Levindale Hebrew Ger Ctr & Hsp

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility staff interview and medical record review, it was determined that the facility failed to accurately document Resident assessments on the Minimum Data Set (MDS) assessment as evidenced by inaccurate coding for Residents. This was found to be evident for 4 (Resident #191, #11, #164 and #40) out of 73 Residents reviewed on the survey. The findings include: The Minimum Data Set (MDS) is a health status screening and assessment tool used for all Residents of long-term care nursing facilities. The MDS is part of the federally mandated process for clinical assessment of all Residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each Resident's functional capabilities and helps nursing home staff identify health problems 1a) The surveyor conducted a record review of the closed medical record for Resident #191 on 11/1/2024 at 9:10 AM. The review revealed documentation in the progress notes that Resident #191 was transferred to the hospital 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 facility's investigation file, review of medical records and interviews, it was determined that the facility failed to honor and respect a resident's wishes for Activities of Daily Living (ADL) cares. This was found evident in 1 (Resident #77) of 3 residents reviewed for Resident rights. The findings include: On 10/29/24 at 9:03 AM, the surveyor interviewed Resident #77. During the interview Resident #77 was able to answer questions by nodding, mouthing answers and using electronic devices to communicate. During the interview Resident #77 confirmed that a Geriatric Nursing Assistant (GNA) held him/her down and continued to perform cares that he/she had expressed he/she did not want or need to be performed. Resident #77 further communicated that he/she had not seen that GNA since the incident. On 11/13/24 at 1:12 PM, the surveyor reviewed Resident #77's medical record. The review revealed that Resident #77 was assessed as cognitively intact on 8/21/24 with a Brief Interview for Mental Status (BIMS) score of 15. Resident #77's Decision Making Capacity 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 record review, and interviews it was determined that the facility failed to notify the Resident's health care Responsible Party (RP) of a change to the Resident's plan of care and the facility failed to provide a Resident's Representative/guardian the right to be involved in the care planning process. This was found evident in 2 (Resident #51 and #40) of 3 Residents reviewed for resident rights. The findings include: 1. On 10/30/24 at 12:59 PM, the surveyor reviewed Resident #51's paper medical record. The review revealed that on 3/3/21 Resident # 51 was deemed not to have the capacity for decision making capacity for medical treatments. On further review it was noted that Resident #51's daughter was the Responsible Party (RP) for Resident #51. On 11/7/24 at 1:36 PM, the surveyor reviewed Resident #51's electronic medical record. The review revealed a change of condition evaluation written on 8/20/24. The evaluation noted a new skin tear on Resident #51. At the end of the report the section titled, Resident Representative Notification had a statement; Name 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 record review and interview, it was determined that the facility failed to maintain a proper resident's Advance Directives in the Resident's medical record and/or offer to formulate one. This was found to be evident for 2 (Residents #32 and #49) out of 7 residents reviewed for the Advance Directives during the annual survey. The findings include: An Advance Directive is a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness. An Advance Directive may also give a person (such as a spouse, relative, or friend) the authority to make medical decisions. 1a) Record review, on 10/31/24 at 1:03 PM, revealed that Resident 32's Medical Orders for Life-Sustaining Treatment (MOLST) certification stated that his/her Advance directives was selected on 8/5/24 by Nurse Practitioner Staff #42. However, no Advance Directives document was found. During the interview, on 10/31/24 at 2:17 PM, the Director of Social Service Staff #6 stated that Advance Directives information was built into…

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

Based on record review and interviews it was determined that the facility failed to inform the Resident's primary care physician of the need to alter treatment. This was found evident of 1 (Resident #51) of 2 residents reviewed for change of condition. The findings include: On 11/7/24 at 11:04 AM, the surveyor reviewed Resident #51's medical record. The review revealed that Resident #51 was admitted to the facility in early 2021. On admission Resident #51 had a percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube that is inserted through the skin and into the stomach to provide direct access to the stomach). The PEG tube was used to provide tube feeding for Resident #51. On further review the surveyor noted Resident #51 had vomited on 10/1/24, 10/10/24, 10/11/24, (an X-ray was ordered) 10/13/24 (tube feed held),10/17/24 (tube feed held for 2 hours),10/18/24 (tube feed held for 2 hours) with notation provided notified, 10/19/24 2 (tube feed held for 2 hours), 10/21/24, 10/23/24 (tube fee on hold), 10/27/24,10/31/24 (tube feed held for 2 hours) and on 11/2/24. The surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's investigation report, record review, and interviews, it was determined that the facility failed to protect a resident from being physically restrained by an employee. This was found evident on 1 (Resident #77) of 7 Residents reviewed for abuse. The findings include: On 10/29/24 at 9:03 AM, the surveyor interviewed Resident #77. During the interview Resident #77 was able to answer questions by nodding, mouthing answers and using electronic devices to communicate. During the interview Resident #77 confirmed that a Geriatric Nursing Assistant (GNA) held him/her down and continued to perform cares that he/she expressed he/she did not want or need to be performed. Resident #77 further communicated that he/she had not seen that GNA since the incident. On 11/13/24 at 1:12 PM, the surveyor reviewed Resident #77's medical record. The review revealed that Resident #77 was assessed as cognitively intact on 8/21/24 with a Brief Interview for Mental Status (BIMS) score of 15. On 11/13/24 at 1:38 PM, the surveyor reviewed the facility's investigation file in the…

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

Based on facility staff interview and medical record review it was determined that the facility failed to provide notification to the Ombudsman of the residents that transferred to the hospital. This was found to be evident in 2 (#191 & #30) out of 3 residents reviewed for hospitalizations. The findings include: 1a) On 11/1/2024 at 11:30 AM the surveyor reviewed Resident #191's closed medical record. Review of the medical record revealed that Resident #191 was transferred to the hospital on 7/20/2024 and 7/29/2024. In an interview at 8:55 AM on 11/4/2024 the surveyor requested from the Director of Nursing (DON) the documentation of the Ombudsman notification for Resident #191's transfers to the hospital on 7/20/2024 and 7/29/2024. The DON stated to the surveyor that the facility does not provide notification to the Ombudsman when a resident is transferred to the hospital and that she would follow-up with the Nursing Home Administrator (NHA). At 9:32 AM on 11/4/2024 the surveyor interviewed the Nursing Home Administrator (NHA) for documentation of Ombudsman notification for Resident…

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

Based on medical record review, and interviews it was determined the facility failed to provide the Resident and/or Representative with a written notice of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 1 (Resident #21) of 3 residents reviewed for hospitalization. The findings include: On 11/6/24 at 11:07 AM, the surveyor reviewed Resident #21's medical record. The review revealed that on 7/14/24 and 8/1/24 Resident #21 was sent out to the hospital. An e-interact note dated 8/1/24 stated Resident #21's legal guardian was notified by the on-call provider of the transfer. No documentation was noted on 7/14/24 or 8/1/24 that the bed hold policy was given to the legal guardian. On 11/6/24 at 2:09 PM, the surveyor interviewed the Director of Nursing (DON). The surveyor asked the DON if the facility provided the bed hold policy to Resident #21's legal guardian related to the transfers on 7/14/24 and 8/1/24 of Resident #21 to the hospital. The DON stated the facility would send the bed hold policy in a packet to the hospital and would also mail…

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

Based on record review and staff interview, it was determined that the facility failed to implement interventions in a care plan. This was evident for 1 (Resident #224) of 13 residents reviewed for care plans. The findings include: On 11/4/24 at 9:10 AM, a review of Facility Reported Incident #MD00203620 was conducted. The report stated that on 3/14/24 at 6:00 PM, Resident #224 pushed Resident #53 causing them to fall. On 11/4/24 at 10:29 AM, a review of the facility's investigation was conducted. The facility conducted an interview with Resident #224 and the resident confirmed they pushed the linen cart knocking Resident #53 to the floor because Resident #53 was trying to wander into Resident #224's room. Resident #224 stated in the interview that they told staff to keep the wandering residents out of his/her room or he/she would hurt them. On 11/4/24 at 11:23 AM, a review of Resident #53 care plans was conducted. A care plan for wandering was created after the incident on 3/14/24. On 11/4/24 at 11:45 AM, a review of Resident #224's care plans. The care plan initiated on 7/12/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility staff failed to ensure a resident's right to participate in the resident-centered care plan meeting and failed to conduct care plan meetings after each resident Minimum Data Set (MDS) assessment. This was found evident in 2 (Resident #147 & #51) out of 13 Residents reviewed for care planning. The findings include: 1) During a floor rounding, on 10/31/24 at 10:47 AM, Resident #147 stated, I don't remember I had a care-plan meeting. And I can be in the meeting. Resident #147 was admitted to the facility on [DATE] with diagnoses of dementia, dysphagia and abnormal gait. This resident's speech was logical, clear and he/she was able to make his/her needs known. Record review, on 10/31/24 at 2:17 PM, of Director of Social Service Staff #6's documentation revealed that the care-plan meeting was held by the care team on 10/21/24 attempted telephonically with this resident's family (no mention about if the resident was invited). Although, after they…

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

Based on interviews and record review it was determined that the facility failed to have an activities program designed to meet the interests and needs of Residents based on the Residents comprehensive assessment and care plan. This was found evident of 1 (Resident #40) of 4 residents reviewed for activity during an annual survey. The findings include: On 10/29/24 at 11:49 AM, the surveyor interviewed Resident #40's family member. During the interview the family member reported that music was such a big part of Resident #40's life and that he/she used to play the guitar. The family member further stated that they had even brought in a music player to his/her room that would play Resident #40's favorite music. On 11/1/24 at 1:50 PM, the surveyor reviewed Resident #40's medical record. The review revealed a progress note dated 8/18/23 that stated a care plan meeting was held with Resident #40's family members in attendance. It further stated that the family was requesting Resident #40 be seen by a music recreational therapist if possible. A previous care plan note written on 6/2/23…

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

Based on observations, interviews, and record review, it was determined that the facility failed to provide treatments according to a Resident's plan of care. This was found evident of 1 (Resident #77) out of 2 residents reviewed for skin care. The findings include: On 10/29/24 at 9:24 AM, the surveyor conducted an interview with Resident #77 who stated that he/she had swelling in both lower legs. On 11/12/24 at 8:14 AM, the surveyor reviewed Resident #77's medical record. The review revealed a progress note written on 4/2/24 by Physician #20 after a follow-up visit. The note stated that Resident #77 reported that he/she spoke to the Nurse Practitioner about his/her feet swelling. The NP recommended compression socks. The note stated Resident #77 agreed to treatment and that Thrombo-Embolic Deterrent (TED) hose (hose or stockings that are applied to the lower legs and are designed to prevent blood clots and swelling in the legs) would be ordered. An order was then placed on 4/2/24 for TEDs to be applied during the day and taken off at night. The surveyor was not able to find any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a Resident in need of hearing aides received services to obtain replacement hearing aides. This was found evident of 1 (Resident #105) of 2 residents reviewed for hearing and vision. The findings include: On 11/1/24 at 9:56 AM, the surveyor reviewed Resident #105 ' s medical record. The review revealed that Resident #105 had a care plan that stated, Resident #105 has a communication problem related to hearing deficit in both ears as evidence by the use of hearing aids. The care plan further documented that Resident #105 had misplaced his/her hearing aids on 10/29/23. The hearing aid care plan updated on 12/29/23 stated that Resident #105 ' s brother would order another set of hearing aids with insurance coverage. The surveyor next reviewed October 2024 Treatment Administration Order (TAR). The treatment order stated, please check right and left ear hearing aids and assist resident and to apply hearing aids every shift. Every day there was a slot for the day time documentation for application…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews it was determined that the facility failed to provide treatment to prevent further decreased range of motion for a Resident. This was found evident of 1 (Resident #40) out of 5 residents reviewed for mobility. The findings include: On 10/29/24 at 12:05 PM, the surveyor observed splints off in the corner of Resident #40's room. The surveyor asked Resident #40's family member if the splints were supposed to be on or off and the family member stated he/she was unclear at this time how they were to be used and that Resident #40 had contracted hands. On 11/12/24 at 1:07 PM, the surveyor interviewed Registered Nurse (RN) #27 in Resident #40's room. During the interview the surveyor asked RN #27 if Resident #40 was supposed to be wearing splints. RN #27 stated that Resident #40 was being trialed for tolerance of the splints by therapy before he/she went out to the hospital. She further stated that once a resident tolerates 8 hours in the splints, therapy gives 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 review of medical records and interviews it was determined that the facility failed to adequately supervise and assist a dependent resident during Activity of Daily Living (ADL) care. This was found evident for 1 (Resident #121) out of 9 residents reviewed for accidents. The findings include: On 11/6/24 at 9:26 AM, the surveyor reviewed Resident #121 ' s medical record. The review revealed that a progress note written on 10/22/24, by Nurse Practitioner (NP) #39 that documented Resident #121 sustained a fall after attempting to transfer him/herself to the bedside commode. The note stated that the Geriatric Nursing Assistant (GNA) helped Resident #121's to the edge of the bed and stand up however left the room before Resident #121 transferred to the commode. Further review revealed Resident #121 had a care plan that was initiated on 10/21/24 that stated Resident #121 has a self-care deficit related to impaired mobility. One of the interventions listed was for Resident #121 to have assistance with toileting. On 11/6/24 at 11:59 AM, the surveyor interviewed the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview it was determined that the facility staff failed to follow appropriate tube feeding treatment and gastrostomy tube (G-tube) site care. This was evident for 1 (Resident #36) out of 2 residents reviewed for tube feeding treatment during the annual survey. The findings include: Gastrostomy tube refers to a medical device which is placed directly into the resident's stomach, used to provide liquid nourishment, fluids, and medications by bypassing oral intake. Observation, on 10/31/24 at 9:26 AM, revealed that Resident #36's feeding pump was turned off but the feeding tubing was connected to the resident's G-tube. No label was on the formula bottle and the feeding tubing was not dated. Observation, on 11/7/24 at 10:15 AM, found that Resident #36's feeding formula bottle with tube feeding was hanging on a pole but not running and the feeding tube was connected to the Resident's G-tube again. No date was on the feeding tubing nor was the feeding formula bottle properly…

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

Based on observation, record review, and interview with facility staff, it was determined that the facility failed to obtain a bed rail assessments and documentation that informed consent was obtained prior to the use of the bed rails. This was evident of 1 (Resident #141) residents reviewed for accidents. The findings include: Bed rails also known as side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks. A Resident or Resident Representative should be provided with the risks and benefits along with a signed consent obtained before the use of bedrails. On 10/29/24 at 11:26 AM, the surveyor observed Resident #141 turned and facing the left side of the bed. All 4 bed rails were noted up and Resident #141 was grabbing the bed rail. On 11/6/24 at 9:09 AM, the surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, reviews, and interviews it was determined that the facility failed to provide necessary behavioral health services according to the identified individual need in the plan of care. This was found evident of 3 (Resident #105, #245 & #214) 3 residents reviewed for behavioral health services. The findings include: 1a) On 10/29/24 at 1:07 PM, the surveyor observed Resident #105 clapping and speaking to things/people that were not in the room. On 10/31/24 at 2:06 PM the surveyor reviewed Resident #105's medical record. The review revealed that Resident #105 had a care plan for altered thought processes related to dementia, hallucinations and psychosis as well as inappropriate/disruptive behavior related to hallucinations and psychophysical visual disturbances. Additionally, Resident #105 had a care plan for mood disturbances related to dementia and major depressive disorder. Listed interventions for this care plan were to administer medications as ordered and behavior health consults as needed. Review of the progress notes revealed a note written on, 4/19/24 by…

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

Based on record review and staff interview, it can be determined that the provider failed to follow through with a pharmacist's recommendation after a medication regimen review. This was evident for 1 (Resident #92) of 5 resident's reviewed for unnecessary medications. The findings include: On 11/06/24 at 11:45 AM, a review of Resident #92's medication regimen reviews was conducted. In the pharmacy medication review conducted on 10/19/24, the pharmacist requested Novolog to be discontinued and to have the resident's A1C checked. Provider agreed to this recommendation and signed and dated the signature 11/11/24 per the documentation provided. On 11/06/24 at 12:00 PM, Resident #92's orders were reviewed. Novolog was shown as an active order and there was no order for an A1C lab since the medication regimen review. On 11/06/24 at 12:06 PM, an interview was conducted with the Director of Nursing (Staff #2). When asked what the expectation was for the providers to place orders on recommendations from the pharmacist that the provider agrees with, Staff #2 stated that if the provider…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices. This was found evident in 3 (Resident #140, #33 and #72) out of 73 residents reviewed during the survey. The findings include: 1a) On [DATE] at 7:23 AM, the surveyor reviewed Resident #140's medical record. The review revealed that Resident #140 had two bed rotation orders. The first order was written on [DATE] and stated, Rotation via bed, when on back, 50% turn to right 50% turn to left, turn for 5 minutes. The second order was written on [DATE] and stated, Total care low air loss bed with rotation, 40% right turn, 40% left turn, 0.5 minute pause. The surveyor reviewed the November Treatment Administration Record (TAR). The review revealed that both orders were checked as completed [DATE]-[DATE]. On [DATE] at 9 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON stated that when an order is changed…

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

Based on facility staff interviews and closed record reviews it was determined that the facility failed to report alleged violations of abuse as required. This was found to be evident in 5 (Resident #11, #217, #195 & #39 & #147) out of 13 Residents reviewed for reporting of alleged violations. The findings include: 1a) On 11/4/2024 at 9:45 AM the surveyor reviewed the facility investigation file for the facility reported incident (FRI) #MD00200402 for Resident #11. Review of the facility investigation file revealed that Resident #11 sustained a fracture of the right hip, and the facility Director of Nursing (DON) reported the fracture as an injury of unknown origin on the initial report form that was submitted to the Office of Healthcare Quality (OHCQ) on 12/8/2023 at 14:30 PM (2:30 PM). Further review of the facility investigation file (FRI) and Resident #11's closed medical record on 11/4/2024 at 11:00 AM revealed that Resident #11 reported that he/she had a fall. A fall risk assessment tool, neurological assessments and change in condition progress note was documented by 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 review and staff interviews, it was determined that the facility failed to protect the residents' private space from unauthorized photographs and recordings. This was evident for 1 (Household 5) out of 10 units. The findings include: On 11/12/24 at 11:53 AM, a review of complaint #MD00194059 was conducted. The complaint stated that Staff #19 recorded themselves in a common care area and posted it on the social media platform Tiktok. On 11/13/2024 at 9:58 AM, Staff #19's employee file was reviewed. The employee file revealed that Staff #19 was terminated for Gross Misconduct. The specific incident causing termination was that the employee was caught recording a video of themselves in a clinical area and posted it on social media. In Staff #19's statement, they stated that she admitted to recording video in the care area while on break. Staff #19 stated that no residents were recorded. On 11/13/2024 at 10:30 AM, an interview with the Director of Nursing (DON) was conducted. When asked if Staff #19 was educated on resident rights and Health Insurance Portability 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, review of the facility's investigation report, record review, and interviews, it was determined that the facility failed to protect a resident from physical and verbal abuse. This was found evident of 2 (Resident #201 & #53) of 7 Residents reviewed for abuse. The findings include: 1a) On 11/15/25 at 8:53 AM, the surveyor reviewed Resident #201's medical record. The review revealed that Resident #201 was re-admitted to the facility related to multiple falls. Further review revealed a progress note written by Physician #34 on 11/30/24 that reported Resident #201 was very confused at baseline and due to impaired gait and high fall risk a 1:1 (one resident to one staff person care services) sitter was ordered. The surveyor reviewed a summary for provider note written by Registered Nurse (RN)# 35 dated 12/26/23. RN #35 described in the note that she heard the 1:1 sitter shouting out from Resident #201's room. When she entered the room Resident #201 was lying in the bed with his legs hanging out of bed. She further reported she did not know what happened in the room…

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

Based on record review and staff interview, it was determined the facility failed to maintain pertinent documentation of a reported investigation. This was evident for 1 (Resident #197) of 24 facility reported incidents. The findings include: On 10/31/24 at 9:00 AM, an interview was conducted with Staff #1 and Staff #2. The staff members provided the surveyors with their investigations for all facility reported incidents. When asked if the documents provided were their complete investigations, they responded that they provided the surveyors with the complete investigation for each of the incidents that were reported. On 11/8/24 at 8:53 AM, a review of Facility Reported Incident #MD00189103 was conducted. On 2/6/23, Resident #197 was sent out for further evaluation related to fever, tachycardia, and hypotension. The facility identified that the nurse incorrectly entered the medications from the discharge summary on 2/8/2023. In the facility's report they stated, The current hospital course c/b AMS and hypotension initially requiring pressor support. Ongoing leukocytosis. Treated 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 record review and staff interview, it was determined that the facility failed to adequately evaluate the effectiveness of pain medication for a resident. This was evident for 1 (Resident #22) out of 14 residents reviewed for pain management. The findings include: On 11/12/24 at 1:24 PM, a review of complaint #MD00194402 was conducted. The complainant stated that Resident #221 did not receive medications including tramadol as ordered. On 11/12/24 at 1:27 PM, Resident #22's orders were reviewed. Tramadol, an opiate and pain relief medication, oral tablet 50 MG was ordered to be given as 1 tablet by mouth every 6 hours as needed for moderate to severe pain. On 11/12/24 at 1:28 PM, a review of Resident #22's administration notes was conducted. A follow-up note on 7/12/2023 at 2:34 AM to the administration of Tramadol on 7/11/2023 at 6:59 PM, stated follow-up Pain Scale was 5 out of 10 and stated [As needed] Administration was: Ineffective. The effectiveness of the pain medication was evaluated 7 hours and 30 minutes after administration. A follow-up note on 7/11/2023 at 5:59 PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's investigation report, record review, and interviews, it was determined that the facility failed to provide a resident with an employee that practiced the appropriate skill set according to their education. This was found evident on 1 (Resident #201) of 7 Residents reviewed for abuse. The findings include: On 11/15/25 at 8:53 AM, the surveyor reviewed Resident #201's medical record. The review revealed that Resident #201 was re-admitted to the facility related to multiple falls. Further review revealed a progress note written by Physician #34 on 11/30/24 that reports Resident #201 was very confused at baseline and due to impaired gait and high fall risk a 1:1 sitter was ordered. The surveyor reviewed a summary for provider note written by Registered Nurse (RN)# 35 dated 12/26/23. RN #35 described in the note that she heard the 1:1 sitter shouting out from Resident #201's room. When she entered the room Resident #201 was lying in the bed with his legs hanging out of bed. She further reported she did not know what happened in the room before she…

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

Based on record review and staff interview, it was determined that the facility failed to protect a resident from significant medication errors by inaccurately ordering medications on admission. This was evident for 1 (Resident #197) of 5 residents reviewed for medications. The findings include: On 11/12/24 at 8:53 AM, a review of facility reported incident #MD00189103 was conducted. Resident #197 had a diagnosis of Heart Failure, Chronic Kidney Disease, and Peripheral Vascular Disease. On 2/6/24 Resident #197 was sent out to to a hospital for further evaluation related to confusion, tachycardia, and hypotension. On 2/8/24, the facility identified that the nurse incorrectly entered the medications from the discharge summary into the resident's chart as active medications on the 1/31/23 admission. The medications include the following: - Lasix or Furosemide (a diuretic) - Quetiapine Fumarate (an antipsychotic) - Metoprolol tartrate (a beta blocker used to help lower heart rate and blood pressure) - Sacubitril-Valsartan (used to treat Heart Failure) On 11/12/24 at 9:11 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 medical record review and interview with the Director of Nursing (DON) the facility failed to notify the responsible party in writing of the transfer to hospital. This was evident for 2 out of 2 residents (Resident #188 and Resident #160) investigated for hospital transfer. Findings include: 1. Resident #188 was readmitted to the hospital on 8/22 through 8/27/19 and underwent upper endoscopy with gastrointestinal and was found to have an ulcer beneath the Gastronomy tube (G-tube) bumper site and treated with a heater probe. A G-tube is a tube inserted through the abdomen that delivers nutrition directly to the stomach. Resident #188 remained thermodynamically stable and no further bleeding occurred. All transfer paperwork was sent to the hospital with the resident, with the exception of a written notice of hospitalization which was sent to the responsible party and not also with the resident. 2. Resident #160 was admitted to the facility in 10/2017 with a past medical history of Multiple Sclerosis, Neurogenic Bladder, Respiratory Failure, Cognitive Disorder, Breast Cancer,…

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

Based on review of medical record and interview with facility staff, it was determined that the facility failed to ensure that residents receiving insulin had physician prescribed parameters and that those parameters were followed. This was evident for 1 of 4 residents (Resident #163) reviewed for receiving insulin. The findings include: Resident #163's medical record was reviewed on 11/18/19 at 9:46 AM. During the review, it was found that the resident was ordered insulin on a sliding scale. The sliding scale order began at 3 units of insulin to be given for a blood glucose of 250-299, 4 units for a glucose of 300-349, and 5 units for a glucose of 350-399. The resident's glucose administration record for the month of October 2019 was also reviewed at this time. The record showed that sliding scale instructions that were handwritten on the side specified two additional doses from the order in the medical record: 1 unit for a blood glucose of 150-199 and 2 units for a blood glucose of 200-249. Furthermore, it was found that it was documented on 10/17, 10/18, and 10/21/19 that…

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

Based on medical record review and interview, the facility failed to reorder Ativan 0.5 mg PRN (as needed) after 14 days. This was evident for 1 out of 4 residents (Resident #143) reviewed for psychotropic medications. Findings include: Resident #143 was admitted to this facility on 9/2017. She/he had a history of Lymphedema, Vascular Dementia, Major depression, HTN, Unspecified symptoms and signs involving cognitive functions and awareness and other diagnoses. Review of Resident #143's record revealed the resident was taking Seroquel 12.5 mg. P.O. BID (by mouth, 2 times per day), Aricept 10 mg, Namenda 10 mg. BID, Cymbalta 30 mg every AM, Depakote 250 mg BID, Gabapentin 400 mg BID, and PRN (as Needed) Ativan 0.5 mg. The last time Ativan was reordered was on 10/15/19. Per record review, Resident #143 was last seen by behavior health on 10/21/19 as a follow-up for agitation and aggressive behavior. During the visit, it was noted the resident was cooperative and pleasant, that the resident was eating and sleeping well and there had been no PRN Ativan taken. Nursing reports noted 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, the facility staff 1) on household #6 failed to properly wash their hands prior to the lunch service. This was evident for 4 out of 5 employees (Staff # 4, #5, #6, #7) observed on one of six households during observations made during the survey and 2) the facility failed to ensure that linen was transported in a sanitary manner. This was observed on one of nine units during observations made during the survey. The Findings Include: 1. On 11/19/19 during the 12:00 lunch service on Household #6 was observed. The following staff washed their hands incorrectly: Staff #4 washed their hands with water and turned off the faucet with bare hands and not with a clean towel (2 times). Transferring germs from the faucet to the clean towels to the hands. Staff #5 washed their hands, used clean towels to turn off the faucet then, dried the hands with the towel used to turned off the faucet. Transferring germs from the towel to the clean hands. Staff #6 washed their hands with water, turned off the faucet with the back of the wet hand, then dried hands with a towel.…

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

Based on observation and staff interview the facility staff failed to maintain kitchen equipment in an operating condition. This was evident for 1 out of 6 satellite kitchens observed during the survey. The Findings include: Six households with in the facility each have their own complete kitchen set-ups that serve the resident's breakfast and lunch. On 11/13/19, around 11:30 AM, while touring the Household #5, it was noted that the stove top in the kitchen of the unit was in a non-working condition. The whole top of the stove, including the burners was covered and taped off. The Household #5 chef informed the writer that the stove top was broken and not operable.

Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that the residents and the resident's representatives were provided written notification of the transfer and the reason for the transfer to the hospital. This was found to be evident for 4 out of 5 residents (#149, #94, #346 and #122) reviewed for hospitalization during the investigative stage of the survey. The findings include: 1. On 6/25/18 review of Resident #149's medical record revealed the resident was transferred to the hospital in May 2018. Further review of the medical record failed to reveal any documentation that the resident or the family had been provided written notification regarding the reason for the transfer. On 6/25/18 at 1:01 PM the charge nurse #14 reported that either nursing or the physician calls the family to inform them why the resident was sent out to the hospital, and confirmed this notification was just verbal. On 6/25/18 the Director of Nursing also confirmed that there was no process for written notification 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 medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1) assess the resident's Activities of daily living (ADL), 2) assess the resident's bowel and bladder status, 3) assess the resident's skin condition and 4) assess the resident's health condition. This was found to be evident for 2 of 5 residents (Resident #346 and #94) reviewed during the investigative stage of the survey. The findings include: The MDS is a federally-mandated assessment tool used by nursing home staff to 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 need. 1a) On 6/21/19 Resident #346's medical records were reviewed. This review revealed that the resident was admitted to the facility for long term care and with diagnosis which included high blood pressure seizure disorder and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of water temperature logs it was determined that the facility failed to 1. have a system in place to address potentially dangerously high water temperatures on two out of the ten units of the facility. Additionally, it was determined the nursing staff failed to properly administer and secure medications left for residents to self-administer (Resident #446 and #118). This was evident for 2 of 5 residents selected for accident hazard investigative review. The findings include: Water may reach hazardous temperatures in hand sinks, showers, and tubs. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability 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 review of employee files and interview it was determined that the facility failed to have an effective system in place to ensure skills competencies were demonstrated by newly hired nurses and geriatric nursing assistants (GNA). This was found to be evident for 1 of 3 newly hired nurses (Nurse #20) and 2 out of 3 newly hired GNAs (GNA #26 and #27) reviewed for staffing during the investigative portion of the survey and has the potential to affect all residents. The findings include: 1) Review of the LPN/RN Orientation Checklist revealed a lists of skill and competencies with areas for the preceptor to document the date and method of validation. On 6/25/18 review of Nurse #20's employee file revealed the nurse was hired in October 2017. Further review of the file failed to reveal any Orientation Checklist validating the nurse's skills and competencies. On 6/25/18 at 3:16 PM surveyor reviewed with Director of Nursing the concern regarding lack of evidence of skills competencies for nurse #20. As of time of exit on 6/25/18 at 7:00 PM no Orientation Checklist had been provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee files and interview it was determined that the facility failed to perform annual performance reviews for the geriatric nursing assistants (GNA). This was found to be evident for 3 out of 3 GNAs (#21, #22, #23) reviewed for regular in-service training. The findings include: On 6/25/18 review of GNA #21, #22, #23 employee files revealed all three have been employed by the facility since before 2015. No annual performance review could be found for the years 2018 or 2017 for any of these three GNAs. On 6/25/18 at 3:16 PM surveyor reviewed with the Director of Nursing the concern regarding failure to have annual evaluations, and training based on those evaluations, for the GNAs. On 6/25/18 at 4:40 PM DON confirmed that there had been no recent evaluation for the reviewed GNAs.

Based on review of staffing sheets it was determined that the facility failed to ensure required information was included on the daily posted staffing. This was found to be evident for all ten of the units in the facility. The findings include: On 6/25/18 review of the daily posted staffing sheets for all 10 units of the facility for the period between 6/15 thru 6/22/2018 failed to reveal documentation regarding the total number and actual hours worked by the nurses and geriatric nursing assistants. Further review of the posted staffing sheets revealed inconsistencies with the posting of resident census as evidenced by blanks in the section for Unit Census for Hall 2 on the following dates/shifts: -6/16/18 evening shift; -6/17/18 day and evening shift; -6/18/18 evening and night shift; -6/19/18 evening shift; -6/20/18 evening shift. On 6/25/18 at 3:16 PM surveyor informed the Director of Nursing that there were concerns in regard to the the posting of staffing. Further review of copies of the staffing sheets that had been provided for review during the survey for Hall 1 failed to…

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

Based on medical record review and interviews with facility staff, it was determined that the facility pharmacist failed to recognize and report the lack of indications for use of ordered medications for 5 of 9 residents reviewed for unnecessary medications (#129, #137, #148, #25 and #88). The findings include: 1. Resident #129 was ordered Ritalin tablets 15 mg twice a day, Senokot Plus 8.6/50mg 2 tablets once a day and Zoloft 50 mg once a day. The orders did not indicate the disease being treated or the symptom these medications were treating. The pharmacist last reviewed the medical record on 5/30/18 and did not report the omission to the Physician or Director of Nursing (DON). 2. Resident #137 was ordered Metoprolol ER tablet 12.5 mg once a day. The orders did not indicate the disease being treated or the symptom being treated. The pharmacist last reviewed the medical record on 5/29/18 and did not report the omission to the physician or the DON. 3. Resident #148 was ordered Canasa suppository 1000mg once a day and Lanoxin tablet 0.125 mg once a day. The orders do not include the…

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

Based on record review and interview, it was determined that the facility staff failed to ensure that medication regimens were free from unnecessary medications. This is evident for 6 of 9 residents (#129, #98, #137, #148, #25, and #88) selected for review of unnecessary medications. The findings include: 1. Resident #98 was ordered Valproic Acid capsules 250 mg to be administered at 2 capsules one time a day at bedtime as a mood stabilizer. This medication requires a behavior monitoring tool to identify the behaviors it is stabilizing and assess the medications effectiveness. On 6-25-18 at 9:15 AM the Director of Nursing (DON) confirmed the facility had not implemented a behavior monitoring tool to identify and assess daily the behavior Valproic Acid is to control. 2. Resident #129 was ordered a Ritalin 15 mg tablet to be administered twice a day, 2 senokot plus tablets 8.6/50 mg once time a day at bedtime and Zoloft 150 mg tablet once a day. The facility failed to identify the indication for use of these medications. 3. Resident #137 was ordered Metoprolol ER 25 mg give 1/2 tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview it was determined that the facility staff failed to follow proper food handling practices to prevent the outbreak of foodborne illness. The deficient practices have the potential to affect all residents in the facility The findings include: On 06/20/18 at 8:25 AM initial tour of the kitchen with Manager of Patient Services (staff #35) was conducted. Observation of Hold Freezer #4 revealed a loosely wrapped package of cookies on one of the shelves. Staff #35 acknowledged observation and removed the package from the refrigerator. Observation in the kitchen meat preparation area with Staff #36 revealed the lids of 2 floor bins labeled Flour and Sugar were opened with the contents exposed. Although several kitchen staff members had walked by the bins Staff #36 approached and closed the lids. Further observation of the lids showed that there was a label instructing to keep them closed. During a later observation of the area at approximately 9:00 AM, surveyor noted the lids were opened. Staff #36 was present, approached and closed 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 family interview, observation, record review and staff interview it was determined that the facility staff failed to include the Responsible Party (RP) in the provision of care for a resident. This was true for 1 of 3 (#179) residents reviewed for care planning during the survey. The findings include: An interview with Resident #179's RP was conducted on 6/20/18 at 11:08 AM in the resident's room. The RP shared that the facility inconsistently informed him/her when specific providers come in to care for the resident. He/She stated that a podiatrist came by to treat the resident but they were not aware until after the visit. S/he went on to say that his/her presence during these visits were important to provide information to the providers since the resident was unable to express him/herself verbally. During the interview, the resident's ophthalmologist (staff #30) arrived. Interview with staff #30 revealed that he was there to complete a visual assessment on the resident that was started 2 days before. The RP stated that although she/he had discussed with facility staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews of residents and staff and a review of facility documents it was determined the facility failed to provide reasonable accommodations for residents and ensure that the showers on the unit were functioning properly and that safe temperatures were maintained. This was found to be evident for 1 unit (Hall 2) after a resident council meeting was conducted during the facility's annual Medicare/Medicaid survey. The findings includes: The survey team conducted a resident council meeting with residents on 6/21/18 at 11:15 AM and the residents who reside on Hall 2 unit stated that they have not been able to take a shower for 2 weeks because the water is either too hot or too cold. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware of this concern on 6/21/18 at 2:00 PM. An interview was conducted with the DON on 6/25/18 at 8:10 AM and s/he submitted an invoice that was dated 5/20/18 in which a service was provided regarding no running hot water on Hall 2 unit.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident council meeting minutes and interview with residents and facility staff, it was determined the facility failed to give adequate responses to grievances that was presented by the resident council. This was found to be evident during a resident council meeting, and a review of the resident council meeting minutes that was completed during the facility's annual Medicare/Medicaid survey. The findings include: Resident Council is a group of residents that meets regularly the on behalf of all residents in the facility to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life. Facility staff are required to consider residents' views and act upon grievances and recommendations. Facility staff must consider these recommendations and attempt to accommodate them, to the extent practicable. Review of the resident council meeting minutes for April, May and June 2018 revealed ongoing concerns regarding food. There were…

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

Based on interviews with residents and facility staff it was determined the facility failed to deliver mail to residents unopened on Saturdays. This was found to be evident after a resident council meeting was conducted during the facility's annual Medicare/Medicaid survey. The findings include: The survey team conducted a resident council meeting on 6/21/18 at 11:15 AM and the residents in attendance stated that mail was not delivered until Monday. The residents were asked if they received mail unopened on Saturdays and they responded, no. The residents further stated that mail was delivered on Friday evening and that it was not delivered again until Monday. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware of this during a meeting on 6/21/18 at 2:00 PM when all the residents' concerns from the council meeting were discussed. An interview was conducted with the DON on 06/25/18 at 9:40 AM and s/he was asked if the facility delivered mail to residents on Saturdays. The DON stated that the facility receives delivery of mail Monday thru Saturday. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and interview with staff it was determined that the facility staff failed to ensure 1) the appropriate Responsible Person was identified and consulted to complete the Medical Order for Life-Sustaining Treatment (MOLST) and 2) the process in determining a resident's decision making capacity and certification regarding medical ineffectiveness of treatment was completed timely. This was evident for 1 of 4 (#94) residents reviewed during the investigative stage of the survey. The findings include: MOLST is a standardized medical order form covering options for cardiopulmonary resuscitation (CPR) and other life sustaining treatments. It is used for medical personnel regarding CPR. 1) On [DATE] Resident #94's clinical records were reviewed. This review revealed that the resident was admitted to the facility in [DATE] and with diagnosis of alcohol abuse, heart failure and status post cardiac arrest and ventilator dependent. Review of the MOLST from February 2018 revealed the following:…

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

Based on medical record review and interview with staff it was determined that the facility failed to 1) notify the responsible party of a change in the resident's condition This was found to be evident for 1 out of 4 residents (#94) reviewed during the investigation stage of the survey. The findings include: On 6/22/18 Resident #94's medical records were reviewed. This review revealed that the resident had 3 Situation, Background, Assessment, Recommendation (SBAR) or change in conditions completed. A SBAR is a way for health care professionals to communicate effectively with one another Review of the nursing note and SBAR that was completed on 2/24/18 revealed that the resident had an unwitnessed fall. The nursing note was reviewed, and it documented that a call was placed to the physician, but staff did not receive a return call. Further review of the nursing note failed to reveal any documentation indicating that family was called and made aware of the resident's fall. The SBAR was completed on 2/24/18 due to the resident having a fall. Review of the SBAR failed to reveal any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication cart observations and staff interviews it was determined the facility staff failed to ensure medical record was kept in confidential manner. This was evident in 1 out of 2 medication carts. The finding includes: On 6/21/18 at 9:30 AM on the third floor Long Term Care unit surveyor observed on top of an unattended medication cart, the nursing third floor shift to shift report document. This document is used by the facilities nursing staff for assigned nursing task preformed during the nurses shift on assigned residents. This shift to shift report surveyor viewed included resident's names, room numbers, vital signs, pain medications, labs, code status, bowel movement status with nursing medication and treatment comments. This document was visible for the public to view for all residents who resided on the third floor which effected resident's #84, #10, and other residents on the unit. On the same day at 9:45 AM during interview of nurse #13, he/she stated, I just stepped away for a minute to assist a resident and forgot to the turn over the report sheet. Nurse #13…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews during an environmental tour, it was determined that the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 1 out of 10 nursing care units The finding includes: On 6/21/18 at 11:05 AM during the environmental tour, surveyor observed with Nurse #12 on Household 5 a Geri-chair in room [ROOM NUMBER] with the arm rest was ripped along the outside of the arm rest with exposed cotton padding. The plastic covering to the handle bar behind the Geri-chair was also broken and ripped off jagged edges. On 6/21/18 at 11:10 AM during interview with Nurse #12, he/she verified the Geri-chair needed repair. On 06/21/18 at 8:30 a.m. Director of Nursing was informed of environmental observations prior to survey exit.

Based on medical record review, observation and interview it was determined that the facility failed to develop comprehensive care plans as evidenced by failure to develop care plans to 1. address the use of a CPAP machine, 2. the use of a Foley catheter and 3. need for oxygen. This was found to be evident for 1 of 38 residents (#149) reviewed during the investigative portion of the survey. The findings include: 1a) Review of Resident #149's medical record revealed the resident was originally admitted to the facility in May 2018 for rehabilitation after hip surgery. On 6/21/18 at 8:50 AM Resident #149 was observed in bed asleep. No CPAP machine or tubing was observed at this time. On 6/22/18 review of resident #149's medical record revealed a diagnosis of obstructive sleep apnea and an order, in effect since 6/13/18, to use the resident's CPAP machine from home at night. CPAP [continuous positive airway pressure] is a common treatment for obstructive sleep apnea. The machine uses a hose and mask, or nose piece, to deliver constant and steady air pressure. Common problems with 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, record review, Resident Representative (RP) and staff interview, it was determined that the facility staff failed to provide routine foot treatment to prevent complications from conditions such as diabetes or immobility. This was found to be true in 1 (Resident #179) of 10 residents reviewed during the initial pool phase of the survey. The findings include: Review of Resident #179's medical record was conducted on 6/20/18 at 1:30 PM. The resident diagnosis included Dependency of mechanical ventilation, Diabetes Mellitus, limited mobility related to Cerebral vascular accident, and hypertension. An interview with Resident #179's responsible party (RP) was conducted on 06/20/18 at 11:08 AM in the resident's room. The RP stated that the facility was inconsistent with identifying potential concerns regarding the condition of the resident's feet and had not provided a podiatrist to come in to evaluate a recent concern he/she reported to nursing staff. During the interview at the RP request, an observation of the resident's feet was conducted. Several dark 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, observation and interview it was determined that the facility failed to 1. ensure the use of a physician ordered treatment for obstructed sleep apnea, 2. ensure a residents respiratory status was monitored as ordered, and 3. inform the physician of continued use of oxygen that had been ordered for use as needed. This was found to be evident for two out of four residents (#149 and #252) reviewed for respiratory care during the investigative portion of the survey. The findings include: 1) On 6/21/18 at 8:50 AM Resident #149 was observed in bed asleep. No CPAP machine or tubing was observed at this time. On 6/22/18 review of Resident #149's medical record revealed a diagnosis of obstructive sleep apnea and an order, in effect since 6/13/18, to use the resident's CPAP machine from home at night. CPAP [continuous positive airway pressure] is a common treatment for obstructive sleep apnea. The machine uses a hose and mask, or nose piece, to deliver constant and steady air pressure. Common problems with the use of CPAP include leaky masks, trouble falling…

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

Based on medical records review and interview with staff it was determined that the facility failed to obtain a radiology test in a timely manner causing a potential delay in treatment. This was evident for 1 out of 4 residents (Resident #94) reviewed during the investigative stage of the survey. The findings include: On 6/21/18 Resident #94's medical records and physician orders were reviewed. This review revealed that the resident was admitted to the facility in January 2018 for rehabilitation. Further review of the medical records reveal that the resident had 3 falls with complaints of pain from the third fall. Review of the physician orders revealed an order dated 5/11/18 for x-ray to right pinky finger. Review of the medical records failed to reveal documentation indicating that the resident had an x-ray completed. During an interview with the Director of Nursing on 6/21/18 the surveyor requested documentation indicating that the x-ray had been completed. On 6/22/18 the DON revealed that the x-ray had been done and that they are unable to locate the films or reports. The DON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form for a Resident (#446). This was evident for 1 of 35 residents reviewed for advanced directives. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. resident records. Resident #446 was admitted to the facility on [DATE]. On 6-20-18 and 6-22-18 the medical record was reviewed and the residents wishes concerning life sustaining measures on the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) was not on the chart. Staff #10 was able to locate the MOLST form after the unit nurses were unable to locate. The MOLST form was in Resident #446's soft, or un-filed, chart kept in a drawer that included 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 staff interview it was determined that facility staff failed to follow transmission-based precautions while providing care to residents. This was true in for 1 of 19 residents (#179) observed during the initial screening process of the survey. This deficient practice however has the potential to affect all the residents on the unit. The findings include: On 06/20/18 at 11:22 AM surveyor observed Geriatric Nursing Assistant (GNA staff #32) enter into the room of resident #179 carrying towels, washcloths and 2 to 3 bottles of commercial brand hygiene products. When the GNA was noted leaving the resident's room, surveyor observed GNA walk down the hallway and place the hygiene products into a locker. Interview with the GNA staff #32 revealed that it was his/her personal items that were stored in her locker and used on her residents for daily grooming. The concern exist that a potential of cross contamination can occur from the sharing of the containers between the residents on the unit. The unit manager (staff #31) acknowledged surveyor's findings

Based on resident and staff interviews and review of facility pest control logs it was determined the facility failed to keep resident's environment safe and free of pests and rodents. This was found to be evident after a resident council meeting was conducted during the facility's annual Medicare/Medicaid survey and had the potential to affect all residents. The findings include: The survey team conducted a resident council meeting on 6/21/18 at 11:15 AM and the residents reported that mice were seen on the Hall 2 Unit. The residents went on to say that mice were a problem throughout the building. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware of this during an interview on 6/21/18 at 2:00 PM. Review of the facility Pest Control Log on 6/21/18 revealed that the facility had been treating a rodent concern for multiple months. An interview was conducted with the Director of Nursing (DON) on 6/25/18 and s/he stated that the building was inspected on 6/22/18. The DON submitted a copy of the report to the survey team. The comments on the work…

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