Future Care Cold Spring

Based on record review and interviews it was determined that the facility staff failed to follow the standard of practice for nurses as evidenced that a nurse failed to notify the physician when a resident refused a treatment and a nurse completed a Change in Condition Evaluation 11 days after the change occurred. This deficient practice was evidenced in 2 (#124 & #125) of 5 resident records reviewed during the recertification survey. The findings include: On 09/30/25 at 11:35 AM a review of Resident #124 electronic health record (EHR) revealed Registered Nurse (RN) #10 completed a change in condition evaluation on 07/07/25 and the form was back dated to 06/26/25. On 09/30/25 at 12:13 PM during an interview with the Director of Nursing (DON) the surveyor asked when the staff are expected to document when a change occurs with a resident. The DON verbalized a change in condition evaluation form should be completed before the end of the shift. The Unit Managers or supervisors are supposed to ensure the staff completes documentation in a timely manner. On 10/03/25 at 8:55 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.

Based on record review and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent Residents. This was evident in 1(Resident #4) out of 2 Residents reviewed for Activity of Daily Living (ADL) care. The findings included: On 10/1/25 at 8:17 AM, the surveyor reviewed Resident #4's medical record. A note written by Physician # 27 on 9/25/25 stated Resident #4 was recently admitted to the facility after functional decline in ambulation and Activities of Daily Living (ADLs) due to a fall with fractures and right upper extremity weakness. On 9/30/25 at 9:35 AM, the surveyor observed Resident #4 in the lounge area in a reclining chair. The surveyor noted long nails on all of Resident's left fingers which all appeared to be 1/2 inch long and had a dark substance under them. The surveyor reviewed the TASK documentation for Activity of Daily Living (ADL) cares for personal hygiene for Resident #4 for the month of September. Resident #4 was documented as dependent for ability to maintain personal hygiene. No refusals…

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 record reviews, the facility failed to maintain acceptable parameters of nutrition for residents and address significant weight gain. This was evident for 1 (Resident #8) out of 5 residents reviewed for nutrition during the annual survey. Significant weight change is defined as a gain or loss of 5% of a person's weight within 30 days, 7.5% within 90 days, or 10% within 180 days. Significant weight change requires clinical evaluation and, if the change is not beneficial, intervention. The findings include: On 10/1/25 at 12:42 AM, the surveyor reviewed the medical record for Resident #8. The review revealed that Resident #8 was admitted to the facility in January of 2024. Resident #8's past medical history included major depressive disorder, peripheral vascular disease, acquired absence of the leg above the knee, and dementia. Further review of Resident #8's medical record revealed weights taken:9/1/25 212.6 Pounds (lbs)8/13/25- 211 lbs8/8/25- 202.8 lbs7/31/25- 203.4 lbs7/2/25- 203.2 lbs6/24/25- 203.26/17/25- 211.2 lbs6/11/25- 212.3 lbs6/6/26- 209…

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, staff interviews and clinical record review, it was determined that the facility staff failed to ensure that a tube feeding bag was labeled. This was evident for 1 resident ( #89) of 3 residents reviewed for tube feedings during the annual survey. The findings include: On 09/29/2025 at 10:57 AM during an initial observation of Resident #89, both the tube feeding formula bag and the flush bag were found hanging on the tube feeding pump. The formula bag was full, and the flush bag was half full. Neither bag was labeled with the resident's name, the type of formula, the date and time the bag was hung, or the name/initials of the staff member who hung them. On 09/29/2025 at 11:15 AM Staff #6, a Registered Nurse (RN), confirmed that Resident #89 receives daily tube feedings. When shown the unlabeled bags and asked about the formula, the recipient, the hanging time, and the staff member responsible, Staff #6, RN stated, I am not sure if Resident #89 received the tube feeding because another shift hangs the bag and night shift takes the bag down by 6:00 AM. Staff #6,…

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's physician failed to acknowledge and/or address recommended interventions for a resident with significant weight gain. This was evident in 1 (Resident #8) out of 5 residents reviewed for nutrition. The findings included: On 10/1/25 at 12:42 AM, the surveyor reviewed the medical record for Resident #8. The review revealed that Resident #8 was admitted to the facility in January 2024. Resident #8's past medical history included major depressive disorder, peripheral vascular disease, acquired absence of the leg above the knee, and dementia. Further review of Resident #8's medical record revealed weight changes over a year. Resident #8 had an 11.13% weight gain from 10/3/24 to 3/6/25 during this 6-month time period, and a 23.75% weight gain from 3/6/25 to 9/1/25, during this 6-month time period. Next, the surveyor reviewed the dietary progress notes. On 6/12/25, a note written by Dietitian #31 confirmed weight gain from the reweight obtained and stated she continued to question a +41 pound weight gain in 6…

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 Geriatric Nursing Assistant personnel files and staff interview, it was determined that the facility failed to complete required annual performance reviews for Geriatric Nursing Assistants (GNAs) at least once every 12 months. This finding was identified for 2 of the 3 GNA staff members (GNA #22 and #23) reviewed during the annual survey. The findings include: On 10/6/2025 at 9:45 PM, annual competencies for three random GNA's were requested. Record reviews revealed that Staff #22, GNA and Staff #23, GNA did not have their annual performance reviews for 2024 and 2025. On 10/06/2025 at 11:56 AM Staff #5, the Regional Clinical Service Manager (RCSM), was interviewed and asked if any additional documentation could be provided for Staff #22 and Staff #23's annual GNA performance reviews. Currently, Staff #22's last annual GNA performance review was on 6/27/2023 and Staff #23's last annual GNA performance review was on 6/29/2023. Staff # 5 RCSM stated what I have given you is all the documentation that I have for these staff members. Staff #5, the RCSM, verbalized…

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, the facility staff failed to 1) obtain and administer medications according to procedures and, 2) failed to accurately and safely to conduct and apply before each meal's insulin sliding scale. This was evident for two residents (#133 and #43) out of 10 reviewed for medications. The findings include:1) On 10/6/25, at 1:06 PM, the surveyor reviewed Resident #133's medical record. The Medication Administration Record (MAR) for May 2024 indicated that four different medications were coded 9 (other, see progress notes) in the administration documentation. Three of those medications had progress notes that stated the medication was ordered, but the pharmacy still needed to deliver them to the facility. The medications were: Famotidine (start date of April 9, 2024) coded 9 on May 3, 2024. Levothyroxine (start date of December 2, 2023) coded 9 on May 29, 2024. Nasal Moist Nasal Solution (start date of May 25, 2024) coded 9 on May 26, 2024. On 10/6/25, at 1:02 PM, the surveyor interviewed Staff #5, the Regional Clinical Service Manager.…

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

Based on a review of the medical record and interviews with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists. This was evident for 1 (#12) of 51 residents reviewed during the annual survey.The findings include:During a review of the consulting pharmacist's monthly recommendations for Resident #12 on 10/03/2025 at 8:30 AM, it was recommended that the prescriber document a rational for use and a duration date for lorazepam. The physician reviewed the recommendation and signed that they would refer to end of life consultant. The current order read, LORazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml by mouth every 6 hours as needed (PRN) for anxiety, agitation end of life care -Start Date08/05/2025 1045. No end date was written. The review was signed as completed by Physician #30. During an interview Physician #30 acknowledged on 10/03/2025 at 11:40 AM, that although the recommendation for the indication for end of life care was made, there was no stop date added as recommended by the Clinical Pharmacist. 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 a record review and interviews, the facility failed to obtain laboratory services in a timely manner. This was found evident of 1 (Resident #2) of 1 resident reviewed for laboratory services reviewed during the annual survey The findings include: On 10/1/25 at 11:47 AM, the surveyor reviewed Resident #2's medical record. The review revealed Resident #2 had a past medical history of dementia and behavioral disturbances. Resident #2's care plan listed a risk for complications related to aphasia and apraxia, affecting response to care, and noted refusal of laboratory (Lab) samples. Next, the surveyor reviewed the progress notes. On 9/26/25, Registered Nurse (RN) #29 documented that a Basic Metabolic Panel (BMP) result was cancelled due to a missing date of birth (DOB) identifier. The note further states that the provider was informed, and a new order for a BMP for Monday 9/29/25 was given. On 10/1/25 at 12:59 PM, the surveyor reviewed Resident #2's orders. No order was found for a redraw of the BMP lab. On 10/2/25 at 1:46 PM, the surveyor interviewed the Director of Nursing…

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

Based on record reviews and interviews it was determined that the facility staff failed to ensure two Geriatric Nursing Assistants (GNA) received Dementia training upon hire and failed to complete an annual employee evaluation. This deficient practice was evidenced in three GNA records reviewed during the recertification survey. The findings include: On 09/30/25 at 2:47 pm a review of Geriatric Nursing Assistant (GNA) #17 employee training record revealed the GNA was hired in March 2025 and did not receive Dementia training. On 10/01/25 at 2:22 pm a review of GNA #18 employee training record revealed there was no documentation to verify the GNA received Dementia training. The GNA was hired on 07/08/24 and was terminated on 04/04/25. A review of GNA #36 employee record revealed the GNA was hired on 04/24/24 and is currently working in the facility. The GNA did not have their annual evaluation after one year of employment. On 10/01/25 10:06 am during an interview with Regional Director of Operations #37 verbalized they don't have evidence to verify GNA#17 received Dementia training,…

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 ensure the amount of the surety bond was comparable to the amount of the resident funds entrusted to the facility. This was evident during a review of Personal Funds during the recertification survey. The findings include: On 3/07/24 at 8:42 AM during an interview with the Nursing Home Administrator (NHA) and the Corporate Accounts Receivable Manager (Staff #33), Staff #33 indicated that resident's personal funds were kept in separate accounts and that the facility had a surety bond to cover the total amount of residents' personal funds. The surveyor asked for a list of residents who had personal fund accounts, the total amount of resident personal funds held by the facility, and for a copy of the surety bond. On 3/07/24 at 12:55 PM a review of the document titled Trial Balance which indicated an as of 03/07/24 date, revealed a list of 75 residents and their corresponding account balances which totaled $172,021.92. A review of the surety bond revealed the Bond Amount: $170,000.00 with an effective…

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 residents and staff it was determined the facility failed to ensure food was palatable and served at a safe and appetizing temperature. These deficient practices have the potential to affect all residents. The findings include: On 2/23/24 at 9:02AM the surveyor conducted an interview with Resident #22 who reported the following concern: The person in charge of the kitchen is no longer here, we were getting really good food, but now, we get food like chicken a'la king with no taste to it, I couldn't eat it. By the time food gets to us, it is cold, our cart is the third cart. On 2/22/24 at 10:50AM the surveyor conducted an interview with Resident #116 who described the facility's food as terrible and reported that most of the time, they did not eat it. On 2/23/24 at 8:50AM the surveyor conducted an interview with Resident # 57 who reported they did not like the food, and it is always cold, never get a warm meal. On 3/11/24 at 12:24PM the surveyor observed the serving line and steam table as lunch was being served and noted that steam was…

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

Based on observations of the facility's kitchen, review of kitchen records and interviews of dietary staff, it was determined that the facility: 1.) failed to ensure sanitary practices were followed in accordance with professional standards for food service safety; 2.) failed to store food in accordance with professional standards for food service safety, 3.) failed to store, label, and monitor expiration, of food in accordance with professional standards for food service safety, and 4.) failed to ensure monitoring and oversight of kitchen equipment and environment. These deficient practices have the potential to affect all residents. The findings include: 1.) On 2/21/24 at 7:58AM, the surveyor conducted observations of the facility's kitchen at which time the surveyor observed Staff #46, Dietary Aide, without a hair restraint, and Staff #45, Dietary Cook, standing over the steam table stirring hot cereal with no hair restraint covering their beard. On 2/21/24 at 8:02AM the surveyor observed Staff #46 obtain and put on a hair restraint. On 2/21/24 at 8:02AM the surveyor conducted an…

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

Based on observation, staff interviews and record reviews, it was determined that the facility 1.) failed to utilize appropriate infection control process with the hanging of a urinary bag (Resident #51) 2.) failed to ensure that the Infection Prevention Control program (IPCP) policy was reviewed and updated annually and 3.) failed to assure that staff were educated to handle and process dirty laundry in a manner to prevent the spread of infection. This was evident during the annual recertification survey. The findings include: 1. Upon surveyor's initial tour on 2/21/23 at 9:39AM an observation was made of Resident #51 lying in bed, Further observation revealed that he had a Urinary catheter a device that drains urine from the bladder. The urinary bag was hanging on a Velcro attached to the bed frame, half of the bag was in contact with the bare floor. On 2/21/24 at 9: 22 AM Staff #15 came into the room while the surveyor was still there, she was shown the urinary catheter touching the floor, she readjusted the bag, so it did not touch the floor and stated that she was just starting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, it was determined the facility staff failed to failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, and ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (Resident #128, #93, #291) of 5 residents reviewed for MDS accuracy, and 1 (Resident #89) of 10 residents reviewed for pressure ulcers. The findings include: The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. A pressure ulcer, also known as pressure sore or decubitus ulcer, is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) On 2/23/2024 at 9:00 AM, in an interview with Resident #57, the resident stated that s/he had facility acquired right buttocks bed sores and a right leg wound. Resident #57 further stated that the wounds were improving, and dressings changed daily. During a review of Resident #57's medical record conducted on 2/29/2024 at 8:45 AM, surveyor noted active physician orders dated 2/6/2024 for right buttock and right calf wounds to Cleanse with NSS (normal saline solution). Apply Calcium Alginate with Medi-honey cover with a border gauze daily, every day shift for wound care. On 2/29/2024 at 11:35 AM, a review of Resident #57's care plan was completed: A Plan of Care was developed for Resident #57 for Actual impaired skin integrity to right lower calf and bilateral buttocks r/t declined mobility as evidenced by pressure injury created on 2/5/2024 with revision on 2/5/2024. The interventions included but were not limited to: Monitor dressing at least every shift to ensure it is intact and adhering. However, the plan…

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 ensure that care plan meetings were conducted as required. This was evident for 4 (Resident #33, #82, #91 and #98) out of 67 residents reviewed for resident care, and one complaint (MD00178503) of 16 complaints reviewed during the recertification 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. The Minimum Data Set (MDS) is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 2/28/24 at 12:44 PM a record review of Resident #91's MDS assessment entries revealed that the resident had a quarterly MDS assessment completed for the assessment reference date 11/21/23. Further record review revealed that…

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

3) A review of Resident #98's monthly Medication Regimen Review (MMR) on 2/28/24 at 12:49 PM revealed that the pharmacist recommendations were made on 7/14/23, 8/15/23, 9/07/23, 10/05/23, 11/08/23, 12/08/23, 1/05/24, and 2/09/24 with details: On 7/14/23, the pharmacist recommended changing the hydrocortisone (for anti-itching) cream to PRN (as needed) or discontinuing it. On 8/15/23, the pharmacist commented that to clarify directions as either one tablet or two tablets for resident has a new order for Oxycodone 5mg give two tabs every 6 hours PRN for give one tab every 6 hours PRN for pain 7-10. On 9/07/23, the pharmacist recommended clarifying the same order as last month (8/15/23). On 10/05/23, the resident ordered Bio-freeze gel twice a day for the back and Menthyl 5% patch for the lower back twice a day. The pharmacist recommended clarifying which medication the resident should be receiving for the lower back. On 11/08/23, the pharmacist commented to change menthol patch and Lidoderm path order one of these to apply one at 9 AM and remove at 9 PM and other patch to be applied…

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 administrative documents, and interviews of residents and staff it was determined that the facility failed to ensure that grievances and concerns from the resident (group) council were documented, reviewed, and responses provided to the group in writing. This was evident in a review of 9 of 9 resident council meeting minutes reviewed. The findings include: An introduction interview was held with the resident council president (Resident #78) on 2/27/24 at 12:00 PM. The resident council president revealed that he/she has lived at the facility for approximately 4.5 years. Upon request the resident council president provided permission for the survey team to review resident council minutes from the past 6-months. The resident council president revealed that the activity's staff assist in conducting the meetings and recording the minutes. Additionally, the resident council president revealed that he/she has not ever reviewed the bimonthly meeting minutes. Copies of the requested resident council minutes were received on 2/28/24. Review of the resident council meeting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews it was determined that the facility failed to maintain safe, clean, comfortable and homelike environment. This was evident on 2 of 4 nursing units reviewed during both the Infection Control facility task and the Resident Council facility task. The findings include: On 3/8/24 at 10:39 AM an abbreviated tour of the environment was conducted with the maintenance director (staff #10). In the 3A central bathing room he confirmed some trash, and a broom was in a dirty nonfunctioning electronic jet tub, One of the 3 shower stalls was without a light, and in another shower stall, water was puddled in 2 areas. In the stall with the inoperable bathing tub were several holes punctured through the wallboard into the hollowness behind the wallboard. The wall on the left side upon entering the bathing room was shown to have a approximate 4 foot by 5 foot unfinished repair with noted white spackle and some scrapes and dings into the unpainted spackle. The maintenance director was unaware…

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 interviews, it was determined that the facility failed to notify the resident/resident's representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 2 (R#118, R#12) of 5 residents reviewed for hospitalization during the recertification/complaint survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1) On 2/21/24 at 12:56 PM during the initial rounds on the unit, Resident #118 revealed that s/he was sent out to the hospital late last year for a medical condition. Resident was asked if s/he was provided a notification for a bed hold prior to hospitalization and s/he stated they were unsure. A review of Resident #118's medical records on 3/5/24 at 2:11 PM revealed a nurse progress noted dated 11/24/23 which documented that resident was sent out to the hospital on November 2023 for a medical condition. On 3/6/24 at 10:10 AM a…

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

Based on medical record review and interview, it was determined that the facility failed to meet professional standards of practice as evidenced by 1) failing to ensure nursing staff documenting opioid use on the Medication Administration Record (MAR) and Controlled Drug Administration Record (also known as control sheet). This was evident for 2 (Resident #88 and #124) out of 3 residents reviewed for administration of narcotic medication, and 2) failing to ensure that a licensed nurse had specific competencies and skill sets necessary to care for a dialysis resident. This was evident during a review of a complaint incident during an annual survey. The findings include: 1) On 02/22/24 at 9:10 AM review of a complaint intake MD00200471 had that an arterial needle and clamp was left in Resident #82's dialysis access point prior to discharging resident from the dialysis session on 11/30/23. Further this was not discovered by the nurse until more than 2 hours later when the resident was found bleeding from the access site with the needle and clamp pulled out. Review of the nurses note…

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

Based on observation, record reviews and staff interviews, it was determined that the facility failed to: 1) to maintain safety by allowing the bed of a resident at risk for fall to be in the up position when care was not being provided thereby placing resident at high risk for injury. This was evident for 1 (#51) of 6 residents reviewed for accidents; 2) to assess residents' fall risk after the fall incident occurred. This was evident of 1 (Resident #98) out of 6 residents reviewed for falls; 3) ensure resident's outside consult appointment had follow-up. This was evident for 1 (Resident #292) out of 67 residents reviewed for following appointments during this recertification/complaint survey. The findings include: 1) On 3/5/24 at 8:52 AM the surveyor observed Resident #51 in bed, fast asleep. The resident's bed was elevated up to about 3 feet high, there was no one in the room and no sign that care was being rendered at the time. Review of the resident's care plan with a completion date of 1/22/24 on 3/5/24 at 9:00 AM revealed that resident had a care plan for fall related 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, staff interview, and observation, it was determined that the facility failed to provide appropriate treatment and services for the care of a resident with a urostomy upon admission. This was evident for 1 (Resident #88) of 1 resident reviewed for urostomy care during the survey. The findings include: Urostomy is a result of a surgery that creates a way for urine to leave your body in cases where your bladder is damaged or removed. During an interview with Resident #88 on 2/21/24 at 10:52 AM, the resident said, I was diagnosed with bladder cancer in 2022. Since then, I had a bag for urine. Also, the resident stated that the facility nurses did not empty, monitor, and assess his/her urostomy. A review of Resident #88's medical record on 2/27/24 at 8:20 AM revealed that the resident had an order to change urostomy per physician order within 24 hours as needed and change catheter tubing and bag for malfunction, contamination, odor or sedimentation as needed. However, there was no order and documentation for urostomy care, including monitoring and…

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

Based on observation, medical record review, and interview, it was determined that the facility staff failed to provide required care to the residents' percutaneous endoscopic gastrostomy (PEG) sites. This was evident for 1 (Resident #290) out of 2 residents reviewed for PEG site management during the survey. The findings include: A PEG is a tube that is inserted through the abdominal wall into the stomach. It is used to provide nutrition and medication to a resident. The routine care of a PEG tube site must include the regular monitoring and cleaning of the insertion site to prevent skin break down, leakage, and infections. Review on 3/11/24 at 3:23 PM of Resident #290's closed record found that he/she was admitted in March 2022 with the diagnoses of cerebral infarction, dysphagia with PEG tube placement, and dementia. However, on 3/11/24 at 3:53 PM, review of the Treatment Administration Record (TAR) from 3/24/22 through 10/22/23, revealed that the PEG site care was not included in the TAR form and subsequently there was no evidence that the PEG site care had been completed 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 observation, medical record review, and interview, it was determined that the facility failed to place a physician's order for the indication of Oxygen administration and develop and implement a person-centered comprehensive care plan with resident-centered goals for respiratory care to include oxygen therapy. This was evident for 1 (Resident #302) of 1 resident reviewed for respiratory care during the survey. The findings include: On 2/22/24 at 9:17 AM, the surveyor observed that Resident #302 had a settled Oxygen nasal cannula 4L (liter) prepped at the bedside. However, Resident #302 did not apply Oxygen. Further observation Resident #302 on 2/28/24 at 10:03 AM, the resident had 2 L of Oxygen via nasal cannula. A record review of Resident #302's medical record on 2/28/24 at 10:20 AM revealed that the resident had an order of Oxygen via Nasal Cannula at 2 Liter started on 2/27/24. However, the order did not indicate why the resident needed Oxygen therapy. Also, no care plan was developed for Resident #302 ' s Oxygen therapy. On 2/28/24 at 11:48 AM, the surveyor interviewed…

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 nurse failed to do a timely assessment on a resident post dialysis, this was evident during a review of a complaint MD00200471 during the survey. The findings include: On 02/22/24 at 9:10 AM review of a complaint MD00200471 alleged that Resident #82 was not assessed immediately upon return to the unit from dialysis and that it took an hour before an assessment was completed. Review of the nurse note documented on 11/29/23 that resident returned back to unit from dialysis at 12pm. Nurse obtained blood pressure at 12:48pm on pt. (patient) right arm and administered pt. medication at 12:49. GNA took pt to room to assist pt back in bed to be changed and setup for lunch at 12:51pm Review on 3/4/24 at 11:55AM of the nurses note dated 11/29/23 documented that the nurse found Resident #82's Arteriovenous Fistula (AVF) a connection between an artery and vein for dialysis access bleeding out at 2:30 PM while doing rounds. A needle and a white clamp were found on the resident's lap in bed. The bleeding was controlled, 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 reviews and staff interviews, it was determined that the facility failed to ensure that a licensed nurse was competent to care for a dialysis resident. This was evident during a review of a complaint incident MD00200471 during an the survey. The findings include: On 02/22/24 at 9:10 AM review of a complaint intake MD00200471, alleged that an arterial needle and clamp was left in Resident #82's dialysis access point prior to discharging resident from the dialysis session on 11/30/23. Further this was not discovered until more than 2 hours later when the resident was found bleeding from the access site with the needle and clamp pulled out. Review on 3/4/24 at 11:55AM of the nurses note dated 11/29/23 documented that the nurse found Resident #82's Arteriovenous Fistula (AVF) a connection between an artery and vein for dialysis access bleeding out at 2:30 PM while doing rounds. A needle and a white clamp were found on the resident's lap at the bedside. The bleeding was controlled, the physician was notified and follow up interventions implemented. Further review of the…

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

Based on a review of the medical record and interview with staff, it was determined the facility staff failed to monitor and/or document the resident's inappropriate behavior related to mental health. This was evident for 1 (Resident #24) of 5 residents who were reviewed for behavioral-emotional issues during the survey. The findings include: A review of the facility's self-report regarding Resident #24 on 3/06/24 at 9:26 AM revealed that the resident had inappropriate behavior, such as entering other resident's rooms, taking their food, and hitting them in June 2023. Further record review for Resident #24 revealed that the Psychologist had followed the resident regularly and as needed after the incident. The Psychologist ordered that Resident #24 be monitored for mood/sleep/appetite/behavior and documented. A review of Resident #24's medical records on 3/06/24 at 10:00 AM revealed that the resident had orders of monitoring inappropriate behaviors but not limited to wandering, disturbed mood, smearing feces on items throughout their room, getting in other residents' beds, eating…

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 a review of the medical record and interview with staff, it was determined that the facility staff 1) failed to ensure narcotics removed from the resident's supply were administered to the resident, as evidenced by staff documenting the removal of narcotics without documentation of the need for the narcotic or documentation that the narcotic was administered to the resident. This was evident for 3 (#88 and #124) of 3 residents reviewed for Controlled drug administration and medication administration records reviewed during the survey, and 2) failed to timely provide medication to meet the needs of the residents. This was evident for 1 (#116) of 5 residents reviewed for medications during the recertification/complaint survey. The findings include: Oxycodone hydrochloride is part of a group of drugs known as opioids. Opioids include any drug that acts on opioid receptors in the brain and any natural or synthetic drugs that are derived from or related to the opium poppy. Tramadol is a strong pain…

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 follow physician orders by administering as needed (PRN) pain medication outside the prescribed parameters. By failing to follow the prescribed parameters for the medication administration, the resident was given an unnecessary medication. This was identified for 2 (#116, #57) of 67 residents reviewed for medications during a recertification/complaint survey. The findings include: 1) On 12/26/2024 at 8:08 AM, review of Resident #116's medical record revealed the resident was admitted to the facility in March 2023 with medical diagnosis that include but not limited to: Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle, pain in right hand, Type 2 Diabetes Mellitus with diabetic neuropathy and Atrial Fibrillation. On 2/26/2024 at 8:20 AM, review of physician orders revealed an active order with a start date of 11/15/2023, for Oxycodone tablet 15 mg, give 1 tablet by mouth every 4 hours as needed for pain 5-10. Further review of the orders revealed a discontinued order…

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

Based on record review and interview it was determined the facility failed to implement a gradual dose reduction (GDR) for a resident receiving a psychotropic medication. This was evident for 1 of 1 resident reviewed for psychiatric medications during the facility's recertification survey. The findings include: On 2/28/24 at 10:45AM the surveyor reviewed the medical record of Resident #37 which revealed the following information in their active medical order: Seroquel oral tablet 25mg, Give one tablet by mouth two times a day. On 2/28/24 at 11:04AM the surveyor reviewed the psychiatry note dated 2/21/24 for Resident #37 which revealed the following information: Current Psychiatric Medications: Quetiapine 25 mg po (by mouth) bid (twice per day.) Decreased from 37.5mg bid to 25mg bid on 2/25/23. GDR Seroquel 25mg po qd (every day) 2/21/24. Upon further review of the note dated 2/21/24 the following recommendation had been made by Staff #61, Certified Registered Nurse Practitioner (CRNP-PMH): GDR of Seroquel is clinically indicated at this time due to improvement in mood and behaviors.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility failed to remove expired medications and properly store medications. This was evident found on 1 of 2 medication storage rooms, and 1 of 3 medication cart, and 1 medication cart left unattended by nursing staff. The findings include: The surveyor observed a refrigerator in the medication storage room at unit 3 B on 2/26/24 at 10:18 AM with attending Licensed Practical Nurse (LPN #4). The surveyor found 2 bags of 100ml (milli-litter) Intravenous Ertapenem (antibiotic medication) in the refrigerator. The bags had labeled with used by 2/15/24. The LPN #4 verified that the medications were expired. On 2/26/24 at 10:24 AM, the surveyor observed 3A unit medication cart with LPN #5. The surveyor noticed that unlabeled med cup with 11 unidentifiable pills located in the 1st drawer of 3A unit med cart. LPN #5 said, these are for Resident #40. She/he just reported having upset stomach, I wanted to hold them at this point. LPN #5 was asked was there…

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

Based on observation, interview, and record review it was determined that the facility failed to ensure residents received needed dental services. This was evident for 1 resident (Resident #101) of 2 residents reviewed for dental services during the recertification survey. The findings include: On 2/21/24 at 10:42 AM in an observation and interview with Resident #101, the surveyor observed that the resident did not have any teeth. During the interview the resident explained that follow-up with a dentist regarding dentures was supposed to have happened in September 2023 but had not happened yet. On 3/05/24 at 9:58 AM a review of Resident #101's medical records revealed documentation dated 7/26/23 that the resident had a dental visit with impressions made for dentures, and that a follow up was to be done on 8/15/23. No documentation of any follow-up was found in the record. On 3/05/24 at 10:15 am in an interview with the Unit Manager (Staff #12), she said that there has been a problem with the company that provided dental services, and that the resident was scheduled to have an…

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

Based on observation, record review, and interview it was determined the facility failed to: 1.) ensure certification for medical ineffectiveness of treatment documentation was complete (Resident #102), and 2.) ensure the accuracy of a medical order (Resident #39). This was evident for one out of one certification of medical ineffectiveness of treatment form reviewed by the surveyor, and one out of one medical order for insulin reviewed by the surveyor. The findings include: 1.) On 2/21/24 at 2:17PM the surveyor observed a form located in the paper chart for Resident #102 which provided certification from two providers regarding the medical ineffectiveness of treatment for the resident. Upon review of this form, it was found that the first certification documented by Staff #43, Physician, failed to identify what treatment(s) were being certified to be medically ineffective. On 2/26/24 at 11:20AM the surveyor conducted an interview with the Director of Nursing who reported Staff #43 was an attending physician for the facility until July 2023, and provided their contact information.…

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

Based on record review and interview it was determined that the facility failed to obtain the proper information for residents who received hospice services. This was evident for 1 (Resident #47) of 1 residents reviewed for hospice services during the recertification survey. The findings include: On 3/05/24 at 2:10 PM a review of Resident #47's electronic medical record revealed an order to admit the resident to hospice services on 5/18/23. No hospice documentation was found in the electronic medical record. On 3/06/24 at 11:29 AM a review of Resident #47's paper chart revealed that there was no Hospice Certification or Recertification forms, no hospice election form, and no hospice plan of care in the resident's record. On 3/06/24 at 12:01 PM in an interview with the Director of Nursing (DON), she was asked where the hospice certification, election form, and hospice plan of care could be found. The DON said that the hospice documentation should be in the resident's paper chart, and that she would look for these documents.

Based on observation and staff interview it was determined the facility failed: 1) to maintain 2 bathtubs in operating condition. This was evident during environmental rounds of the facility for 2 of 2 bathtubs found out of 4 observed bathing areas of the facility; 2) ensure lift equipment utilized for resident care was maintained in a safe condition for use. This was evident for 2 out of 2 lift devices observed during the survey. The findings include. 1. Environmental observations conducted on 3/5/24 at 2:26 PM in the 3A central bathing room found The Bather 2001 electronic jet tub with trash and a broom in the dirty tub. The tub was not in working condition. Observation of the 2A central bathing room found The bather 2001 in non-working order. On 3/8/24 at 10:39 AM the maintenance director (staff #10) confirmed the dirty non-operational electronic jet tub in the 3A central bathing room and per discussion he indicated that both electronic jet tubs did not work. On 3/12/24 at 3:45 PM, a concern related to the in operational tubs in the 3A and 2A central bathing rooms was shared 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 documentation review and interview, it was determined that the facility failed to maintain an effective training program for new and existing staff. This was evident for Geriatric Nursing Assistant (GNA #50) and Registered Nurse (RN #53) of 8 employees' training records reviewed during this recertification survey. The findings include: 1) The surveyor review of staff training records on 3/13/24 at 11:05 AM revealed that GNA #50 was hired on 12/20/23, and the GNA facility orientation form (a checklist for care areas like resident care, mobility, devices, vital signs, infection control, others, and documentation with the completed date and observed person's signature) filled out on 1/08/24. However, the review revealed that some skilled areas did not have the completed date and signatures of the observed person. The blank session included, but was not limited to, nail care, suprapubic care, ostomy care, wheelchair seatbelt, lap buddy, side rails, temperature, feeding, meal set up, encouraging fluid intakes, thick liquids, intake/output, care of enteral residents, 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 a review of employee file documentation and interviews, it was determined that the facility failed to have a process to ensure all Geriatric Nursing Assistants (GNAs) have no less than 12 hours of education per year, and the education included annual dementia management training and resident abuse prevention training. This is evident for 1 (GNA #52) of 5 GNA employment files reviewed during this recertificate survey. The findings include: The surveyor reviewed randomly selected 5 GNAs employee files on 3/13/24 at 11:05 AM. The review revealed that GNA #52 was hired in October 2021. The file contained the staff who received training upon hire in 2023. However, there were no annual training records, including dementia management and resident abuse prevention, in 2022. During an interview with the Director of Nursing (DON) on 3/13/24 at 1:32 PM, the DON stated that the corporate office would assign employees' annual training through a computer-based training program and in-person training provided as needed. The surveyor shared GNA #52' s training records with the DON. 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.

Based on medical record reviews, staff interviews and observations, it was determined that the facility failed to accommodate resident's need and preferences. This was evident for 1 (R#33) of 5 residents reviewed for personal property during the survey. The findings include: On 3/8/24 at 1:02 PM review of the investigative report of a facility reported incident MD00200936 revealed that Resident #33 reported to the unit manager that s/he lost $57 dollars left on their bedside table. This incident was investigated by the facility and was not substantiated. The facility report had that Resident #33 was provided a key to their nightstand for safekeeping of their belongings. In an interview with Resident #33 on 3/11/24 at 12:29 PM, the resident was asked about the incident. S/he stated that the money was left on their table before they fell asleep, was gone before they woke up, Resident was asked why s/he left the money on the bedside table. Resident #33 explained that their nightstand did not have a lock. Resident stated further that the facility administrator was yet to provide a key…

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 the review of facility self-report investigation records, observation, and interview, the facility staff failed to provide a safe/secure storage space for resident's personal belongings. This was evident for 1 (Resident #279) out of 16 residents reviewed for facility self-reported incidents. The findings include: Record review, on 03/04/24 at 9:20 AM, revealed that Resident #279 had complained on 07/25/23 to the Staff #12 who filled out a Resident Concern Form. In this complaint, the resident stated that he/she expected to be reimbursed $2,332 for missing or damaged items. Further review of the facility self-report investigation of the resident's allegation found that it could not be clarified whether and how the resident's personal belongings went missing or were damaged. Observation, on 3/4/24 at 12:20 PM, of a storage room for residents' personal belongings on the second floor across from the nursing station found the following: multiple large black trash bags on the floor and multiple boxes stocked in piles holding residents' belongings. Some of the boxes were open 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 that the facility staff failed to timely report an allegation of abuse/harassment and resident elopement to the State Agency, the Office of Health Care Quality, immediately but not later than 2 hours after the allegation is made. This was evident for 2 (Resident #279 and Resident 392) out of 2 residents reviewed for elopement and abuse during survey. The findings include: 1. On 3/4/24 at 12:46PM the surveyor reviewed the facility's self-report form sent to the Office of Health Care Quality for an incident which occurred on 1/26/22 regarding Resident #92. The self-report form indicated Staff #59, Executive Director, Nursing Home Administrator, received a call on 1/26/22 at approximately 5:45PM from the hospital regarding the resident having been found by EMS walking in the facility neighborhood and was brought to the emergency room. The surveyor noted the time on the self report form dated 1/26/22 was documented as 8:17PM, and it was documented that local law enforcement was contacted at 8:17PM. On 3/4/24 at 12:46PM 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 review of facility reported incident investigations and interview and record review, it was determined the facility failed to thoroughly investigate allegations of: 1.) misappropriation of resident property, and 2.) elopement. This was evident 2 out of 4 residents reviewed for personal property (Resident #116 and Resident #99) and 1 out of 2 residents reviewed for elopement (Resident #92) during the facility's recertification/complaint survey. The findings include: 1) On 2/26/2024 at 11:05 AM, review of Facility Reported Incident (FRI), MD00196890, revealed that Resident #116 reported on 9/12/2023 missing a $100 bill from a pair of joggers. The facility initiated an investigation and did not determine misappropriation of property. Further review of the facility investigation report of the incident revealed that there were witness statements from staff and the resident's roommate. However, review of interview statements dated 9/19/2023 did not indicate the titles nor identify the persons completing the forms. The interview statement of the resident's roommate was not signed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, facility staff failed to provide correct notice to pay for (or to have paid under Medicare or Medicaid) a stay at the facility and to provide sufficient skilled rehabilitation treatment, and to assure the safe discharge of a resident. This was evident for 1 (Resident #282) out of 1 resident reviewed for proper notice of stay and safe discharge during the survey. The findings include: Review on 3/12/24 at 11:00 AM, of Resident #282's closed record found that the resident was a skilled admission on [DATE] to the facility and Physician Staff #35 ordered the skilled rehabilitation therapy four times per week for 12 weeks including allowing time for caregiver education and discharge planning and dialysis treatments. Further review found that the resident's discharge was improperly planned, as evidenced by: a) Review on 3/12/24 at 1:23 PM, of social service notes, dated 7/11/23 at 5:11 PM, revealed that social worker staff #36 issued the Notice of Medicare Non-Coverage (NOMNC) to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview of facility staff it was determined the facility failed to: 1) ensure physician ordered wound treatments are performed and receive timely wound consultation and 2) provide accurate ongoing assessment of skin and wounds and receive timely wound consultation. This was evident for 2 ( #295, #293) out of 10 residents reviewed for wounds during the facility's recertification survey. The findings include: 1) Resident #295's closed medical record was reviewed on 2/27/24, in relation to MD00192462, MD00192745, and MD00193830. Resident #295 was admitted to the facility on [DATE]. Review of a Skin and wound record dated 4/7/23 revealed that the facility staff identified a pressure injury on the resident buttock. Documentation revealed that the resident's attending physician was notified and indicated treatment to clean left buttocks wound with wound cleanser, dry apply bacitracin daily till healed. Review of the April 2023 treatment administration record did not show 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 interviews it was determined that the facility failed to ensure resident's care was directed by a physician. This was evident for 1 facility reported incident (MD00203534) of 27 facility reported incidents reviewed during the recertification survey. The findings include: On 3/13/24 at 9:15 am a review of the facility reported incident MD00203534 revealed that Resident #71 went on a leave of absence (LOA) on 3/02/24 and returned later that same day. A review of the resident's medical record revealed documentation that confirmed the resident left the faciity on 3/02/24 and returned to the facility later the same day. Further review of the resident record revealed that there was no order for the resident's leave of absence on 3/02/24. On 3/14/24 at 10:55 am an interview with the Director of Nursing (DON) was conducted. When asked if she could locate the physician's order for the LOA on 3/02/24 she explained that the resident had an order to go on a LOA on 3/01/24 but the resident did not go that day. The DON explained that there was a physician's order 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 observation, resident interview, and staff interview it was determined that the facility staff failed to ensure a cord used to turn on/off a call light was attached to the call system. This was evident for 3 of 5 call lights in the 3A central bathing room. The findings include: On 3/5/24 at 2:26 PM observations of the 3A central bathing room revealed that 2 of 3 shower stalls did not have a cord attached to the call switch wall panel. The call switch wall panel for the toilet did not have an attached cord. The call system should be accessible to a resident lying on the floor and without a cord that reaches the floor a resident would not be able to access the call system. On 03/08/24 at 10:39 AM, the maintenance director (staff #10) confirmed the findings with the surveyor of call cords not attached to the 3 of the 5 call switch wall panels in the 3A central bathing room. On 03/11/24 at 1:30 PM the nursing home administrator was informed of the observations made with the maintenance director of the call system that lack cords to the shower room floor in the 3A central shower…

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 (#36 and #50) with showers and failed to provide Resident (#63) with food preferences. This was evident for 3 of 3 residents selected for review of choices during the survey process and 3 of 47 residents selected for review during the annual process. The findings include: 1. The facility staff failed to provide showers to Resident #36. Surveyor interview with Resident #36 on 3/14/19 at 10:00 AM revealed the resident is not provided showers, but only bed baths. Review of facility staff documentation revealed the facility staff failed to provide showers to Resident #36 on: 2/20/19, 2/23/19, 2/27/19, 3/2/19, 3/6/19, 3/9/19, 3/13/19 and 3/16/19. It is the expectation residents be provided showers at least 2 times a week unless medically contraindicated. Review of the medical record also failed to reveal any evidence of Resident #36 refusing showers. Interview with the Director of Nursing on 3/21/19 at 1:30 PM confirmed the facility staff failed to provide showers 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 Residents (#44, #90, #118 and #326) with care that promoted the highest practicable well-being. This was evident for 4 of 47 residents selected for review during the survey process. The findings include: 1. The facility staff failed to apply a wet to dry dressing to surgical wound on back as ordered for Resident #44. Medical record review for Resident #44 revealed on 02/27/19 the physician ordered: Wound to back - clean with wound cleanser. Pat dry and apply wet to dry dressing. Cover with tegaderm film. Change two times a day. Surveyor interview of the resident on 03/15/19 at 12:29 PM revealed the resident 's commented that his/her wound on his/her back was supposed to have a dressing change twice a day and sometimes, the wound dressing is only changed one time a day. Further medical record review revealed the treatment record failed to demonstrate that the surgical wound dressing was changed twice a day: a. on 3/5/19 the evening shift dressing change was not completed.…

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

Based on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication for Residents (#63 and #90). This was evident for 2 of 2 resident selected for pain assessment and 2 of 47 residents selected for review during the annual survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. 1. Medical record review for Resident #63 revealed on 7/9/18 the physician ordered: Oxycodone 5 milligrams by mouth every 8 hours as needed for pain level 6-10. Oxycodone is a strong narcotic…

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 hold blood pressure medication for Resident (#34 and #123) when the documented blood pressure was below the set parameter as ordered by the physician, failed to document the heart rate and blood pressure for Resident (#36) when the physician ordered parameters, and failed to document the use of a medication (#274). This was evident for 4 of 6 residents selected for un-necessary medication review and 4 of 47 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to hold blood pressure medication for Resident (#34) when the documented blood pressure was below the set parameter as ordered by the physician. Medical record review for Resident #34 revealed on 12/4/18 the physician ordered: Coreg 25 milligrams by mouth 2 times a day, hold for systolic blood pressure (top number) less than 110 or heart rate less than 60. Coreg is used for treating high blood pressure. Coreg reduces the heart's rate and force of contraction and thereby…

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

Based on observation and interview, it was determined the facility staff failed to provide Resident (#54) with the most dignified existence, failed to honor a resident's right to explore living arrangements in the community (#61), and failed to promote and enhance a resident's dignity and rights by obtaining weights and blood pressures on Resident (#174). This was evident for 3 out of 3 residents investigated for dignity during the survey process and 3 of 47 residents selected for review during the annual survey process. The findings include: 1 A. The facility staff failed to feed Resident #54 in a timely manner. Surveyor observation of Resident #54's lunch on 3/14/19 at 12:23 PM revealed the resident's lunch was in the room, sitting on the over-bed table. Further observation revealed the facility staff failed to feed the resident until 12:33 PM (at least 10 minutes after the tray had been sitting in the room) and the facility staff failed to re-heat the resident's lunch per surveyor's observations. 1 B. The facility staff failed to feed the resident in the most dignified manner.…

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, resident and staff interview, it was determined that the facility staff failed to ensure that a Minimum Data Set (MDS) Assessment accurately reflected a resident's status (#100). This was evident for 1 out of 1 resident reviewed for skin conditions during the annual survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gather 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 require. Resident #100's MDS' transmitted to the state on 2/23/19, 11/23/18, and 8/23/18 reflect Resident #100's Brief Interview for Mental Status (BIMS) as a score of 15/15 which means alert and oriented to person, place and time, with no impairment. On 3/13/19 at 11:00 AM during the initial interview Resident #100 could answer most of this surveyor's questions but had to be prompted and many questions clarified before she could understand what was being asked. A second review 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 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 (#61, #274, and #123). This was evident for 1 of 2 residents reviewed for presence of a urinary catheter and 2 of 6 residents reviewed for unnecessary medications 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. 1. During an interview with Staff #8 on 3/18/19 at 9:00 AM it was revealed that Resident #61 empties his/her urinary catheter device bag when filled with urine and changes the bag without the assistance of the facility staff. Review of Resident #61's care plans revealed no care plan that showed Resident #61 was capable of caring for their urinary catheter nor was doing the required tasks. On 3/18/19…

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

Based on medical record review and interview, it was determined the facility staff failed to thoroughly review dental recommendations for Resident (#36) and act upon those recommendations. This was evident for 1 of 3 residents selected for dental review and 1 of 47 residents selected for review during the annual survey. The findings include: Medical record review revealed Resident #36 was seen by the dentist on 12/18/18. At that time, the dentist assessed the resident and determined Resident #36 had poor teeth condition and heavy plaque buildup. Tartar/plaque is a yellow or brown colored deposit that forms when plaque hardens on your teeth. Tartar forms below and above the gum line. It is rough and porous and can lead to receding gums and gum disease. At that time, the dentist stated Resident #36 would benefit from Peridex and consult with physician. Peridex Mouthwash. Peridex is a medication used along with regular tooth brushing/flossing to treat gingivitis, a gum disease that causes red, swollen, and easily bleeding gums. Peridex oral rinse to treat gingivitis, to help reduce 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, it was determined the facility staff failed to provide services that would allow resident the ability to achieve the greatest independence with performing Activities of Daily Living to Resident (#63). This was evident for 1 of 4 residents selected for review of ADL during the survey process and 1 of 47 residents selected for review during the annual survey. The findings include: Activities of daily living are routine activities people do every day without assistance. There are six basic ADLs: eating, bathing, getting dressed, toileting, transferring and continence. It is the expectation the facility staff will provide dietary assistance to residents; cut food up, open milk and juice containers, butter breads and ensure the food is within reach to the resident. Surveyor observation of Resident 63's lunch on 3/19/19 at 1:00 PM revealed the resident in bed; however, the resident was noted to be positioned in low fowlers position, approximately elevated 30 degrees. The Semi-Fowler's position is a position in which a patient, typically in a nursing…

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

Based on medical record review and interview, it was determined that the nursing staff failed to implement protective measures to prevent a sacral pressure ulcer (#274) from occurring. This was evident for 1 of 6 resident's selected for review of pressure ulcers during the annual survey. A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to 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), and Stage IV (full thickness skin loss with extensive damage to muscle, bone, or tendon). The findings included: Resident #274 was admitted from the hospital without a pressure ulcer in the sacral (coccyx) area according to the 1/17/19 nursing admission evaluation. On 2/28/19 Resident #274 developed a Stage 1 reddened area on the sacrum which progressed in the…

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

Based on observation of medication pass and interview, it was determined the facility staff failed to maintain an environment free from potential accidents for Resident (#19). This was evident for 1 of 4 residents observed for medication observation and 1 of 27 opportunities for error. The findings include: Medical record review for Resident #19 revealed on 3/1/19 the physician ordered: Humalog 5 units SQ (subcutaneous) with meals for diabetes. Humalog (a fast-acting insulin) works to manage blood sugar and may help keep the sugar levels in balance. Humalog should be taken within 15 minutes before eating or right after eating a meal. A subcutaneous injection is administered into the layer of skin directly below the dermis and epidermis, collectively referred to as the cutis. Subcutaneous injections are highly effective in administering medications such as insulin. Observation of medication pass on 3/18/19 at 8:20 AM revealed the facility staff nurse #13 drew the insulin up from the bottle; however, the nurse failed to slide the protective shield down to cover and protect the needle.…

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 adequately use Provale cups for Resident (#36) with as ordered. This was evident for 1 of 8 residents selected for review of Nutrition during the annual survey process and 1 of 47 residents selected for review during the annual survey process. The finding includes: Medical record review revealed on 2/25/19 the physician ordered: 5 cc blue lid Provale cup on all trays. Provale cups are designed to deliver small swallows (specific predetermined volume of thin liquid in a normal drinking motion. Prevents over delivery and promotes safer swallowing and more independence. Use one or two easy-grip removable handles. Separate chamber inside delivers the specific volume in each mouthful without the need to suck. Plastic. Clear base. Comes apart easily and is dishwasher safe. Available in 5cc or 10cc delivery. Surveyor observation of the resident's breakfast trays on 3/14/19 at 8:20 AM and 3/18/19 at 8:40 AM revealed the facility staff supplied the resident with the blue lid Provale…

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 physician staff provided contradictory medical information concerning a resident's end of life wishes (#84). This is evident for 1 of 6 residents reviewed for advanced directives during the annual survey. The findings include: On 12-28-18 Resident #84 was admitted to the facility with dementia. On admission Physician #2 completed a MOLST (Maryland Medical Orders for Life-Sustaining Treatment) document with Resident #84. The MOLST is a portable and enduring medical order covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based on a resident's or a Medical Power of Attorney's wishes about medical treatments. Physician #2, with the resident, made the complex medical decision to do CPR if Resident #84's heart stops. The MOLST was originally dated 12-28-18 and changed to 12-26-18. At the same time on 12-28-18 Physician #2 completed a Physician's Certification of Incapacity To Make an Informed Decision form stating Resident #84 incapable of making complex…

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

Based on record reviews and staff interviews it was determined that the facility's pharmacist failed to identify and report irregularities in Resident #326's drug regimen. This was evident for 1 (#326) of 10 residents whose medications were reviewed. The findings include: On 3/18/2019 medical record review for Resident #326 revealed a physician order dated 3/2/19 for the medication Propranolol (a medication used to treat high blood pressure.) The order indicated to hold (do not administer) the medication if the resident's Systolic Blood Pressure was (SBP) was greater than (>) 110. However, review of the resident's Medication Administration Record for March 2019 showed that the medication was administered when SBP was greater than 110. In addition, a review of the facility's Consultant Pharmacist (Staff #15) medication regimen review for Resident # 326 indicated that there were No Irregularities found regarding the order or the administration of the medication. The findings were discussed with the Regional Clinical Service Manager (Staff #11) on 3/18/2019 at 10:06 AM who acknowledged…

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 during the initial tour of the kitchen and garbage disposal area, it was determined that 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 3/13/2019 at 8:00 AM. Various debris including discarded gloves, plastic spoons and cups 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 Food Service Manager (Staff #14) at 8:15 AM.

Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Residents (#22, #46 and #123). This was evident for 3 of 47 residents selected for medical record review during the annual survey process. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. 1. The facility staff failed to document the administration of a medication for Resident #22. Medical record review for Resident #22 revealed on 2/26/19 the physician ordered: Oxycodone 10 milligrams by mouth every 8 hours as needed for pain. Oxycodone is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated. It belongs to the group of medicines called narcotic analgesics (pain medicines). Oxycodone acts on the central nervous system (CNS) to relieve pain. Review of the medical…

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