Fayette Health and Rehabilitation Center

Based on record review and interviews it was determined that the facility staff failed to ensure residents who had impaired vision received vision care and a recommended assistive device. This deficient practice was evidenced in 2 (#12 & #91) of 2 resident records reviewed for vision services during the recertification survey.The findings include:On 11/19/25 at 8:53 am, while interviewing Resident #12, they verbalized their vision was blurred. A review of the resident's diagnoses revealed the resident had a history of Primary Open Angled Glaucoma.On 11/21/25 at 11:12 am during an interview with the Director of Nursing (DON) the surveyor asked how they ensure residents receive vision care. The DON verbalized Health Drive comes to the facility; they have a list of residents that need vision care, and they will schedule an appointment for them to come into the facility. The surveyor reported Resident #12 had a history of Glaucoma with blurred vision.On 11/25/25 at 12:32 pm a review of Resident #91 electronic medical record (EMR) revealed the resident's last eye exam was done by Health…

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

Based on record review and interviews, it was determined that the facility failed to ensure that Nephrostomy drainage bag care was provided to a resident with a Nephrostomy . This was evident for 1 (#4) of 1 resident reviewed with a Nephrostomy. The findings include: On 11/24/2025 at 11:08 AM, during the initial interview of Resident #4, they stated that the staff did not empty or change their nephrostomy drainage bag and that they were forced to take care of it themselves and that their family provided the bags. On 11/24/2025 at 1:15 PM during a record review, it was noted that on the Task Administration Record (TAR) there is no documentation of the resident's urostomy bag being emptied and changed. On 11/24/2025 at 2:00 PM, The Director of Nursing (DON) was interviewed and he/she stated the urostomy bag was being changed but the staff was not documenting it. The DON was asked that if it wasn't documented how could they be sure that the change had been made and just as importantly how could the facility prove it had been done. The DON acknowledged that they couldn't.

Based on observations and interviews with facility staff, it was determined that the facility failed to maintain proper infection control procedures while serving breakfast. This was evident during the annual rectification survey. The findings include:On November 20, 2025, at 9:06 AM, the surveyor observed Staff #5, a Dietary Aid, while preparing beverages on clean trays for breakfast. Staff #5 knocked a tray onto the floor, then picked up the tray along with the silverware, napkin, and beverages from the floor. Staff #5 placed these items back on the tray and then positioned the fallen tray beside the clean trays on the serving line. Staff #6, another Dietary Aid, informed Staff #5 that this was unacceptable and removed the tray. No staff member cleaned the counter after the fallen tray was removed from beside the clean trays. Staff continued to serve breakfast, sliding clean trays down the service line over the area where the dirty tray had been. Staff #3, the Dietary Manager, was made aware that a tray fell and was picked up with the silverware and beverages, and that the items…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to maintain the facility in a safe operating condition as evidenced by the heating/AC unit front in a resident's room was on the floor, damaged drywall in residents' rooms, a sink wasn't secured to the bathroom wall, holes in residents' bathroom door, an electrical plate was not secured to the wall, a bed control had exposed wires, an armoire with dry rotten wood, damaged tile in the shower room, a hole in the wall in the laundry room & damaged floor tile, multiple soiled ceiling tile in the stored linen room. This deficient practice was discovered in different areas in the facility during the recertification survey.The findings include:On 11/18/25 at 7:30 am during observation rounds the surveyor observed the front of the heating/AC unit was on the floor in room [ROOM NUMBER]. In the shared bathroom in room [ROOM NUMBER] the surveyor observed holes in the bathroom door. At 7:43 am while in room [ROOM NUMBER] the electrical…

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

Based on observations and interviews it was determined that the facility failed to keep a sanitary environment. This was evident for 2 of 2 Residents (Residents # 64 and # 72) rooms observed during the annual recertification survey.The findings include:On 11/18/2025 at 11:27 AM, during the initial observation, a fly strip containing several dead flies and other insects was observed suspended from a cork bulletin board positioned directly above Resident #64's bed. Resident #64 was lying in bed, asleep, beneath the fly strip at the time of the observation.On 11/19/2025 at 10:34 AM, Staff #7, a Licensed Practical Nurse (LPN), was interviewed about the item hanging from the cork bulletin board above Resident #64's bed. Staff #7 identified the item as a fly strip/trap, explaining that Resident #64 had previously complained about flies in the room. When asked about the dead insects on the strip, Staff #7 confirmed, stating, there are dead flies and bugs stuck on the fly trap/strip above the residents bed. Staff #7 acknowledged that having a fly trap with dead insects in the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility's nursing staff failed to ensure that an newly admitted resident (resident #17) had a complete discharge summary from the local hospital. This failure to have a complete discharge summary from the local hospital led to the facility being unsure if they had the complete list of medications needed for the resident's care. This was evident for 1 of 2 residents reviewed for neglect during a complaint survey. The findings include:On 8/12/25 at 8:00am, the surveyor reviewed complaint MD00210531/ IQIES 342276 which alleged that the facility failed to provide continuous oxygen to resident #17 when he/she was admitted to the facility on the evening of 10/3/24. Resident #17 had a family member call 911 for assistance and the resident was transferred to the local hospital on [DATE]. On 8/12/25 at 8:10am, surveyor review of resident #17's medical records revealed the resident was admitted from the local hospital with a portable oxygen 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility's nursing staff and telehealth provider failed to ensure that a newly admitted resident with respiratory issues (resident #17) had an order for oxygen administration. This was evident for 1 of 2 residents reviewed for neglect during a complaint survey. The findings include:On 8/12/25 at 8:00am, the surveyor reviewed complaint MD00210531/ IQIES 342276 which alleged that the facility failed to provide continuous oxygen to resident #17 when he/she admitted to the facility on the evening of 10/3/24. Resident #17 had a family member call 911 for assistance and the resident was transferred to the local hospital on [DATE]. On 8/12/25 at 8:10am, surveyor review of resident #17's medical records revealed the resident was admitted from the local hospital with a portable oxygen tank that was administering 3 liters of oxygen though a nasal cannula. Further review of the medical record revealed that the resident complained of the tank being empty at 11:15pm 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 resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure residents received showers at least twice a week. This was evident for 4 residents (#81, #111, #116, and #28) out of 48 residents who were part of the survey sample. The findings include: 1) This surveyor interviewed Resident #81 on 3/18/24 at 9:19 AM. The resident stated that he/she has not had a shower in three days and needs one. Resident declared that he/she stinks. Resident stated that he/she has requested showers, but the staff say to just go even though the resident cannot physically go on his/her own. A review of Resident #81's clinical record revealed that the Geriatric Nursing Assistants (GNA) documented only providing bed baths for the resident during the months of February and March. This surveyor interviewed the Unit Manager (Staff #50) on 3/28/24 at 9:06 AM. The lack of showers and the resident's right to showers twice a week was discussed. The Unit Manager said he was not surprised that Resident #81 complained and that he would look into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) and to maintain a proper resident's Advance Directive in the resident's medical record. This was found to be evident for 7 (Resident #27, #64, #61 and #111) out of 9 residents reviewed for advance directives. The findings include: Medical Orders for Life-Sustaining Treatment (MOLST) is a medical order form that relays instructions between health professionals about patient care. MOLST certifies orders that were agreed to by a patient or a patient's health care agent as named in the patient's advance directive. MOLST determines resuscitation status and includes other 8 sections of treatment choices. An Advance Directive is a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness. An advance directive may also give a person (such as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and medical record review, it was determined that the facility failed to have an effective system in place to ensure that residents and resident representatives are notified in writing of the bed hold policy upon transfer to the hospital. This was found to be evident for 4 (Residents #16, #63, #109, and #117) out of 6 residents reviewed for hospitalization during the annual 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 must 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 3/28/24 at 9:40 am the surveyor conducted a review of Resident #16's medical record. According to the documentation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview and medical record review, it was determined that the facility failed to accurately document resident assessment on the MDS (Minimum Data Set) as evidenced by the inaccurate coding for residents. This was found to be evident for 4 out of 6 Residents (#13, #16, #24, & #28) reviewed for accuracy of MDS assessments. The findings include: The MDS (Minimum Data Set) is a health status screening and assessment tool used for all residents of long-term care nursing facilities. The 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. Hemodialysis is a process of filtering the blood of a person whose kidneys are not working normally and is a treatment to filter wastes and water from the blood, as the kidneys did when they were healthy. Hemodialysis helps control blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This was found evident for 3 (#97, #33, and #81) of 6 residents reviewed for care planning. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team. 1) On 3/19/24 at 9:05 AM, the surveyor interviewed Resident #97. During the interview Resident #97 stated he/she was never invited to a care plan meeting. On 3/22/24 at 9:36 AM, the surveyor conducted an interview with Social Worker Staff #16. During the interview Staff #16 stated that Resident #97 was a long term care resident and her Social Work Assistant, Staff #17, would be more…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, record review, and observation it was determined that the facility failed to provide wound care treatments according to professional standards. This was found evident of 4 (Resident #101, #21, #332, and #74) of 6 Residents reviewed for skin and wound care. The findings include: 1) On 3/22/24 at 11:54 AM, the surveyor interviewed Resident #101 along with his/her significant other. During the interview Resident #101 stated his/her significant other was performing the wound care and that he/she was content with this arrangement. Resident #101's significant other stated he/she had no problem with providing the wound care. He/she further stated that until recently the facility's wound nurse would watch and evaluate the wounds while they were being changed; however, the wound nurse had not been in for several weeks and since then no other staff had watched the wound dressing change. On 3/26/24 at 9:53 AM, the surveyor reviewed Resident #101's care plan. On 2/14/24 a care plan was initiated that stated Resident #101 had his/her wound care treatment preference. 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 review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by: 1) safeguarding resident identifiable information from the public and 2) keeping accurate documentation. This was found evident in 4 of 45 (Resident #73, #101, #332, and #533) residents reviewed during the survey. The findings include: 1) On 3/19/24 at 9:25 AM, the surveyor observed an unattended medication cart on the third floor with a computer on top of the cart. The computer screen was facing out into the hallway. On further observations, the computer screen had Resident #73's medication profile displayed and the surveyor could see a list of medications. On 3/19/24 at 9:26 AM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #25 who had walked up to the medication cart. During the interview Staff #25 closed out the computer screen and confirmed that the computer screen should not have been displaying the…

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

Based on observations and interviews it was determined that the facility failed to ensure staff sanitized medical equipment between residents and failed to ensure gowns were available for staff use as posted on the Enhanced Barrier Precaution signage at the door. This was found to be evident for 1 out of 3 staff observed for infection control and for 4 rooms (#300, #336, #338, and #340) out of 10 rooms observed for Personal Protective Equipment (PPE)availability. The findings include: 1) During an observation of the medication administration conducted on 3/20/24 at 8:38 AM for Resident #113, the surveyor observed Certified Medication Aide (CMA) #14 obtain the resident's blood pressure reading with a blood pressure monitor that had a wrist blood pressure cuff. The CMA returned to the medication cart and placed the blood pressure monitor on top of the medication cart. The CMA did not sanitize the blood pressure monitor and cuff. On 03/20/24 at 9:08 AM, the surveyor observed the CMA retrieve the blood pressure monitor with the wrist blood pressure cuff off the top of the 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 observation and interviews, it was determined that the facility staff failed to ensure the dignity of the residents as evidenced by: 1) Nursing staff failed to wear a name tag and 2) Nursing staff use of a personal cell phone during Resident's (#16) care. This was found to be evident for 1 out of 1 Resident for dignity. The findings include: 1) On 3/18/24 at 9:13 AM the surveyor observed Geriatric Nursing Assistant (GNA) #12 on the 3rd floor nursing unit without a name tag. During an interview the surveyors asked GNA #12 what was the facility's expectation for name tags. The GNA advised the surveyors that she was expected to wear a name tag at all times. The GNA #12 then wrote her name on a piece of tape and placed it on her uniform. On 3/20/24 at 6:30 AM the surveyors observed that Registered Nurse (RN) #22 walked out of resident room [ROOM NUMBER] and into the hallway toward the 3rd floor nursing station without a name tag. During an interview the surveyors asked the RN what was the expectation for…

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

Based on interviews and record review it was determined that the facility failed to honor the rights, delegated to a Resident's Representative by informing them of changes to the plan of care. This was found evident of 1 (Resident #77) of 9 residents reviewed for advanced directive during an annual and complaint survey. The finding include: On 3/19/24 at 10:08 AM, the surveyor reviewed Resident #77's medical records. The review revealed that Resident #77 was admitted to the facility in early August 2023. Further review revealed on 9/8/23 and on 9/11/23 two providers evaluated Resident #77 and documented their findings on a form titled, Physician Certification Related to Medical Condition, Substitute Decision Making, and Treatment limitations. Both providers evaluated that Resident #77 was unable to understand and sign admission documentation, unable to understand the nature, extent or probable consequences of the proposed treatment, and unable to make a rational evaluation of the burdens, risks, and benefits of the treatments. Both Providers deemed Resident #77 incapable of making…

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

Based on observations, interviews and documentation review it was determined the facility failed to ensure that personal property was not lost. This was found to be evident for 1 (Resident #28) out of 1 Resident observed for missing property. The findings include: During the initial tour conducted on the 3rd floor nursing unit on 03/17/24 at 12:25 pm, the surveyors interviewed Resident #28. The Resident informed the surveyors that he/she had missing clothes and that he/she went down to the laundry department often to look for clothes. The Resident further stated that he/she had reported the missing clothes several times to the Nurses, Social Service Director, and the Administrator. On 3/29/24 at 9:05 am the surveyors interviewed the Nursing Home Administrator (NHA) about the process for missing personal property. The NHA conveyed to the surveyors that an inventory list is completed when the Resident is first admitted to the facility. The facility will review the inventory form when Residents have a concern about missing items, a grievance form would be completed and an investigation…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that the reporting of reasonable suspicion of an abuse result in serious bodily injury was no later than 2 hours to the State Agency after informing the State Agency of the suspicion of an abuse incident. This was evident for 1 (Resident #64) out of 12 residents reviewed for the facility self-report incidents. The findings include: An incident that involves a reasonable suspicion of abuse of a resident must be reported in an initial facility self-report to the State Agency within 2 hours after the incident was reported. Record review, on 03/28/24 at 1:20 PM, of the facility's self-report file found that an initial self-report (MD00200322) was sent, on 12/6/23 at 5:45 PM, to the State Agency. Further review revealed that within the facility's self-report investigation form, the alleged incident date and time was on 12/4/23 at 10:49 PM. It meant the incident occurred 2 days prior to the initial report date. On page 5 out of 7 of the self-report investigation form Resident #64 complained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 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. This was found evident of 3 of 6 (Resident #332, #63, and #109) residents reviewed for hospitalization during the survey. The findings included: 1a) On 3/18/24 at 9:49 AM, the surveyor conducted an interview with Resident #332. During the interview Resident #332 stated he/she had recently been hospitalized . On 3/22/24 at 7:56 AM, the surveyor reviewed Resident #332's medical record. The review revealed that in early February 2024 Resident #332 was transferred to the hospital. Further review revealed a change of condition progress note written by Licensed Practical Nurse (LPN) Staff #50 for the hospital transfer. The note stated, the resident was notified of the reason for transfer. However there was no indication that the resident received a written notice for the reason for transfer or that the…

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

Based on interview and record review it was determined that the facility failed to develop and provide the baseline care plan to a newly admitted resident. This was found to be evident for 1(Resident #125 and #109) of 6 residents reviewed for care planning during the survey. The finding include: On 3/21/24 at 8:51 AM the surveyor reviewed Resident #125's medical record. The review revealed that Resident #125 was admitted to the facility in late January 2024. Further review revealed no baseline care plan note. A nursing evaluation was completed on 1/24/24, however in the evaluation there was no indication that any care planning was discussed with the resident or that the resident received a summary. The evaluation did not document the therapy services the facility planned to provide, the resident's goals to be obtained or a summary of the resident's medications with dietary instructions. On 3/21/24 at 12:54 PM, the surveyor requested the baseline care plan for Resident #125 from the Nursing Home Administrator (NHA). On 3/21/24 at 1:41 PM, the NHA returned stating that nursing does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review it was determined that the facility failed to develop a care plan for smoking. This was found to be evident for 3 (Resident #28, #125, and #111) out of 6 residents reviewed for care plans. The findings include: On the initial tour of the facility on 3/17/24 at 12:10 PM the surveyors smelled smoke in Resident #28's room as they entered the room. Resident #28 was the only resident residing in the room at that time. The surveyors immediately interviewed the resident with the Unit Manager #50. The resident conveyed that he/she does not smoke. The surveyors and Unit Manager #50 observed 3 cigarette butts in water in a plastic cup and an empty pack of [NAME] cigarettes on the dresser in the rsident's room. Resident #28 denied the use of these cigarette butts. Review of the care plan for Resident #28 conducted by the surveyor on 3/17/24 at 1:00 PM revealed that the resident did not have a care plan for smoking. The surveyors interviewed the Nursing Home Administrator…

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

Based on resident interview, staff interview, and observation it was determined that the facility staff failed to ensure that residents toenails were cut. This was evident for 1 (#183) out of 48 residents in the survey sample. The findings are: This surveyor observed Resident #183 on 3/18/24 at 9:59 AM and witnessed that the right foot had a long toenail on the big toe that measured about one inch above the toe. This surveyor interviewed Resident #183 on 3/18/24 at 10:02 AM. The resident stated that no one has cut the toenails even after the dressings on the feet were changed. The resident's toenail was observed on 3/22/24 at 1:13 PM to still be long. The Regional Clinical Director (Staff # 20) was interviewed on 4/2/24 at 11:40 AM. He confirmed that the resident had a podiatry appointment last week and said the facility will complete an 100% audit of all residents to ensure nails would be cut.

Based on interviews and record review it was determined that the facility failed to have an activities program designed to meet the interests and needs of residents based on the resident's comprehensive assessment and care plan. This was found evident of 2 (Resident #7 and #79) of 5 residents reviewed for activity during the survey. The findings include: 1) On 3/18/24 at 10:33 AM, and on 3/19/24 at 10:21 AM, the surveyor observed Resident #7 lying in bed with the covers pulled over his/her head. On 3/21/24 at 6:43 AM, the surveyor reviewed Resident #7's medical record. The review revealed that Resident #7 was admitted to the facility in early 2020 with a medical diagnosis, of, but not limited to, paranoid schizophrenia, major depressive disorder, adjustment insomnia, and mild cognitive impairment. Further review revealed a Minimum Data Set (MDS) assessment was conducted on 1/15/24 for Resident #7 and indicated his/her preferences in section F of the assessment. Resident #7 indicated it was very important to do things in group activities, keep up with the news, go outside,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the medication error rate of 5% or less. This was found to be evident for the medication administration observation during the re-certification survey. The findings include: During an observation of medication administration conducted on 3/20/24 at 8:38 AM for Resident #113, the surveyor observed Certified Medication Aide (CMA) #14 check off Vitamin D 25 mEq (milliequivalent) 2 tablets in the resident's electronic health record as administered. The surveyor observed the CMA retrieve and place all medications ordered for 8:00 AM except for Vitamin D in a medication cup. The CMA entered the resident's room, handed the resident the medication cup and stated here are your morning medications. During the continued observation of the medication administration conducted on 03/20/24 at 9:08 AM, CMA #14 and the surveyor reviewed Resident #72's electronic health record for medications. The resident had an order for Levothyroxine 50 mcg (1 millionth of a gram) to be administered before…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a safe and effective system for securing medication and treatments in designated carts on the nursing units. This was found to be evident for 1 out of 7 medication carts and 2 out of 5 treatment carts observed during random tours of the facility. The findings include: During a random tour of the 1st floor nursing station conducted on 03/18/24 at 6:30 AM, the surveyor observed a medication cart unlocked. This surveyor was able to open each drawer of the cart and observe medications that were labeled with the resident's name and room number, as well as, house medications. On 03/18/24 at 6:33 AM an interview was conducted with the Licensed Practical Nurse (LPN) #18. During the interview the LPN confirmed that the unlocked medication cart was assigned to him and that he was responsible for the cart being unlocked. The LPN further stated the facility's expectation was for the medication cart to be always locked when…

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

Based on observation, interview and medical record review it was determined that the facility staff failed to assist the resident as necessary to make appointments for dental care or treatment. This was found to be evident for 1 (Resident # 13) out of 3 residents reviewed for dental treatments during an annual survey. The findings include: During observation and interview, on 03/18/24 at 10:06 AM, Resident #13 showed that he/she only had 3 teeth left and reported some of the gum areas were hurting. Record review, on 3/26/24 at 2:43 PM, of Resident #13's record revealed that the admission date was 6/11/2015 with the diagnoses of tobacco use, bilateral above knee amputations, dementia and anxiety. Further review of a dental on-site visit on 4/3/23, signed by Dentist Staff #58 for dental cleaning, found that Resident #13 had dormant retained roots and the dentist recommended extractions. However, during the following two on-site visits on 6/23/23 and 7/5/23 teeth were not extracted. And no further dental appointment was made. During interview, on 3/27/24 at 12:07 AM, the Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee file review it was determined that the facility failed to employ a Licensed Practical Nurse in accordance with Maryland State laws. This was found evident in 1 (Staff #13) out of 11 employees reviewed during the survey. The findings include: On 3/20/24 at 1:37 PM, the surveyor reviewed Staff # 13's employee file. In the review it was noted that Staff #13 had an active Virginia Practical Nurse License, however the employee file was not complete. No education transcripts, hire application, evaluations or disciplinary actions were in the file. The surveyor requested the entire employee file from the Nursing Home Administrator (NHA). On 2/21/24 at 9:59 AM the NHA provided additional documents as part of Staff #13's employment file. The surveyor reviewed the additional paperwork. Staff #13 was hired in May of 2022. However, no up-to-date human resources documents were in the file. On 3/22/24 at 11:09 AM, the surveyor interviewed the Corporate Human Resources Business Partner Staff # 30. During the interview Staff #30 confirmed that Staff #13 was hired…

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

Based on observations and interviews it was determined that the facility failed to ensure that a resident's bed mattress was properly secured to the bed frame. This was found evident of 2 residents (Resident #85, & #97) on 4 different observations. The findings include: 1a) On 3/19/24 at 9:17 AM, the surveyor observed Resident #97's mattress slid over and approximately 4 inches of the bed frame exposed while Resident 97 was laying in his/her bed. The surveyor asked Resident #97 why the mattress was slid over and Resident # 97 stated the mattress always slides over when he/she gets into bed. On 3/25/24 at 1:25 PM, the surveyor again observed Resident # 97's mattress slid over approximately 4 inches exposing the bed frame. On 3/27/24 the surveyor reviewed Resident #97's medical record. The review revealed on admission, Resident #97 had a history of falling and on the February 6, 2024 Minimum Data Set (MDS) assessment Resident #97 required supervision or touching assistance while moving from sitting to lying flat in bed. On 3/28/24 at 8:56 AM, the surveyor conducted an interview with…

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

Based on observation and interview it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of insects. This was found to be evident for 1 out of 1 resident's (#77) room observed for pest control. The findings include: During a medication administration observation conducted on 03/21/24 at 7:11 AM, this surveyor observed multiple gnats swarming around the inside of the resident's room. The surveyor left the room to asked the Director of Nursing (DON) who was at the 3rd floor nursing station to come to the resident's room for the concern of gnat infestation. Both the surveyor and DON observed a privacy curtain covered in gnats from the top of the curtain to the bottom of the curtain. The DON took a picture of the infestation and stated she would report the observation to the Nursing Home Administrator (NHA). During an interview conducted on 03/21/24 at 11:25 AM, the surveyor asked the NHA what the facility's plan was to address the gnat infestation in Resident #77's room. The NHA stated she was not aware of the infestation…

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

Based on employee record review and interviews it was determined that the facility failed to monitor staff to ensure required in-service training for nurse aide staff was completed. This was found evident in 1 out of 5 Geriatric Nursing Assistants (GNA# 48) reviewed. The finding include: On 3/20/24 at 1:17 PM, the surveyor reviewed the employee file for Geriatric Nursing Assistant (GNA) Staff #49. During the review of the employee's file the surveyor noted the facility completed a criminal background check, a sex offender registry check and a licensure check. The application and hire date for Staff #48 was 10/16/2023. No other documentation was in the employee file. 3/21/24 at 09:59 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the surveyor informed the NHA that Staff #48 had no records of education in his employee file. The NHA stated she would look to see if there were more documents. On 3/22/24 at 8:18 AM, the surveyor conducted an interview with the facility's staff educator, Staff #3. During the interview, Staff #3…

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

Based on a review of clinical records, staff interview, and an investigation of Intake #MD00203099 it was determined that the facility staff failed to ensure a resident's personal and medical information. That was placed in another resident's clinical record. This was evident for 1 (#382) out of 48 residents in the survey sample. The findings include: A review of Resident #382's clinical record on 4/3/24 at 10:50 AM revealed that a discharge summary and Preadmission Screening and Resident Review (PASRR) form for Resident #41 was present. Interviewed the Administrator 4/3/24 at 12:12 PM. Showed the attached personal information and she stated that it should not be there.

Based on record review, review of facility incidents, and interviews it was determined that the facility failed to ensure that a resident was free from verbal abuse. This was found to be evident for 2 (Resident #24 and #78) out of 9 residents reviewed for abuse. The findings include: 1) On 3/20/24 at 12:18 PM, the surveyors reviewed the Facility Reported Incident (FRI) dated 11/27/23 that had an allegation of verbal abuse against Resident #24. The resident alleged that the Registered Nurse (RN) used profane words and was dismissive when he/she advised the RN that he/she had a cold room.The statement obtained by the facility during their investigation revealed an admission from the RN that she had used profanity and was dismissive of the resident's concern. The surveyors reviewed the facility's Policies and Standard Procedures for Abuse on 3/20/23 at 12:45 PM. The definition of verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents, or within hearing distance, regardless of their age,…

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

Based on a review of facility-reported incidents, employee personnel files, closed clinical record review, facility abuse policy review, and staff interview, it was determined that facility staff failed to ensure resident # 71 was free from verbal abuse. This was evident for 1 out of 3 residents reviewed during a complaint survey. Findings include: On 9/25/23 at 11:20 AM a review of facility-reported incident #MD00197120 revealed that the facility reported an allegation of staff-to-resident verbal abuse on 9/17/23 in which Geriatric Nursing Assistance (GNA) #32 cursed at Resident #71. A medical record review on 9/25/23 at 11:20 AM revealed Resident # 71 was admitted to the facility in August 2023. A continued medical record review on 9/25/23 at 11:30 AM revealed an investigation of an alleged staff-to-resident verbal abuse incident that took place on 9/17/23 at 12:10 PM. GNA #32 observed Resident #71 brushing Resident #79's hair and feeding Resident #79 food and asked resident #71 to stop. Resident #71 left the area near Resident #79 and walked to his/her room loudly saying…

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

Based on review of a facility reported incident, administrative files and staff interview, it was determined that the facility administration failed to implement the facility abuse policy by not performing a back-ground check on an employee. This was evident for 1 of 8 employee files reviewed for abuse during a complaint survey. The findings include: Review of facility reported incident MD00146699 on 08/21/2023 revealed an allegation GNA #1 was physically abusive to Resident #36 when providing care on 10/14/2019. In an interview with the facility's Director of Nursing (DON) on 08/31/23 at 9:10 AM, the DON stated that s/he was unable to locate a background check for GNA #1 in the administrative files. The facility administration failed to implement the facility abuse policy for GNA #1 when s/he was hired as an employee and obtain a back ground check.

Based on review of a complaint and a closed health record, as well as staff interview, it was determined that the nursing staff failed to administer an antibiotic as ordered. This was evident for 1 (Resident #45) of 70 residents reviewed during a complaint survey. The findings include: Review of complaint MD00182802 on 08/23/23 at 10 AM, revealed an allegation that Resident #45 did not receive his/her intravenous antibiotics as prescribed by his/her physician. A review of Resident #45's closed medical record revealed a physician's order, dated 08/04/22, instructed the nurses to administer the antibiotic, Cefazolin, 2 grams, intravenously, every 8 hours for 6 weeks, to treat Bacteremia. Further review of Resident #45's closed medical record revealed that the nursing staff did not sign off that Resident #45 received a dose of the antibiotic on the following days: 08/14/22, the evening shift, 10 PM dose. 08/18/22, the evening shift, 10 PM dose 08/19/22, the evening shift, 10 PM dose. 08/25/22, the evening shift, 10 PM dose. There were no nurses progress notes indicating a reason why…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record, and staff interview, it was determined the facility failed to timely provide medication to meet the needs of the residents. This was evident for 1 (Resident #35) of 70 residents reviewed during a complaint survey. The findings include: A review of complaint MD00176023 on 08/21/23 revealed an allegation that residents are complaining prescribed medications are not available. A review of Resident #41 closed medical record on 08/21/23 revealed that Resident #41 was admitted to the facility on [DATE] with diagnoses that included but are not limited to a status post knee replacement, sciatica, poor vision, and osteoarthritis. Further reviewed revealed that on 10/10/22, a physician ordered the nursing staff to administer Oxycodone, 10 mg orally, every 4 hours as needed for pain. A review of Resident #41's October 2022 medication administration record (MAR) on 08/23/23, failed to reveal the nursing staff had administered any Oxycodone to Resident #41 from 10/10/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records and staff interviews, it was determined that the facility staff failed to 1) have a process to ensure the clinical pharmacist's monthly medication reviews were reviewed by the physician with a documented response in the resident's medical record. This was evident for 1 (Residents #41) of 70 residents reviewed during a complaint survey. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough monthly evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. Resident #41's medical record was reviewed on 08/22/23 at 10 AM. The pharmacist's monthly medication regimen reviews (MRR) were documented under the evaluations tab in the electronic health record (EHR) and reviewed for monthly compliance. The MRR dated 10/11/22 indicated…

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

Based on facility staff roster review and staff interview, it was determined that the facility has a bed capacity of 150 and did not employ a qualified social worker from January 2016 to the present on a full-time basis. This deficient practice was found during a complaint survey and has the potential to affect all residents. The findings include: Interview with the Social Services Director #8 on 8/24/2023 at 1:00 PM revealed that the facility's Social Services Department employs staff that are unlicensed and uncertified. Social Services Director #8 also revealed that none of the Social Services staff, including him/herself, had the educational qualifications to be a qualified social worker. Social Services Director #8 further revealed that the facility has a contract with a qualified Social Worker that reviews resident records weekly by telephone. On 8/30/23 at 11:30 AM, the Surveyor interviewed the Director of Nursing (DON) regarding the contract with the Social Worker Consultant. The DON confirmed the Social Worker Consultant was employed by the facility since March 2022. The DON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident /or the resident representative and ombudsman. This was found to be evident for 5 out of 5 residents reviewed for a facility-initiated transfer during the investigative portion of the survey. The findings include: 1. A medical record review for Resident #109 was conducted on 03/3/19. Review of the physician order written on 11/02/18 revealed that Resident #109 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident/ or the resident representative and the ombudsman. The Director of Nursing (DON) was interviewed and made aware of the findings at on 03/07/19 at 08:10 AM, No evidence of the notification was made provided to the team prior to exit. 2. A review of Resident #14'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 medical record review, observation and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for Residents (#57 and #23). This was evident for 2 of 40 residents selected for investigation during the survey process. Findings include: 1. Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Surveyor observation of Resident #57 on 03/03/19 at 09:50 AM revealed the resident in his room with a 1/2 pack of cigarettes. Medical record…

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

Based on medical record review and interview, it was determined the facility staff failed to document/obtain the blood pressure for a resident with parameters (Resident #102 and #23). This was evident for 2 of 40 residents reviewed during survey investigation. The findings include: 1. Medical record review for Resident # 102 revealed on 12/6/2017, the physician ordered: Clonidine HCl Give 0.2 mg by mouth two times a day for Hypertension hold for systolic blood pressure (top number) <100 (less than and hold for diastolic blood pressure (bottom number) below 60. Clonidine is a medication used alone or with other medications to treat high blood pressure (hypertension). Review of the Medication Administration Record revealed the facility staff failed to obtain/document the resident's blood pressure from 2/1/19 to 3/5/19 at 8:0O AM and 8:00 PM as ordered by the physician. Interview with the Director of Nursing on 03/07/19 10:10 AM confirmed the facility staff failed to document/obtain Resident's #102 blood pressure as ordered by the physician. 2. Medical record review for Resident #23…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood specimens on Residents (#12, #23, #84, #59 and #90). This was evident for 5 of 44 residents selected for review during the survey process. The findings include: 1. The facility staff failed to obtain laboratory blood specimen as ordered for Resident #12. Medical record review for Resident #12 revealed on 12/28/18 the facility staff obtained laboratory blood results. At that time, the Certified Registered Nurse Practitioner (CRNP) was notified and ordered intravenous fluids of dextrose 5% with water (D5W) at 100cc per hour for 2 liters and repeat BMP tomorrow (12/29/18). The Basic Metabolic Panel (BMP) can be used to evaluate kidney function, blood acid/base balance, and levels of blood sugar, and electrolytes. Components of the BMP are four electrolytes: sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine and glucose. Further record review revealed the facility staff failed to obtain the laboratory blood test as ordered by the CRNP. 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 resident complaints and surveyor observation it was determined the facility failed to provide food at a safe and appetizing temperature. This deficient practice has the potential to affect all residents. The findings include: On the morning of 3/6/2019 the Director of Culinary Services (DCS, Staff #5) was asked to provide a test tray of a regular diet lunch to the 4th floor of the facility in response to resident complaints of cold food. The 4th floor is the last floor to receive food service and is serviced by one meal cart via elevator from the ground floor kitchen. On 3/6/2019 at 1:00 PM the DCS arrived on the first floor hand carrying the requested lunch test tray containing cooked tilapia, broccoli and rice. The remainder of resident lunches for the floor were located in a metal food cart. At 1:02 PM the temperature of the food was taken with a calibrated thermometer in cooperation with the DCS. The tilapia measured 100 degrees Fahrenheit (F). The broccoli measured 95 F. The rice temperature could not be accurately measured due to the interstitial space between the…

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

Based on observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 3/3/2019 at 8:45 AM an initial tour of the facility's food storage and kitchen was conducted and the following observations were made: 1. Boxes of chemicals including degreaser and detergent observed stored in the dry goods storage room. 2. The kitchen hand washing sink nearest the walk in refrigerator was blocked by a trash can preventing access for food service employees. 3. A mop was observed stored within a mop bucket containing dark grey water. Mop buckets should be emptied and cleaned after use and mops should be stored off the ground. 4. Wet stacked pans were observed on the drying rack. Air drying dishes is required to ensure adequate sanitization. 5. The thermometer in the walk in refrigerator was attached to the compressor under the outlet which pumps cold air into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 of facility staff, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This deficient practice has the potential to affect all residents. The findings include: On 3/3/2019 at 9:12 AM an inspection of the facility's on site emergency water was conducted with the Environmental Services (EVS) Director. Emergency water for the facility was stored outdoors in a locked wooden shed beside the dumpsters. The interior of the shed showed extensive white/brown mold growth on the top right ceiling approximately 2 feet in diameter as well as water damage to the roof and walls. The plastic containers of emergency water were stored below the mold growth on shelves. The shed did not provide insulation from freezing or extreme temperatures or shield emergency water from potential contamination from mold spores. The EVS Director confirmed that all on site emergency water for the facility was stored in this shed. These findings were acknowledged by the EVS Director at the…

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

Based on record review, observation and interview, it was determined the facility staff failed to provide Resident #23 with the most dignified existence. This was evident for 1 of 44 residents selected for resident rights during the annual survey. The findings include: Surveyor observation of Resident #23 on 3/6/19 at 12:45 PM revealed the resident's breakfast tray was still in the room, on the over-bed table and sitting in front of the resident. Of note, breakfast is usually served 8:15 AM. Observation revealed the breakfast tray was not removed until the resident was served lunch at 12:45 PM. Further observation of Resident #23 on 3/6/19 at 12:45 PM revealed the resident was in bed, in a hospital gown and the gown was noted with multiple dried stains. Interview with the interim Director of Nursing on 3/11/19 at 1:30 PM confirmed the facility staff failed to provide Resident #23 with the most dignified existence.

Based on medical record review, observation and interview, it was determined the facility staff failed to promote self-determination for Residents (#23 and #92). This was evident for 1 of 44 residents selected for review of self-determination during the annual survey process. The findings include: 1. The facility staff failed to honor Resident's 23 certification of inability to make informed decisions. Medical record review for Resident #23 revealed on 10/31/17, 2 physicians assessed the resident and determined: the resident was unable to understand and sign admission documents and other documents; unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment; unable to make a rational evaluation of the burdens, risks, and benefits of the treatment and unable to effectively communicate a decision. Further record review revealed on 11/12/18 the facility staff approached the resident about the flu vaccine. Influenza (Flu) is a viral infection that attacks the respiratory system - the nose, throat and lungs. Influenza vaccines…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 surveyor observation and resident interview during facility environmental observations it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The findings include: On 3/3/2019 the following observations were made: 1. At 9:08 AM in room [ROOM NUMBER], bed A was observed to have a bag on the floor covered in debris beside the damaged bedside cabinet. At 9:19 AM, in room [ROOM NUMBER], bed B was observed with spills and debris on the bedside table. 2. At 9:55 AM in room [ROOM NUMBER], a hole was observed in the wall next to the A bed and Resident #92 stated that the blinds in that room do not close properly. 3. At 10:42 AM in room [ROOM NUMBER], bed B was observed with a damaged footboard and a dirty wheelchair. These findings were reviewed with the Director of Nursing and Administrator on 3/11/2019.

Based on medical record review and staff interview it was determined the facility staff failed to document accurate assessment for Resident (#23) on the MDS. This was evident for 1 of 44 residents selected for review of MDSs assessment during the annual survey process. The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment the interdisciplinary team develops the plan of care…

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

Based on review of the medical record and interviews with staff, it was determined that the facility staff failed to develop a comprehensive care plan for a resident (#131). This was evident for 1 of 2 residents reviewed for urinary tract infections during the annual survey. The findings include: A care plan is a written guideline of care based on the individual resident's needs developed by an interdisciplinary team which includes nursing, rehabilitation staff, and dietary that communicates to other health care professionals. A written care plan decreases the risk of incomplete, incorrect or inaccurate care. During the initial resident interaction on 3-3-19 at 11:27 AM Resident #131 was asked why he/she had three urinary straight catheters lying on top of the bed. Resident #131 said the catheters were for him/her to do a straight catheter insertion to empty his/her bladder. Resident #131 performs self-catherizations every 6 hours due to a paralyzed bladder from being a paraplegic. On 3-7-19 at 12:00 PM Employee #10 stated Resident #131 performs his/her own catherization to empty…

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

Based on medical record review and interview, it was determined the facility staff failed provide care to promote the highest well-being to residents. The facility staff failed to obtain an infectious disease consultation for Resident (#12) as ordered; failed to obtain a Hematology/Oncology consultation as ordered for Resident (#71) and failed to provide a dressing change as ordered for Resident (#251). This was evident for 1 of 44 residents selected for review for provision of care during the annual survey process. The findings include: 1. The facility staff failed to obtain an infectious disease consultation as ordered by the physician. Medical record review for Resident #12 revealed on 11/4/18 and 11/9/18 the physician ordered: infectious disease consultation. Infectious diseases are disorders caused by organisms - such as bacteria, viruses, fungi or parasites. Further record review revealed the facility staff failed to obtain the consultation as ordered by the physician. Interview with the interim Director of Nursing on 3/11/19 at 1:30 PM confirmed the facility staff failed to…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#23) with a sippy cup as ordered and failed to notify the Certified Registered Nurse Practitioner (CRNP)/physician of a weight loss for Resident (#71). This was evident for 2 of 44 residents selected for review during the annual survey process. The finding includes: 1. The facility staff failed to provide Resident #23 with a sippy cup. Medical record review for Resident #23 revealed on 2/27/18 the physician ordered: sippy cup. A sippy cup has a screw or snap on lid and a spout that lets the resident drink without spilling. Surveyor observation of the resident's breakfast on 3/6/19 at 8:30 AM and lunch on 3/6/19 at 12:00 PM revealed the facility staff failed to supply the resident with the sippy as ordered by the physician. Interview with the interim Director of Nursing on 3/6/19 at 1:30 PM confirmed the facility staff failed to provide Resident #23 with a sippy cup as ordered by the physician. 2. The facility staff failed to notify the CRNP or physician of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews with facility staff, it was determined that the facility staff failed to obtain and administer an ordered pain medication (Resident # 304) and failed to follow physician orders in administering a pain medication (Resident #84). This is evident for 2 out of 3 residents reviewed for pain management. The findings include: 1. Resident #304 was ordered on admission [DATE] methadone 15 mg three times a day for pain. Resident #304 received the ordered methadone on 11-1-18 at 12:00 AM, 11-2-18 at 8:00 AM, 4:00 PM and 12:00. The methadone was not administered on 11-3-18 at 8:00 AM, 4:00 PM, 12:00 AM and 11-4-18 at 8:00 AM. The 4 missed doses were due to the facility not having the Controlled Substance Prescription signed by the physician. The facility filled out the form on 11-2-18 but did not have the physician sign and fax the form to the pharmacy until 11-4-18 at 11:33 AM. After the 11-3-18 dose was not available Employee #12 stated during interview on 3-7-19 at 8:00 AM…

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

Based on medical record review and interview, it was determined the facility staff failed to have enough staffing to ensure Resident #71 was provided an escort for an appointment. This was evident for 1 of 44 residents selected for review of enough staffing during the survey process. The findings include: Medical record revealed on 2/19/19 Resident #71 was seen in a cardiology consultation. At that time, it was ordered for the resident to return to the clinic on 3/1/19 to have device checked. Interview with the Certified Registered Nurse Practitioner on 3/7/19 at 11:30 AM revealed Resident #71 has a: Linq ICM System in place. The Reveal LINQ (Trademark) Insertable Cardiac Monitor is a wireless and powerfully small insertable cardiac monitor ideal for patients experiencing infrequent symptoms that require long-term monitoring or ongoing management. The study using small, subcutaneous implantable cardiac monitors for long-term, 24-hour a day monitoring, detected a high incidence of atrial fibrillation (AF) in patients previously undiagnosed but suspected to be at high-risk for AF and…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain a psychiatric consultation for Resident #84 in a timely manner. This was evident for 1 of 44 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #84 revealed on 2/5/19 the physician ordered: psychiatric consultation for depression. Depression is classified as a mood disorder. It may be described as feelings of sadness, loss, or anger that interfere with a person's everyday activities. Further record review during the survey process revealed the facility staff failed to obtain the psychiatric consultation as ordered. Interview with the interim Director of Nursing on 3/11/19 at 1:30 PM confirmed the facility staff failed to obtain the psychiatric consultation as ordered for Resident #84.

Based on medical record review and interview, it was determined the consultant pharmacist failed to conduct a thorough medical record review to identify and bring to the facility staff's attention Resident #23 not receiving blood pressures and heart rate ordered by the physician. This was evident for 1 of 5 residents selected for review of un-necessary medications. The findings include: Medical record review for Resident #23 revealed on 2/5/18 the physician ordered: Carvedilol 6.25 milligrams by mouth 2 times a day for blood pressure, hold for SBP (systolic blood pressure-top number less than 110 and heart rate less than 60). Carvedilol is used to treat high blood pressure. This drug works by blocking the action of certain natural substances in your body, such as epinephrine, on the heart and blood vessels and this effect lowers the heart rate and blood pressure. Carvedilol belongs to a class of drugs known as alpha and beta blockers. On 2/5/18 the physician ordered: Procardia XL, 90 ER (extended release) milligrams by mouth 1 time a day, call physician for SBP above 170. Procardia…

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

Based on observation and staff interview, it was determined the facility staff failed to dispose of garbage and refuse properly. The findings include: An observation of the facility's dumpster/trash disposal area was conducted on 3/3/2019 at 9:11 AM with the Environmental Services (EVS) Director (Staff #6). Discarded medical gloves and trash were observed on the ground beside the dumpster. Garbage and refuse should be disposed of properly to prevent harborage and feeding of pests. The findings were acknowledged by the EVS Director.