Maryland Baptist Aged Home

Based on record review and interviews it was determined that the facility staff failed to complete and transmit a Minimum Data Set assessment within the required 14-day timeframe. This deficient practice was evidenced in 1 (#1) of 2 resident MDS assessments reviewed for timely completion during the recertification survey. The findings include: On 05/30/25 at 12:27 PM a review of Resident #1 quarterly MDS assessment revealed the assessment review date (ARD) was 04/05/25 and the assessment was signed on 04/25/25 which was outside of the 14-day window to complete and transmit the assessment. On 05/30/25 at 12:47 PM during a telephone interview with the MDS Coordinator the surveyor asked why Resident #1 MDS assessment was completed outside of the required 14-day timeframe. The MDS Coordinator verbalized that the assessment was not completed within the required timeframe because the staff who needed to complete Section E & Section Q did not complete their assessments in a timely manner. After the facility staff completed their portion of the assessment, the assessment was submitted. 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 it was determined that the facility staff failed to complete a narcotic count when a registered nurse assumed control over the nursing assignment. The deficient practice occurred during the recertification survey. The findings are: On 05/29/25 at 8:40 AM a review of the Controlled Drug Count Verification form revealed on 05/18/25 7AM - 3 PM shift a nurse signed the form as the incoming nurse. The outgoing nurse's signature 3PM - 11PM was different from the incoming nurse's signature. On 05/19/25 3PM-11PM shift the incoming nurse's signature and the outgoing 11PM- 7 AM shift was different. The surveyor could not verify if the narcotic count was completed by the nursing staff if another nurse completed the shift other than the incoming nurse. On 05/29/25 at 9 AM during an interview with the Director of Nursing the surveyor reported concerns about the nurse's completing the narcotic count as a nursing professional standard of practice. When the surveyor asked was the narcotic count completed when the nurse assumed control of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and observation it was determined that the facility staff failed to ensure the use of a hand splint as stated in the care plan. This was true for 1 (Resident # 9) out of 29 residents reviewed during the annual survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 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. On 5/29/2025 at 2:17 PM, A record review was conducted. Resident # 9 was admitted to the facility on [DATE]. He/She had hemiplegia affecting the left non dominant side and left-hand contracture. On 5/30/2025 at 11:38 AM, a review of Resident # 9's medical record was conducted, there was no documentation of any rehabilitation…

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 consistently provide Activities to residents who were unable to participate in communal Activities. This deficient practice was evidenced in 2 (#1 & #22) of 2 resident records reviewed for staff providing Activities to bedbound residents during the recertification survey. The findings include: On 05/28/25 at 9:25 AM while speaking with Resident #22 the surveyor asked does someone come to the room and do Activities with him/her. Resident #22 verbalized a lady used to come to their room and do Activities with him/her, but the lady no longer works there, and it stopped. On 05/29/25 at 2:24 PM during a review of Resident #1 Activities Log revealed the last documented activity session was on 05/01/25. A review of Resident #22's Activities Log revealed the last documented Activity session was 04/28/25. During an interview with Activities Director #6 he/she was unable to verbalize why the resident's were not receiving Activities regularly.

Based on observation and staff interview, it was determined that the facility failed to: 1.) properly label medications and dated once opened, and 2). Remove expired medications from the medication cart. This was evident for 2 of 2 medication carts reviewed during the annual survey. The findings include: 1.) On 5/30/2025 at 08:58 AM, a medication observation was conducted in the presence of staff # 8 (Certified Medication Aide) and revealed for medication cart 1 to have 2 eye drops, Dorzamide and Latanoprost eye drops for Resident # 8 both opened without a date they were opened. Resident # 20 had Dorzamide eye drops and found to be not dated. Upon further observation, medication cart 2 was noted to have 2 bottles of Nystatin powder for Resident # 14 with no date when both bottles were opened. It was also found to have 2 tubes of Duoderm Hydroactive gel without any label and not dated. Staff # 8 acknowledged the findings. Upon further medication storage observation, a canister of blood glucose strip was found in medication cart 2 without the date when it was opened. This 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, clinical record review and observation, it was determined that the facility failed to provide an Occupational Therapy evaluation for 1 (Resident # 9) out of 29 residents reviewed during the annual survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 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. On 5/28/2025 at 09:39 AM, an initial interview was conducted, Resident # 9 stated, I don't have any therapy. On 5/29/2025 at 2:17 PM, a record review was conducted. Resident # 9 was admitted to the facility on [DATE]. He/She had hemiplegia affecting the left non dominant side and left-hand contracture. On 5/30/2025 at 11:38 AM, a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined that the facility staff failed to have an effective system in place to identify, report, track, investigate, and analyze information relating to adverse events that occur within the facility. This deficient practice was discovered during the recertification survey. The findings include: On [DATE] at 10:26 AM after reviewing the Quality Assurance Performance Improvement (QAPI) plan the surveyor interviewed the Director of Nursing (DON). The surveyor informed the DON that the QAPI plan was ineffective because it lacked a systematic approach that identify problems, track, investigate, and analyze data. The DON verbalized the team meets monthly, and they were instructed to do review problems in the areas that needed to be approved. Their major concern was staffing. At first they were not using agency but started to meet the needs of the residents. The surveyor asked for documentation to show how they were monitoring that the building was properly staff. 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 record review and interviews it was determined that the facility staff failed to include the Infection Preventionist in the Quality Assurance Performance Improvement (QAPI) meetings. This deficient practice was discovered during the recertification survey. The findings are: On 05/30/25 at 2:42 PM the surveyor reviewed the sign-in sheets for QAPI meetings held on 01/31/25, 02/19/25, 03/19/25 and the Infection Preventionist's name or signature was not included on any of the sign-in sheets. On 05/30/25 at 2:56 PM during a telephone interview with Infection Preventionist #3 the surveyor asked did he/she attend any QAPI meetings. IP #3 verbalized they did not attend the QAPI meetings in person but was present via telephone. IP #3 was made aware that their name was not included as attending the meetings in person or by telephone. The surveyor asked when the last time he/she participated in a meeting. IP #3 was not able to provide the information requested. On 05/30/25 at 3:13 PM the Director of Nursing was made aware the Infection Preventionist is required to attend QAPI…

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

Based on observation and interviews with facility staff, it was determined that the facility failed to ensure that they had an adequate emergency water supply and were unaware of the building's water system and unable to provide a description of it, a diagram and no testing of the water had been done for legionella and/or other opportunistic waterborne pathogens. The findings include: On 05/28/25 at 10:27 AM the surveyor spoke with two housekeeping staff and the Director of Maintenance (Staff #1) regarding water testing and emergency water supply. Staff #1 said the city took care of water testing and would notify the facility if there was a problem. The surveyor informed him that the City provided the water up to the facility, but that the facility was responsible for the water system inside the building including testing for Legionella and other waterborne bacteria. He was completely unaware that the facility was responsible for testing the water and stated that they had not tested it anytime during the 2 years he had been employed in the facility. He also stated that they had not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility staff failed to apply for a room waiver for rooms less than the required square footage. This deficient practice was discovered during the annual survey. The findings include: On 05/28/25 at 8:33 AM during the entrance conference with the Director of Nursing (DON) the surveyor asked did the facility have any waivers. The DON verbalized the facility had a waiver for rooms that are less than the required size. The surveyor requested a copy of the waiver. On 05/29/25 at 9:15 AM the surveyor reviewed a document received after the entrance conference. The document indicated rooms [ROOM NUMBERS] was less than the required square footage. The surveyor asked the Administrator for a copy of the waiver. The Administrator verbalized they were told not to apply for a waiver unless the survey team asked for the waiver. The surveyor made the Administrator aware the waiver should have been available prior to the survey to avoid noncompliance.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the facility on 6/27/22, the facility failed to provide maintenance services to keep the resident's environment safe and in good repair. This was evident in all resident rooms and hallways. In addition, it was determined that the facility failed to ensure that resident rooms were kept in a home like environment. This was found to be evident for 1 out of 3 (affecting Residents #10, #16 and #22) resident rooms observed during the re-certification survey. The findings include: 1. An environmental tour was conducted by three surveyors at 10 AM on 6/27/22. Another tour of the facility was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 6/29/22 at 11 AM. It was noted that the floor in the hallways was uneven with gouges and separation in the tile with mix matched tiles as a temporary fix to the floor. In the bedrooms mix matched tiles throughout the rooms was observed with exposed rough, uneven edges. The floor tiles were also loose and/or missing in 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 observation, staff interviews, and documentation review, it was determined the facility failed to post the daily nurse staffing hours and ratios at the beginning of each shift. This was evident for nursing assignments posted from June 28, 2022, to June 30, 2022. The findings include: During tour of the facility on 06/28/22 6:40 AM the surveyor observed staff assignments posted on the whiteboard opposite the nurses' station which read: Date: 6/27/2022 Shift:7 AM to 3 PM. Actual staffing hours and staffing ratios worked by licensed and unlicensed staff not found. On 6/28/2022 at 6:45 AM Staff #6, stated he worked the 6/27/2022 3 PM to 11 PM shift as well as the overnight shift 11 PM to 7 AM. During a subsequent tour of the facility on 06/29/22 at 6:13 AM the surveyor observed staff assignments posted on the whiteboard opposite the nurses' station which read: Date: 6/28/2022 7 AM to 3 PM Shift. Actual staffing hours and staffing ratios worked by licensed and unlicensed staff not found. On 6/29/2022 at 6:55 AM Staff #7, stated that she worked the 6/28/2022 11 PM to 7 AM shift…

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 and observation of medical records, Controlled Drug Count Verification sheet and interview with staff it was determined that the facility failed to: 1. ensure that an account of all controlled drugs was completed with two licensed nurses at the change of each shift. This was evident for 1 of 1 available narcotic count logs. The findings include: During the first observation of medication pass on 6/29/2022 at 7:35 AM, surveyors started by reviewing the medication administration logs of the current residents to see when medication pass times were scheduled for and the different medications that would be scheduled. During review and as part of the medication storage task, the narcotic log was reviewed. The nightshift slot for the 7-3 shift was signed off as of 7:37 AM and the corresponding day shift signature was not. The day shift LPN, staff # 3 and the night shift LPN, staff #6 were present at the nursing desk. Staff #6 was asked if they had completed the narcotic count for the change of shift. He stated 'no, they were getting ready too.' He was then shown the book 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 review the facility failed to notify Resident # 21 and the resident's responsible party in writing of the reason for the transfer to the hospital and send a copy to the Ombudsman. This was evident for 2 (resident #9 and resident # 21) of 3 residents reviewed during the closed record review portion of the survey. The findings include: 1. On 06/27/22 at 10:08 AM a medical record review was conducted for Resident # 21. The resident had been sent to the hospital on 2 different occasions. On 4/7/22-4/15/22, Resident #21 was sent to the hospital due to a change in mental status. Resident # 21 was found to be lethargic and unresponsive. He has a history of cognitive impairment, Chronic obstructive pulmonary disease (COPD), cerebrovascular accident (CVA) and tachycardic. The resident was placed on antibiotic therapy and an appointment was made to follow up with the urology clinic for staghorn calculus. He was also placed with a urinary catheter for retention. On 5/25/22 Resident #21 was sent to the…

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

Based on resident medical record review, the facility failed to develop a care plan for Resident # 21 who has a history of urinary track infections and kidney stones in addition to retention of urine. This was evident for 1 out of 3 residents reviewed for care plans. The findings include: On 06/27/22 at 10:08 AM a medical record review was conducted for Resident # 21. The resident had been sent to the hospital on 2 different occasions. On 4/7/22-4/15/22 the resident was sent to the hospital due to a change in mental status. Resident # 21 was found to be lethargic and unresponsive. He has a history of cognitive impairment, COPD, CVA and tachycardia. Resident was placed on antibiotic therapy and a appointment was made to follow up with urology clinic for staghorn calculus. He was also placed with a urinary catheter for retention. On 5/2522 Resident #21 was sent to the hospital for a complicated UTI (Urinary tract infection) associated with catheter use. Resident has surgery (ureteroscopy) on 6/3/22 to remove staghorn calculus. Resident # 21 was also placed on Cefdinir 300 mg 2 times…

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

Based on observation, interview, and medical record review, it was determined that the facility staff failed to follow physician orders regarding nutrition for a resident exclusively dependent on gastrostomy tube (also called a G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding and ensure that s/he was fed all scheduled and ordered tube feeding nutrition. This was evident for 1 of 1 residents (#14) in the facility that were ordered gastrostomy tube feedings. The findings include: During an interview on 6/29/2022 at 7:35 AM with the night and day shift staff, Licensed Practical Nurse (LPN) #6, and LPN #3 respectively. The Surveyors inquired as to the next scheduled time that Resident #14 was to receive his/her g-tube feeding. The facility staff both simultaneously stated that Resident #14 received g-tube feeding 3 times a day and that s/he will not be due again until 2:00 PM. The Surveyors continued with their review of Resident #14's medication administration record (MAR) and paper chart as part of the closed record review portion…

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

Based on medical record review and interview with facility staff, it was determined that the facility failed to: 1. complete a discharge summary on a resident to include a recapitulation of the resident's medication and 2. Provide a resident with discharge instructions at discharge. This was evident in 1 of 3 residents (#26) reviewed for discharge. The findings include: Review of the closed medical record on 6/29/2022 at 12:31 PM for Resident #26 revealed a discharge from the facility on 4/4/2022 according to his/her electronic health record (EHR), specifically the nursing progress notes that documented the resident was discharged home on 4/4/2022 at 5:40 PM. This progress note though did not address any training or review any medications the resident was to be discharged home on. In addition during this review no physician discharge summary was located in the residents closed chart. A social work note completed on 4/1/2022 documented that medications were reviewed with the resident on 4/1/22 at a care plan meeting, however there was no documentation in the chart 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 observation, record review, and interview with facility staff, it was determined that the facility failed to arrange a follow up appointment for a resident's venous stasis ulcer. This was evident for 1 (Resident #23) of 1 resident reviewed for wounds. The findings include: On 6/28/22 at 10:27 AM, the surveyor observed Resident #23 in his/her room. During the observation, the resident was noted to have a wound to his/her right leg. There was an intact bandage on the leg wound. The resident was unable to be interviewed. On 6/30/22 at 8:13 AM, the surveyor reviewed Resident #23's medical record. The record showed that the resident's right leg wound was present on admission in 2021 and improved as of a physician's note written on 10/31/21. However, a note was found from a vascular surgery appointment on 1/19/22 that indicated Resident #23's right leg venous wound had reopened. The note indicated that the resident should be ordered compression dressing, should elevate the extremities, should wear compression stockings, and will need to continue to be followed by a vascular…

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 medical record reviews, it was determined that this facility failed to follow Physician Orders regarding management of Tube Feeding for a resident totally dependent on gastrostomy tube feeding. The findings include: During tour of the facility on 6/28/2022 at 8:55 AM Resident #14 was observed in his/her room asleep. Observation of Resident #14's room revealed the presence of a 60-cc syringe used for gastrostomy tube feeding on the resident's bedside table. On 6/29/2022 during review of the medication administration record (MAR) for Resident #14, surveyor noted that s/he was scheduled for feeding via the gastrostomy tube at 10:00 AM. Surveyor interviewed staff Licensed Practical Nurse (LPN) #3 and #4 regarding when Resident #14 was scheduled to be fed again and they both stated not until 2 PM and further that s/he only is fed 3 times a day. On 6/29/2022 at 9:00 AM, while observing staff LPN #3 on Medication Pass, LPN # 3 was interviewed on, how many times each day, Resident #14 is fed. LPN# 3 answered three times. This Surveyor asked her 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 interview with facility staff it was determined that the facility staff failed to document an accurate overview of the resident during a physician visit. This was evident during 1 of 3 physician record reviews. (R #12) The findings include: Review of the medical record for Resident #12 on 6/29/22 at 8:26 AM revealed a physician visit note dated 3/26/2022 documenting 11 medications in the resident's profile, with one medication listed 3 times and two different medications referred to twice. A review of the resident's concurrent medication administration record revealed Resident #12 was only 12 medications, however, only 9 of the medications that were listed in the physician note. Two of the medications listed; Aricept and Abilify were not documented as administered since before December 2021. These medications were also listed on the physician progress notes for 4/9/22 and 5/14/22, 6/11/22 and 6/19/22. These concerns were reviewed with the facility Director of Nursing throughout the survey and again on 7/1/2022 at 9:30 AM and again during the survey…

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

Based on record review and staff interviews, it was determined that the facility failed to ensure that a nurse aide had no less than twelve hours of in-service education per year. This was evident for 1 (Staff # 16) of 3 Geriatric Nursing Assistants (GNAs) reviewed during the Sufficient and Competent Staffing Review portion of the survey. The findings include: During review of Staff #16's personnel file On 6/30/2022 8:30 AM , it was revealed that the most current GNA training was completed by Staff #16 on 5/29/2020. On 6/30/2022 9:45 AM an interview was conducted with the DON. During the interview the DON stated: the file we submitted is our current in-service and training record for Staff #16. The concern regarding failure to ensure a nurse aide had no less than twelve hours of in-service education per year was addressed with the Administrator and DON on 6/30/2022 1:30 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility failed to ensur:e 1) appropriate temperature maintained for the medication refrigerator, 2) expired medications were properly disposed, 3) ensure medications were kept in secured locations, and 4) food items were not kept in medication storage room. This was found to be evident in 1 out of 1 medication storage rooms observed during the recertification survey. The findings include: 1) On 06/30/22 at 10:43 AM the surveyor and Director of Nursing (DON) conducted an observation of the medication storage room. The surveyor and DON found the medication refrigerator thermostat temperature at 50 degrees Fahrenheit. The medication refrigerator log stated minimum temperature of 36 degrees Fahrenheit and a maximum of 46 degrees Fahrenheit. 2) On 06/30/2022 at 10:45 AM the Surveyor and DON observed the inside of the medication refrigerator and found 3 Latanoprost eye drops that expired on 2/25/2022 and 3 Trulicity insulin pens that expired 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 observation, interview, and medical record review, it was determined that the facility failed to provide dental services and assessments within a reasonable time frame. This was found to be evident for 1 out of 4 residents (Resident #10) reviewed for dental. The findings include: During a tour conducted on 06/27/2022 at 11:55 AM surveyor observed resident #10 with missing teeth and a broken tooth on the left side of the resident's mouth. During an interview conducted on 06/27/2022 at 11:56 AM, resident #10 stated he/she had not seen a dentist since he/she had resided at the facility and currently had a sore mouth from his/her broken teeth. The Resident stated he/she had not told the facility about the mouth pain. On 6/28/22 at 02:26 PM a record review of the physical chart was conducted. The surveyor located 1 dental/oral assessment conducted on 07/17/2019. The assessment documented the resident #10 had a total of 6 teeth in his/her mouth. During an interview conducted on 06/28/2022 2:32 PM Medical Records #13 reviewed the resident's chart and confirmed the resident had one…

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 with facility staff, it was determined that the facility failed to ensure that leftover foods were cooled in a safe and sanitary manner. This practice had the potential to affect all residents. The findings include: During a tour of the kitchen that took place on 6/28/22 at 12:40 PM, the surveyor interviewed the Certified Dietary Manager (CDM). During the interview, the CDM was asked if the facility maintains any leftover food after it has been prepared. The CDM stated yes, the facility does keep leftover foods in small quantities after some meals. The surveyor asked if the facility tracks the cooling temperatures of potentially hazardous cooked foods to ensure that they cool from 135°F to 70°F within 2 hours and from 70°F to 41°F within 4 hours. The CDM indicated that there was not such a process, stating that there was no expectation that staff take the temperature of cooling foods prior to refrigeration. The CDM denied having any cooling log of potentially hazardous leftovers.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that food service was operated in a clean and sanitary manner. This practice had the potential to affect all residents. The findings include: The surveyor conducted a tour of the kitchen on 6/28/22 at 12:40 PM. The tour revealed the following findings: - the surveyor noted a used scoop for serving sugar and flour that was being kept inside the bin for the sugar and flour, exposing the food to the contaminated handle. - the surveyor noted approximately 8-10 seasoning containers with heavily soiled lids. The containers were placed next to the steam trays and had evidence of being contaminated by splash from food preparation. The lids all had thick brown crust on their tops and sides. The Certified Dietary Manager (CDM) indicated that the containers were reused because of their smaller size, and that staff refilled them from larger storage containers of the respective spices. The CDM indicated that she would obtain new smaller spice containers. - the surveyor identified a red…

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 documentation and interview with facility staff, it was determined that the facility failed to maintain a facility-wide assessment of necessary resources for resident care and review and update the assessment at least annually. This practice has the potential to affect all residents in the facility. The findings include: On 6/30/22 at 9:50 AM, the surveyor interviewed the Administrator. During the interview, the administrator stated that she recalled completing a 2 page document that she thought served as a viable facility assessment. The Administrator couldn't say when it was last reviewed or seen, but stated that she expected to find it in the survey resource binder. During a follow up interview that took place on 6/30/22 at 10:05 AM, the Administrator stated that she had reviewed the facility resource binder and couldn't locate the facility assessment there or anywhere else.

Based on record review and interview it was determined the facility failed to ensure the appropriate staff attended the Quality Assurance and Performance Improvement (QAPI) committee meeting. This was found to be evident for 5 out of 5 QAPI meetings held. The findings include: On 06/27/2022 at 11:25 AM a record review of the Quality Assurance and Performance Improvement (QAPI) meeting attendance sheets revealed the Medical Director was not in attendance for meetings held January, February, March, April, and May 2022. During an interview conducted on 06/27/2022 at 12:27 PM the Director of Nursing (DON) stated he/she had taken the role to conduct the QAPI meetings since the last person left in December of 2021. The Administrator confirmed the Medical Director was not listed as an attendee because the Medical Director attended the QAPI meetings by telephone. The Surveyor requested supportive documentation to confirm the Medical Director attendance. On 06/27/2022 at 1:35 PM the surveyor reviewed the QAPI meeting notes and was for January, February, March, April, and May 2022 and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on previous room measurements, observations and interviews, it was determined that the facility failed to provide at least 80 square feet of floor space per resident in 2 of the 11 residents rooms. The findings include: As previously determined the floor space for rooms [ROOM NUMBERS] is calculated to be 75.5 square feet of floor space per resident. Both rooms are equipped to house two residents each. The Nursing Home Aadministrator had acknowledged that rooms 101, and 102 did not meet the floor space requirement during environmental rounds conducted on 6/27/22 at 11 AM. The Administrator also presented a waiver to the survey team. During the survey, there were 2 residents in 101 and 102. The residents in these rooms had no issue with the size of the rooms. The calculated room size did not meet the 160 square foot requirements for a 2 person room.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that handrails were secure to provide a safe environment. This was found to be evident for 1 out of 5 handrails observed during the re-certification survey. The findings include: During a tour of the facility conducted on 06/27/2022 at 8:32 AM, the surveyor observed a handrail hanging in a downward position away from the wall located in the hallway between resident room [ROOM NUMBER] and the restroom. During an interview conducted on 06/27/2022 at 8:35 AM the Maintenance worker #2 stated he/she would repair the handrail. The Surveyor observed Maintenance worker #2 attach the handrail to the wall. On 06/27/2022 at 9:05 AM the surveyor advised the Administrator of the findings during an interview.

Based on observation and staff interview it was determined that the facility staff failed to ensure the privacy of medical information. The findings include: This surveyor observation of the outside of the facility on 4/9/2019 at 12:00 PM revealed: 1. The back of the facility revealed 11 overflowing boxes of varies medical and staff information including a Resident to Resident investigation dating back to 2009. 2. The back of the facility revealed 4 overstuffed, blue duffle bags that was not completely closed and had current medical information including empty medication packages. 3. The fence around the facility needed repair and was unsecure. Anyone in the back of the facility had visible to the medical information. The Director of Nursing and Administrator was interviewed on 04/09/19 at 12:44 PM, revealed that the company Shred-It was to come out today and pick- up the bags to be destroy. The Administrator stated that she understood the findings of unsecure medical information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the 4/3/2019, observation of resident bedrooms and bathrooms, it was revealed that there was evidence of unattended maintenance necessary to maintain a clean, comfortable and homelike environment. This was evident for 3 of 18 residents selected for review during the survey process. The findings include: During the initial tour of the facility on April 3, 2019, the survey team observed the following evidence of unattended maintenance and/or housekeeping concerns: 1. room [ROOM NUMBER] was found with the base board molding to the right of the door, approximately 2 feet long pulled away from the wall. In addition, there was a missing floor tile next to the night stand. 2. On 4/3/2019 at 11:30 AM Resident #20's wheel chair padding on both arms was torn. 3. On 4/3/2019 at 11:00 AM Resident #21's wheel chair was repaired with grey duct tape. 4. All nursing homes must assure that adequate housekeeping and maintenance services were provided as necessary to maintain a sanitary, orderly, and comfortable…

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 upon resident interview, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine and emergency dental care. This was evident for 1 of 2 residents (Resident #21,) during the investigative portion of the survey. The findings include: 1. An interview was conducted with Resident #21 on 4/3/2019 at 8:30 AM. When asked if the resident was experiencing any dental or oral issues the resident responded I have missing teeth and tooth pain. I told them I wanted to see a dentist. Medical record review reveals an evaluation of oral/dental status on 8/8/2018, at that time the Resident requested to be seen by a Dentist 2nd to missing teeth. Further, medical record review reveals a Physician order on 3/16/19 to start amoxicillin 500mg by mouth every 12 hours, times 7 days for tooth ache/abscess. Interview with the Director of Nursing on 4/8/19 at 9:30AM, confirmed the facility staff failed to obtain the dental consult. Following surveyor intervention, a dental consultation was scheduled for the resident.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview with staff it was determined that the facility failed to maintain all essential mechanical, electrical, equipment in safe operating condition. The findings include: On 4/3/2019 at 8:30 AM, during an initial tour of the facility's the following observations was made: 1. Resident's room [ROOM NUMBER]A has a call bell cord attached to the wall with expose wires. 2. Observation of the laundry on 4/8/19 at 12 Pm, revealed that there were multiple issues in evidence of unattended maintenance. The dryer room revealed lint attached to the walls, floor and covering the exhaust fan. These findings were acknowledged by the Director of Nursing on 4/9/19 at 9 AM.

Based on observation and staff interview it was determined that the facility staff failed to ensure all of the rooms met the requirement for square footage. The findings include: The Administrator was asked on 4/3/19 if the facility had any waivers. She informed the team that she had a waiver for the square footage of two of the rooms, 101 and 102. The floor space was calculated to be 75.5 square feet of floor space per resident for both rooms. Both rooms are equipped to house two residents each. The nursing home administrator confirmed that the rooms do not meet the requirement and informed me that a waiver request had been faxed to OHCQ on 2/18/19. There are two residents currently living in each room. None of the residents complained about the room size.