that the linen cabinet was missing a door leaving clean linen exposed. On 9/28/2023 at 10:34 AM, this finding was verified by Staff #3, the Unit Manager, who said that he did not know how long the door had…

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

Based on clinical record review and family interview it was determined that the facility failed to ensure that a resident had access to a working adaptive device. This was evident for 1 (#121) out of the 140 residents that are part of the survey sample. The findings include: Resident #121's clinical record was reviewed starting on 10/30/23 as part of the investigation into intake #MD00189052. A nurse wrote in a nursing progress note on 1/23/23 that the resident had a follow up Angiogram [scan that shows blood flow through the circulatory system] appointment today (1/23/23) at [name of hospital]. Was unable to go to the appointment because we are unable to provide ambulance transportation at this time, [the resident] transfers using a Hoyer [a device used to lift a person off of a bed] which is also broken. The appointment was rescheduled. The resident's spouse was interviewed on 11/6/23 at 2:28 PM. Spouse said the resident needed the Hoyer lift to get out of bed. The facility Administration was informed of the results at the exit conference.

Based on interview and record review the facility to ensure that Agency Staff received facility training prior to working. This was found to be evident for 1 (# 62) out of 1 Agency Staff interviewed regarding facility training. The findings include: The surveyor asked Agency Geriatric Nursing Assistant (GNA) # 62 on 10/25/2023 at 9:46 AM, who was sitting at the 4th floor nurses station what she would do if the shower wasn't working. She stated, I would tell the nurse. I am agency this is my second time here. When asked if she received training by the facility she replied, I have not had training by this facility. This is my second day here. On 10/25/2023 at 10:11 AM, Regional Director of Clinical Operations was interviewed about the process of Agency training prior to working on the floor. She stated she would call the Human Resources (HR) Director to speak to the surveyor but everyone should be trained prior to working on the floor. During an interview, on 10/25/2023 10:30 AM, the HR Director # 8 stated the agency training process has been in place for 2 months. As the HR Director…

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

Based on reviews of a facility reported incident, a nursing assistant's employee files, and staff interview, it was determined that the facility failed to confirm an agency nursing assistant had abuse, neglect, exploitation, and misappropriation of resident property education before allowing the agency nursing assistant to work with residents in the facility. This was evident for 1 of 12 nursing assistants reviewed during an annual recertification survey. The findings include: Review of facility reported incident #MD00184909 on 11/01/23 revealed details were staff member #87 was asked by Resident #144 to go buy him some cigarettes on 10/22/22. In addition to buying the smoking materials with Resident #144's bank card, staff member #87 also withdrew an additional $40 dollars cash without Resident #144's permission. In an interview with the facility Director of Human Resources (HR) on 11/14/23 at 3:15 PM, the HR director was unable to produce documentation that staff member #87 received education regarding resident rights and abuse before being allowed to work with residents. Cross…

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