Future Care Charles Village

Based on observations and interviews, it was determined that the facility failed to provide activities to meet the needs and preferences of residents. This was evident for 2 (Resident #13 and #119) of 2 residents interviewed for activities during the annual survey.The findings include:On 9/29/2025 at 2:30 PM, the surveyor observed 14 residents on the first-floor dining/activities room and noted that eight residents were sitting in their wheelchairs, and six residents were sitting in the Geri chairs, where two residents have fully extended their recliner seats positioned to elevate their legs. When the surveyor asked to speak with resident #13, five other residents had to rearrange their chairs out of the dining/activities room to allow the resident to exit from the corner of the limited spaced dining/activities room.On 10/2/2025 at 9:30 AM, the surveyor observed five residents on the second-floor dining/activities room and noted that three residents were sitting in front of the large screen TV while two other residents were staring out the windows.On 10/3/2025 at 2:15 PM, 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, medical record review and interviews with residents, residents' family members and facility staff, it was determined that the facility failed to: 1) ensure ordered splints were in place, 2) failed to get an X-ray and the appropriate higher level of care for a resident who had sustained a fall that had resulted in a hip fracture in a timely manner, 3) failed to get a resident who was experiencing abdominal pain and had made multiple request for the facility to call 911 transported to the hospital in a timely manner. This was evident for 2 (Resident #2 and #15) of 2 residents reviewed for neglect during the annual survey.The findings include:1) Surveyor completed a tour of the facility and multiple observations of Resident #2 on 9/2/2025. During these observations Resident #2 was observed lying in his/her bed without any noticeable splints or braces in place. Upon review of the Medication Administration Record (MAR), it was discovered that the nurse had signed off that the splints had been applied but failed to do so. The Director of Nursing (DON) was notified.2)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 surveyor observation, facility staff interview, and surveyor record review it was determined that the facility failed to follow appropriate respiratory care and services. This was found to be evident in 1 (Resident #30) out of 2 Residents reviewed for respiratory care and services.The findings include:On tour of Unit 3 on 9/29/2025 at 2:35 PM the surveyor observed Resident #30 in bed with an oxygen concentrator in the room in use. There was not an oxygen signage posted on Resident #30's room door upon entry to the room.The surveyor conducted a record review of Resident #30's medical record on 10/2/2025 at 7:45 AM. Review of the medical record revealed that Resident #30 had a current physician order dated 6/3/2025 for oxygen via nasal cannula at 3 liters/minute every shift for shortness of breath.Additionally, the surveyor reviewed the nursing home facility's Respiratory Therapy: Oxygen Therapy Policy and Procedure on 10/2/2025 at 8:15 AM. The policy indicated that oxygen will be delivered in a safe manner.In an interview with the Unit Manager on Unit 3 at 11:10 AM on…

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

Based on observations, record review, and interviews, it was determined that the facility failed to provide sufficient physician-ordered thickened drinks to maintain resident hydration needs and preferences. This deficiency was evident for 1 (Resident #13) of 1 resident reviewed during the annual survey.The findings include:On 9/29/2025 at 2:30 PM, the surveyor observed Resident #13 in the dining/activities room without a hydration cup at the table. The surveyor requested to escort the resident back to their room for a private conversation, whereupon the resident requested a cup of water.On 9/30/2025 at 9:40 AM, the surveyor observed Resident #13 with a therapist; however, no hydration cup was present next to the bedside tray table or dresser drawer.On 10/2/2025 at 10:20 AM, the surveyor observed Resident #13 with a therapist; however, no hydration cup was present next to the bedside tray table or dresser drawer.On 10/3/2025, at 12:49 PM, a record review indicated that the resident was on a regular diet, level 7, and level 2 mildly thick consistency liquid, with no straws and no…

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

Based on record review and interview with facility staff, it was determined that the facility failed to ensure that the resident's Treatment Administration Record was documented in accordance with physician's orders. This was evident for 1 (Resident #114) of 1 resident's records reviewed during the survey.The findings include:On 10/3/2025 at 3:05 PM, a record review indicated that Resident #114 had a physician's order for a topical ointment to be applied to the right hip four times a day for pain. A record review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that Staff #8, Staff #29, and Staff #30 made 11 consecutive entries over a three-day period, from 3/6/2025, to 3/8/2025, indicated that the topical ointment was applied to the resident's both hips.On 10/6/2025 at 9:45 AM, the surveyor requested the Regional Clinical Services Nurse to verify the inconsistency noted in the resident's MAR and TAR report.On 10/7/2025 at 9:00 AM, the Administrator and the Regional Clinical Services Nurse confirmed that all three staff have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with facility staff, it was determined that the facility failed to provide a call bell system accessible to residents in the restrooms. This was evident for 3 of 3 restroom call bell systems reviewed during the annual survey.The findings include:On 9/29/2025 at 11:00 AM, the surveyor observed that the restroom call bell cords in rooms [ROOM NUMBERS] were wrapped around the toilet handrails making them inaccessible to residents if they were on the restroom floors.On 10/3/2025 at 1:40 PM, the Regional Director of Operations was informed of these findings and confirmed that the call bell cord would be extended to the restroom floors to ensure resident accessibility.On 10/6/2025 at 12:05 PM, the surveyor noted an additional restroom call bell cord in room [ROOM NUMBER] wrapped around the toilet handrail making it inaccessible to residents if they were on the restroom floor.The Administrator, Regional Director of Nursing (DON), Regional Clinical Services Nurse, and the DON were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations, and interview it was determined that the facility staff failed to: 1) consistently document whether a resident was having psychotropic medication side effects or behaviors. This deficient practice was evidenced in 1 (Resident #32) of 3 Behavioral Records reviewed during the survey; and 2) document in the progress notes, the consent of the resident or the resident representation prior to the installation of the side rails. This was evident for 3 out of 3 residents, (#2, #28, and #80) reviewed for siderail consent. The findings include: 1) On 01/12/24 on 12:15 pm Review of Resident #32's Behavioral Record for November 2023 there was no documentation on the behavioral record on 11/18/23 and 11/19/23 during day shift for signs and symptoms of depression, inappropriate behaviors towards female staff, or psychotropic medication side effects. In December 2023 there is no documentation on 12/04/23, 12/09/23, and 12/14/23 for behavioral monitoring for signs and symptoms of depression, inappropriate behaviors towards female staff, or psychotropic…

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

Based on staff interviews and observations, it was determined the facility staff failed to: 1) provide a resident with a locked cabinet to secure valuables, and 2) maintain residents' shower rooms to be operational, usable, and in good repair. This was evident in 1(#59) of 1 resident records reviewed for accommodation of needs during the survey and 6 out of 9 resident shower stalls observed during the survey. The findings include: 1) On 01/10/24 at 10:05 am during an interview with Resident #59, he/she reported having money taken from his/her drawer a month prior and requested to have a lock on the bedside table. The surveyor checked the bedside table, and a lock was not in place. On 01/18/24 at 2:16 pm, the Administrator reported a Concern Form was completed in November 2023 and they spoke with the resident. He/she indicated she misplaced the money and didn't believe it was taken. A lock box with a key will be provided. Review of the Concern Form dated 11/01/23 revealed that maintenance would apply a lock to her stand/closet. On 01/23/24 at 10:52 am during 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3) An observation was made on 1/18/24 at 11:00 AM of a resident room during an interview with the resident to discuss concerns. Resident #141 stated that a mouse was seen in the room and that the mouse retreated in a hole that is in the wall behind the toilet. At that time an observation was made of the bathroom and there was a hole in the wall next to the toilet and above the base board. It was approximately the size of 3 silver dollars. Review of the maintenance logs that were provided to the survey team indicated that the building was treated on 1/5/24 by a pest control company for mouse complaints on the first floor. An interview was conducted with the Maintenance Director on 1/18/24 at 3:40 PM and he was made aware of the resident concern regarding the mice and the observation of the hole in the resident bathroom and he stated that he would repair the hole. The Maintenance Director returned to the survey team on 1/19/24 and reported that the hole in the resident room was repaired. He also stated that the…

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

Based on record review and interview it was determined that the facility failed to protect a resident from verbal abuse. This deficient practice was evident in 1 (#241) of 4 facility reported incidents investigated during the survey. The findings include: On 01/24/24 at 2:50 pm a review of the facility's investigation of MD00184620 revealed that on 10/11/22 while providing personal care to Resident # 241 the Geriatric Nursing Assistant (GNA) #49 yelled at and spoke to Resident #241 in a demeaning manner according to the resident's roommate. On 01/24/24 at 3:24 pm further review of the investigation revealed Resident # 241's roommate reported the GNA #49 was verbally abusive to the resident. The alleged GNA was interviewed. A complaint was filed with the Maryland Board of Nursing (MBON) on 10/18/22. Review of the five-day follow-up report submitted by the facility indicated the allegation of abuse was not substantiated. On 01/26/24 at 12:38 pm the surveyor asked the Director of Nursing why abuse was not substantiated when GNA #49 was terminated on 10/18/22 and reported to the MBON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administrative record review and interviews with facility staff it was determined the facility failed to report allegations of abuse to the state agency within the two hour timeframe. This was found to be evident for 4 of 22 facility reported abuse investigations reviewed during the facility's survey. Findings include: 1) While the survey team was conducting the survey, the facility administration team was informed on 1/17/24 at 2:19 PM of an allegation of abuse by residents regarding a staff member. The facility stated to the survey team that they would investigate. A meeting was conducted with the Administration team on 1/22/24 at 10:30 AM and they gave an update to the survey team. The Administrator was asked if the facility sent an initial report to the state agency and he stated that after conducting their investigation, abuse was unsubstantiated and that it was a customer service concern provided education to the staff. The Administrator returned to the survey team on 1/23/24 and stated that he submitted a late initial report to the state agency and will follow-up by…

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

Based on record review and interview it was determined that the facility staff failed to send a copy of a resident's transfer to the hospital to the Ombudsman. This deficient practice was evident in 1 (#20) of 2 resident records reviewed for transfer/discharge paperwork during the survey. The findings include: On 01/10/24 at 11:34 am, a review of Resident #20's electronic medical record revealed the resident was transferred to the emergency department on 10/20/23. On 01/23/24 at 3:04 pm the surveyor requested a copy of the resident's transfer notice sent to the responsible party and verification a copy was sent to the ombudsman. On 01/24/24 at 9:32 am the surveyor received a copy of the October 2023 admission/discharge list that was emailed to the ombudsman on 11/01/23 at 7:12 am. Resident #20 was not included on the list. On 01/24/24 at 10:41 am during an interview with Regional Nursing Director #3 who verbalized the staff did not do the quick editing and when the Administrator pulled the report, Resident #20 was not on the list which was realized on 1/23/24.

Based on medical record review and interview it was determined that the facility staff failed to: 1) initiate a patient centered care plan for a resident who was ordered oxygen therapy, 2) initiate a care plan for a resident who had a significant weight loss, and 3) establish a care plan specific to one of the resident's primary diagnosis. This deficient practice was evident in 3 (#20, #32, #12) out of 6 resident records reviewed for the initiation of care plans for residents. The findings include: 1) On 01/17/24 A review of Resident #20's electronic medical record revealed the resident had an order for oxygen therapy. Further review of the EMR revealed the resident did not have a patient specific care plan for oxygen therapy. On 01/17/24 at 12:38 PM during an interview with Director of Nursing #1, If a resident has a diagnosis indicating the need oxygen he/she would put the care plan under respiratory or cardiac depending on the resident's needs. DON #1 confirmed Resident #20 did not have a patient specific care plan for oxygen therapy. 2) On 01/17/24 at 11:30 am a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with facility staff it was determined the facility failed to: 1) update a resident care plan to address the resident specific needs (Resident #63), 2) have quarterly care plan meetings including the dietician for a resident who had a significant weight loss (Resident #89), 3) initiate a diagnosis specific care plan for a resident during the resident's length of stay (Resident #12). This was found to be evident for 3 of 62 residents, reviewed for care plan timing. Findings include: 1) During an observation made on 1/10/24 at 12:10 PM, Resident #63 was observed lying in the bed and the resident was noted to have lesions present to the right neck area near the ear and left ear area. The area had redness with a small amount of heme (blood) present. A staff nurse who was present at the nurse station was made aware of the observation and she stated that she would assess the resident. Resident #63's medical record was reviewed on 1/23/24 at 11:30 AM and upon review it revealed the…

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

Based on record review and interviews it was determined that the facility staff failed to provide a summary of a resident's stay and a copy of the most recent comprehensive assessment to a resident who initiated a discharge. This deficient practice was evident in 1 (#241) of 1 resident-initiated discharge record reviewed. The findings include: On 01/25/24 at 10:14 am a review of Resident #241's electronic medical record (EMR) revealed the resident was discharged on 07/01/23. On 01/25/24 at 11:01 am during an interview with Director of Social Services #5 revealed the resident initiated the discharge so arrangements were made after gathering information with the resident for needs at home and process is to provide discharge instructions, prescriptions and a medication list. On 01/25/24 at 11:05 am the surveyor requested to view Resident #241's discharge instructions, post discharge plan of care, and all the documents provided to Resident #241 when discharged . On 01/25/24 at 11:40 am the surveyor reviewed Resident #241's post discharge plan of care, 17 prescriptions, and a 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 reviews, observations, and interviews it was determined that the facility failed to ensure that residents requiring assistance with activities of daily living (ADL's) such as bathing and/or showering were provided these services. This was found to be true for 3 of 3 residents (#32, #38, and #82) reviewed for activities of daily living. The findings include: 1. On 1/22/24 at 10:12 AM the surveyor toured three clinical units in the facility. The surveyor was informed by the administrator that there were three single occupancy resident rooms with private showers. The surveyor observed that the bathroom in room [ROOM NUMBER] did not have a shower curtain and there was storage of a wheelchair, and walker inside the shower stall. Resident #82 was present in his/her bed watching the TV, dressed in civilian clothes. At approximately 10:15 AM on 1/23/24 the surveyor interviewed Resident #82 who stated that he/she had not been provided a shower since his admission, but the staff had assisted him…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility staff failed to prevent new pressure ulcers/in-house acquired wounds from occurring. This was evident for 2 (Resident #242 and #92) out of 3 residents reviewed for new pressure ulcers during the survey. The findings include: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved prolonged pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and /or eschar in the wound bed). 1). Record review, on 01/25/24 at 11:50 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 administrative record review and interviews with facility staff it was determined the facility failed to: 1) ensure annual staff performance reviews were completed as required, 2) ensure an annual performance review for the facility Geriatric Nurse Aides (GNAs), 3) provide performance related outcomes based staff education. This was found to be evident for 1 of 7 clinical employee files reviewed and for 1 of 5 GNA's that were reviewed during the survey. Findings include: On 1/26/24 at 2:00 PM two employee files were reviewed after Resident #143 reported allegations of abuse to the facility staff on 1/24/24. Upon review of the employee file for Licensed Practical Nurse (LPN) #43 who was hired in 2021 did not contain documentation of a performance evaluation. Further review of LPN #43's file revealed a documented disciplinary notice dated 11/15/22 with an (x) documented next to written warning, for not following proper infection control procedures. On 1/4/23 LPN # 43 did not complete schedule evaluations for a shift and on 1/5/23 she did not complete lab report 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.

Based on observations, interviews and review of facility documentation the facility failed to properly store medications and biologicals under proper temperature controls according to professional standards. This was evident in 1 out of 3 medication storage refrigerators observed during the survey. The findings include: During observation rounds of the facility 2nd floor medication storage room on 01/12/24 at 11:37 AM with Staff (#3) the refrigerator storing medications and biologicals thermometer read 58 degrees F. Several medications and biologicals for facility residents were found in this refrigerator. During an interview on 01/12/24 at 11:50 AM Staff (#3) stated that yes, the refrigerator was too hot and confirmed that the refrigerator thermometer read 58 degrees F. Staff (#3) stated that he/she will get someone to come now to fix it. Review of facility policy for Medication Storage on 01/12/24 at 3:30 PM revealed that medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are to be kept in a secure refrigerator with a thermometer to allow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, it was determined that the facility failed to follow a resident's food intolerance list and to honor requested double-portion meals. This was evident for 1 (Resident #391) out of 9 residents reviewed for food preference and nutritional adequacy. The findings include: On 1/9/23 at 10:28 AM, the surveyor interviewed Resident #391 who stated I could not do too much .too weak and needed to re-strengthen. I was hungry and told the staff that I need .more food on my tray, like a doubled portion. This resident was observed in bed with a 30 degrees up sitting position. Visibly excessive nasal and neck muscles were being used to gain air intake from his/her oxygen supply. During record review on 1/11/24 at 13:19 PM, it was revealed that Resident #391 was admitted to the facility on [DATE] after an intensive care hospitalization. The resident had a history of gastro-esophageal reflux disease (GERD). Gastroesophageal reflux disease (GERD) is a common condition in which 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 interview regarding the facility kitchen's operation, it was determined that the facility failed to store food in accordance with professional standards for food service to prevent the potential for contamination. This was evident for 2 out of 3 observations in the kitchen. The findings include: On 1/9/24 at 10:31 AM, a tour was conducted in the kitchen with Regional Kitchen Director Staff #13. The surveyor observed and pointed out that there was a bucket sitting on the floor with labeled food items and dates. Further observation, on 1/22/24 at 10:00 AM, revealed that a stack of fresh bread in eight large trays was sitting on the kitchen floor in the middle of a high foot traffic area. The last tray was only less than one inch from touching the floor. During interview, Kitchen Director Staff #39 stated that she was about to move the bread.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility staff failed to maintain infection control practices as evidenced by a resident's oxygen tubing being uncovered and draped over the oxygen concentrator and five used, unlabeled, and undated urinals being left in the bathroom cabinet. The deficient practice had the potential to affect Resident #20 and the residents who reside in room [ROOM NUMBER]. The findings include: During observation rounds on Unit 1 on 01/09/24 at 9:32 am, while in Resident #20's room the surveyor observed the resident's oxygen tubing draped over the oxygen concentrator. Under further inspection the surveyor noted the oxygen tubing was not labeled or dated. The sterile water connected to the oxygen concentrator was not labeled or dated. Geriatric Nursing Assistance (GNA) #7 was in the resident's room and confirmed the surveyor's findings. On 01/10/24 at 2:05 pm while in room [ROOM NUMBER]'s bathroom, the surveyor observed five used urinals under the bathroom sink. 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.

Based on observations and interviews of facility staff it was determined the facility failed to ensure an effective pest control as flying gnats were observed throughout the building. This was found to be evident during the survey. Findings include: During the survey multiple observations were made of gnat sightings throughout the building. On the first day of the survey on January 9, 2024, surveyors were placed in one of the facility's rooms and with multiple flying gnats observed in the room. During a resident council meeting conducted on 1/11/24 at 10:00 AM in the dining room on the second floor, the residents that were in attendance were swatting at the gnats throughout the meeting. The residents stated that at one time, the problem with the gnats were brought under control, but currently, it has been an ongoing problem. A meeting was conducted with the Regional Director of Operations (RDO) Staff # 5 and the DON on 1/11/24 at approximately 10:38 AM after the resident council meeting, to make the facility aware of the resident's concerns. They told the survey team 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 medical record review and interviews it was determined that the facility failed to ensure the resident, or the resident's representative, was notified in writing regarding the reason for a hospital transfer. This was found to be evident for two out of four residents (Resident #85 and #52) reviewed for hospitalization during the survey. The findings include: 1) On 2/14/19 review of Resident #85's medical record revealed the resident had resided at the facility for several years and whose diagnosis included severe dementia. The resident had a hospital transfer in December 2018. On 2/14/19 at 2:14 PM the Unit Nurse Manager #13 reported that a Notice of Facility Initiated Transfer form is sent with the resident to the hospital, a copy is kept on the chart and one is mailed to the responsible party. Further review of the medical record failed to reveal documentation that the resident or the responsible party had received a Notice of Facility Initiated Transfer. On 2/14/19 at 2:19 PM this information was reviewed with the Unit Nurse Manager. On 2/14/19 at 2:42 PM the corporate…

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

Based on medical record review and interviews it was determined that the facility failed to ensure the resident, or the resident's representative, was notified in writing of the bed-hold policy at the time of a hospital transfer. This was found to be evident for two out of four residents (Resident #85 and #52) reviewed for hospitalization during the survey. The findings include: 1) On 2/14/19 review of Resident #85's medical record revealed the resident had resided at the facility for several years and whose diagnosis included severe dementia. The resident had a hospital transfer in December 2018. On 2/14/19 at 2:14 PM the Unit Nurse Manager #13 reported that the bed-hold policy is sent with the resident to the hospital, a copy is kept on the chart and one is mailed to the responsible party. Further review of the medical record failed to reveal documentation that the resident or the responsible party had received a copy of the bed-hold policy at the time of the December 2018 transfer. On 2/14/19 at 2:19 PM this information was reviewed with the Unit Nurse Manager. On 2/14/19 at 2:42…

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

Based on medical record review, and interview with facility staff it was determined that the facility failed to develop person-centered comprehensive care plans as evidenced by 1) failure to develop a care plan to address a resident diagnosis and 2) failure to develop a care plan to address the prevention and treatment of pressure ulcers. This was found to be evident for two out of twenty-four residents (Resident #78 and #398) reviewed during the investigative stage of the 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 2/13/19 Resident #78's medical records were reviewed and revealed the resident was originally admitted to the facility in December 2018 for long term care and with diagnosis which included breast cancer. Further review of the medical records revealed that the resident had monthly follow-up related to the diagnosis and was currently receiving chemotherapy. Review of the care plans failed to reveal a care plan for cancer. During…

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

Based on medical records review and interview with staff it was determined that the staff failed to 1) revise care plans with appropriate goals and interventions and 2) review and revise the care plan for a resident after a significant change. This was found to be evident for two of twenty-nine residents (Resident #78 and #397) reviewed for care plan timing and revisions during the investigative stage of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress. 1) Review of Resident #78's medical record on 2/13/19 revealed the resident's diagnoses which included cancer and a remote history of substance abuse. Review of the resident medical records also revealed that the resident developed a wound secondary to her/his medical diagnosis. Further review of the medical records revealed weekly visits by the wound team. Review of the impaired skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow their policy for proper notification of a physician when Resident #62 left the facility. This was evident for one out of one residents (Resident #62) reviewed during closed record reviews. Findings include: A medical record review conducted on 02/14/19 at 10:03 AM for Resident #62 revealed Resident had signed out Against Medical Advice (AMA) on 1/30/19 and left the facility. Review of the facility's policy regarding Residents signing out AMA conducted on 02/15/19 at 08:57 AM revealed the Administrator and attending physician must be notified immediately of the AMA discharge. Review of medical record at this time failed to provide documentation of either the Administrator or physician being notified on 1/30/19. These concerns were discussed during an interview with the Corporate Manager on 2/15/19 at 11:00 AM who confirmed that no documentation was found verifying that the Administrator and physician had been notified when Resident #62 signed out AMA on 1/30/19.

Based on medical record review and interview with facility staff, it was determined that the facility failed to: 1) have an effective system in place to ensure that the hand off communication regarding resident consultations and prescriptions were clearly and effectively communicated with staff and 2) make a referral to hospice in a timely manner. This was evident for two of twenty-nine residents (Resident #78 and #93) reviewed during the investigation process of the long-term care process. The findings include: 1) On 2/15/19 Resident #78's medical records were reviewed. This review revealed that the resident was admitted to the facility in 2016 for long term care and with diagnoses which included cancer, Lymphedema (swelling that generally occurs in one of your arms or legs and is most commonly caused by the removal of or damage to your lymph nodes as a part of cancer treatment). Medical record review also revealed that the resident had monthly visits with the Oncologist. Further review of the medical records revealed that on 1/4/19 the resident returned from the oncologist…

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

Based on medical record review and staff and resident interviews it was determined that the facility failed to properly assess and implement interventions to prevent the development of a pressure ulcer for Resident #398. This was evident for one out of five Residents investigated for pressure ulcers. Findings include: A medical record review conducted on 02/12/19 at 02:40 PM revealed documentation that on 2/8/19 Resident #398 had developed a new Stage II sacral pressure ulcer. Further record review at that time revealed this resident had diagnoses of but not limited to a left leg above the knee amputation, iron deficiency anemia and generalized weakness. Although there were several documented occasions that the Resident was refusing care, i.e. physical therapy and showers, the facility failed to implement strategies to encourage him/her to do so. A resident interview was conducted on 02/14/19 at 01:13 PM. The surveyor asked Resident #398 how often someone helps him/her change positions and/or get out of the bed. The resident stated only when h/she asks or when they bring the food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide Resident #397 with the necessary behavioral health care in the expected time frame. This was evident for one out of two residents (Resident #397) noted to be receiving behavioral health services. Findings include: Record review on 02/12/19 on 03:00 PM for Resident #397 revealed an eInteract change of condition note written on 1/31/19 that stated the Resident was depressed and a possible suicide potential. Further record review revealed that on 1/31/19 the Social Worker (SW) #25 met with Resident #397 and determined h/she was not a suicide risk, however h/she was depressed and did not desire to live anymore. At that time the SW called the physician who wrote an order for a psychology consult. During an interview with SW #25 conducted on 02/15/19 at 11:35 AM she revealed per her evaluation on 1/31/19 of Resident #397 that the Resident was sad and depressed over his/her current medical conditions and wanted to die but did not have a plan to hurt his/herself. An interview with the Corporate…

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

Based on medical record review and interview with facility staff it was determined that the facility failed to maintain records that were legible. This was evident during the review of two of two medical records (Resident #38 and #93) reviewed during the annual review. The findings include: 1. Review of the medical record for Resident #38 regarding unnecessary medications on 02/14/19 at 10:56 AM revealed physician notes from 1/29/18 thru 1/27/18 that were not legible to the surveyor. The Corporate Nurse and Unit Manager and Director of Nursing (DON) were subsequently called in and asked to read the physician notes from the Physician in the presence of the survey team. They were unable to decipher the entirety of the physician notes from 1/29/18 thru 1/27/19. 2. During the review of the medical record for Resident #93 on 2/15/19 at 8:31 AM surveyor attempted to review the physician documentation related to the resident's assessment. Again, the surveyor was unable to decipher the physician's documentation and showed the physician notes to the Corporate Nurse on 2/15/19 at 2:49 PM who…

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