Resorts Of Augsburg

Based on record review and interview with facility staff, it was determined the facility failed to 1) ensure the monitoring of a psychotropic medication for a resident and 2) ensure a resident's medication regimen was free from unnecessary medications. Specifically, the facility prescribed as needed (PRN) psychotropic medication without documentation of a supporting evaluation This was evident for 2 (Resident #7 and #13) out of 5 residents reviewed for unnecessary medications during the facility's recertification/complaint survey.The findings include: The Centers for Medicare & Medicaid Services (CMS) defines a psychotropic medication in the regulations at 483.45(c)(3), as any drug that affects brain activities associated with mental processes and behavior (CMS, 2023). These drugs include, but are not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medications. These medications can have serious potential risks, including side effects, drug interactions, and the possibility of neuroleptic malignant syndrome (a rare but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a facility reported incident #2623258, record review and interviews, it was determined that the facility failed to report the investigative results of an alleged resident-to resident interaction which resulted in serious bodily injury, to the Office of Health Care Quality (OHCQ) within 5 working days as required. This was true for 1 of 10 (#2623258) facility reported incident reviewed during the survey process.Findings Included:On 12/3/25 at 11:15 AM, a review of Intake #: 2623258 revealed that Resident #128 reported that Resident #136 punched him/her in the face and turned over his/her wheelchair.On 12/3/25 at 12:48 PM, a review of the facility's documentation related to the above-mentioned incident report revealed that approximately 11:45 PM on 9/19/2025 Resident #128 alleged that he/she was punched in the face by Resident #136. According to the report, Resident #128 requested to be sent to the hospital after the alleged incident and Resident # 136 was incoherent and denied the assault.A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility staff failed to 1) ensure that a written notice which specifies the duration of the bed-hold policy and return to the facility was provided to the resident and/or to resident representative(s) at the time when the resident was transferred to the hospital, and 2) ensure written notice of a hospitalization and the reason for the hospitalization were provided to the resident and to family. This was evident for 2 (Resident #89 and #128) out of 2 residents sent to the hospital that were reviewed during the recertification/complaint survey.Findings Included:Situation, Background, Assessment, and Recommendation (SBAR) is a communication tool that aides healthcare professionals to share information about a patient's condition in a concise manner. 1) On 12/3/25 at 11:15 AM, a review of the facility's incident report revealed that Resident #128 was sent to the hospital on 9/20/2025 after an alleged assault with injury. Further review…

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 staff interview, it was determined that the facility staff failed to accurately code Minimum Data Set (MDS) assessments. This was evident for two (Resident #4 and #8) of five residents reviewed during this recertification/complaint survey.The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each resident receives the care they need. Active diagnoses documented on the MDS assessment are those attending provider-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. 1) On 12/04/25 at 8:52 AM, a review of Resident #8's medical record revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with facility staff, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review Level II determination and evaluation report into the resident's care and refer residents to the appropriate state-designated authority for review when a resident was identified with newly evident or possible serious mental disorders, intellectual disabilities, or a related condition. This was evident for 1 resident (Resident #83) of 4 residents reviewed for PASARR during the recertification survey. The findings include: According to the State Operations Manual, The Pre-admission Screening and Resident Review (PASARR) process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders (MD) or intellectual disabilities (ID) and related conditions. This initial pre-screening is referred to as PASARR Level I and is completed prior to admission to a nursing facility. A…

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

Based on a medical record review and an interview with facility staff, it was determined that the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) form was completed prior to or upon admission to the facility. This was evident during the review of two residents (Resident #5 and #13) of the 3 residents reviewed for PASARR screening during this recertification/complaint survey.The findings include:Preadmission Screening and Resident Review is a federal requirement designed to help ensure that individuals are not inappropriately placed in nursing homes for long-term care. Every individual who applies for admission to a nursing facility must be screened for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions. 1) During the review of facility residents on 12/02/25 at 11:50 AM, it was revealed that Resident #13 did not have a completed PASARR upon his/her admission. In an interview with the Social Worker on 12/03/25 at 1:52 PM, he confirmed that the facility should…

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 medical records and interviews with facility staff, it was determined that the facility failed to ensure a written summary of the baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP) and evidence in the resident's medical record that it was provided. This was evident for 1 (Resident #98) out of 36 residents reviewed during the investigation phase of the facility's recertification survey.The findings include:A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and current medication list must be given to each resident and/or his/her representative and documented in the medical record. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety,…

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 reviews and interviews, it was determined that the facility failed to 1)develop and implement person-centered comprehensive care plans as required and 2) to ensure interventions agreed to as part of a resident's care plan are initiated. This was evident for three (Resident #5, # 9 and #29) of 76 residents care plans reviewed during the survey process.Findings Included:The Minimum Data Set (MDS) is a standardized comprehensive assessment tool that measures health status in nursing home residents. 1) On 12/01/2025 at 11:09 AM, in an interview with Resident #9, the resident reported that he/she had multiple urinary tract infections since admission. On 12/08/2025 9:44 AM, a review of Resident #9 medical records revealed that the resident had a positive urine culture for urinary tract infection (UTI) on 6/22/2025 at 09:00 AM. A review of the resident's orders revealed that on 6/23/2025 the resident was started on Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by mouth every 24 hours for UTI for 5 Days.…

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 and staff interviews and review of the medical record, it was determined the facility failed to ensure that dependent resident's personal hygiene needs were adequately met by providing incontinence care in a timely manner. This was evident for 1 (Resident #9) out of 2 residents reviewed for Activities of Daily Living (ADL's) during the facility's recertification survey. The findings include: Activities of Daily Living (ADLs) are the basic, essential self-care tasks individuals perform to maintain their daily lives such as hygiene, eating, mobility, and toileting.On 12/1/2025 at 11:27 AM in an interview with Resident #9, he/she stated he/she had not been changed since the previous shift (7PM-7AM) at approximately 6:00 AM. During the interview he/she stated that it was the norm and that he/she was not usually changed until after 11:00AM during the 7AM-7PM shift. Resident #9 stated, I get changed at 5/6 AM (by the 7PM-7AM shift) and then when I'm wet and need to be changed on the 7AM-7PM shift, they're serving breakfast and feeding residents. I have to ask them around…

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

Based on observations and interviews, it was determined that the facility failed to: 1) ensure that the resident received treatment and care by assisting a resident with transportation to medical appointments and 2) meet the professional standards of practice during medication administration task. This was evident for 1 (Resident #9) of 2 Resident reviewed for missed medical appointments. This was evident for 1 of 29 opportunities for medication error observed during the medication administration task reviewed during the recertification/complaint survey.Findings Included1) On 12/01/2025 10:45 AM, in an interview with Resident #9, the resident alleged they stopped me from getting mobility. I got the form to renew it, and all the facility had to do was give them the size of my wheelchair and have the doctor sign it and they wouldn't. They said I couldn't use both transportation and to use theirs. So I've missed appointments. The resident continued to explain that the most recent appointment he/she missed was with the vascular doctor and another missed appointment was with the Ear-Nose…

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 interviews, it was determined that the facility failed to ensure that the resident received assistive devices to maintain vision abilities. This was true for 1 (Resident #9) of 2 Residents reviewed for vision impairment during the recertification/complaint survey.Finding Included:On 12/01/2025 at 10:57 AM, in an interview with Resident #9, the resident explained that he/she got fitted for glasses, but he/she never received the glasses, and it has been a few months. During the interview, the surveyor did not observe the resident in possession of any glasses at bedside.On 12/08/2025 at 2:36 PM, a review of a progress note written on 7/29/2025 at 1:27 PM revealed that Resident #9 went to eye appointment in-house this morning. The resident came back with no glasses stated that the appointment was just for the measurement of the frame and no new appt scheduled at this point. A 8/25/2025 7:18 PM NURSING QUARTERLY CHARTING stated, vision is adequate Wears glasses.On 12/08/2025 at approximately 3:30 PM, in an interview with Staff #12 (unit manager)…

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

Based on resident interview and staff interview it was determined that the facility staff failed to ensure a resident's colostomy bag was monitored and changed as needed by staff. This was evident for 1 (Resident #2) out of 1 resident reviewed for colostomy care during the recertification/complaint survey. The findings include:Resident #2 was interviewed on 12/03/2025 at 9:04 AM. The resident stated that they don't check their colostomy bags more than once per shift.The resident came down to the ground level where the survey team was located on 12/4/25 at 1:00 PM. The resident said that yesterday at 10:30 AM the colostomy bag exploded, and they were not changed until 3:00 PM. The resident stated that they had feces all over [their] body, pants, and shoes. The physical therapist (staff # 27) was interviewed on 12/5/25 at 2:44 PM. This surveyor asked if she worked with the resident yesterday. She confirmed that she worked with the resident yesterday,12/4/25. She initially was not sure what time but after thinking for a few seconds she said it was definitely before noon. She was asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident medical records and an interview with facility staff, it was determined that the facility failed to timely address significant weight loss for a resident. This was evident for two (Residents #6 and #13) of the four residents reviewed for nutrition during this recertification/complaint survey.The findings include:1) During the initial screening of Resident #6 on 12/02/25 at 7:26 AM, it was noted that the resident had a triggered weight loss alert on the Minimum Data Set (MDS, which is a federally mandated, standardized assessment tool used by Medicare/Medicaid certified facilities to comprehensively evaluate residents' health, functional, and psychosocial needs for care planning, quality improvement, and funding.)A review of Resident #6's medical records on 12/03/25 at 1:09 PM revealed the following documented body weights:5/01/25: 203 lb. (pound) via Hoyer5/30/25: 184.4 lb. via Hoyer6/02/25: 184.2 lb. via Hoyer6/09/25: 185.4 lb. via Hoyer7/03/25: 185.0 lb. via Hoyer8/05/25: 175.4…

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

Based on surveyor observation, review of the medical record, and interview with facility staff, it was determined that the facility staff failed to provide necessary respiratory care services by failing to document the indication for oxygen therapy, failing to properly label the oxygen tubing, and failing to administer oxygen at the prescribed flow rate. This was evident for 1 (Resident #6) of 3 residents reviewed for Respiratory Care during this recertification/complaint survey.The findings include:During the initial tour on the first floor of the facility on 12/01/25 at 2:26 PM, it was observed that Resident #6 was receiving Oxygen at 1.5 L/minute through a nasal cannula. At this time, it was noted that the oxygen tubing was not labeled.On 12/05/25 at 9:56 AM, a second observation was conducted by the surveyor. It was noted that Resident #6's oxygen tubing did not have a label, and the oxygen was infused at 1.5 L/minute.A review of Resident #6's medical record on 12/05/25 at 9:41 AM revealed that the resident had an order: [resident's name] wears O2 at 2 L/min via nasal cannula…

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

Based on resident interview and observation of a test tray, it was determined that the facility staff failed to ensure residents are served hot and palatable meals. This was evident for 5 (Residents #2, 9, 50, 98, 110) out of 47 residents in the survey sample.The findings include:An interview with Resident #2 on 12/3/25 at 9:15 AM revealed that the resident was not happy with the quality of the food. Four residents (#9, #50, #98, and #110) were interviewed on 12/4/25 as part of the Resident Council task. This surveyor asked if the food served was good and/or served hot. They said the food is often cold. They said they have requested microwaves, but the administration has said microwaves are against company policy. They added that the administration said they may revisit the issue in the future. One resident added that the rumor was that a staff member got burnt but another resident chimed in and said the administration initially blamed the state. Two test trays were ordered from the kitchen for the last service of the day on 12/8/25. The two trays would be one with pureed food 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 review of medical records and interviews with facility staff, it was determined that the facility failed to 1) maintain a medical record in the most accurate form for residents and 2) ensure that residents' indication of medication was documented. This was evident for 3 (Resident #7, #8, and #11) out of 27 residents reviewed during the facility's recertification/complaint survey.The findings include: 1) On 12/4/25 at 11:15 AM while reviewing Resident #7's paper chart on the unit, Resident #35's face sheet and 11/7/25, 8 page discharge summary from Northwest Hospital was observed. On 12/4/25 at 11:23 AM in an interview with Unit Manager (UM #12), when asked if resident records stored in charts should be accurate and reflect that specific resident, she stated, The resident's information should be stored in their chart. No other resident's information should be in there. During the interview, a dual observation of Resident #7's chart was conducted. When asked whose chart it was, UM #12 stated, [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 interviews and a review of medical records and facility documentation, it was determined that the facility failed to properly monitor and track antibiotic usage and resistance data. Specifically: 1) the facility's antibiotic stewardship log failed to include essential elements of antibiotic use, and 2) an antibiotic was initiated for a resident before the infecting organism was identified by the laboratory. This deficiency affected one of five residents (Resident #7) reviewed for antibiotic use and the antibiotic stewardship program during the recertification/complaint survey.Findings include:1) On 12/07/25, as part of the Infection Control task, the surveyor requested copies of the antibiotic stewardship logs from January 2025 to the present.On 12/08/25 at 8:54 AM, the surveyor reviewed the facility's log, which was a spreadsheet including resident names, room numbers, infection sites, and prescribing clinicians. However, the log failed to consistently list the duration of antibiotic use, and several entries in the organism identified section were either left blank or…

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

Based on medical record reviews and staff interviews, it was determined that the facility failed to document the provision of education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine to residents. Additionally, the facility failed to maintain required documentation related to staff COVID-19 vaccination status. These findings were evident for one resident (Resident #89) out of five reviewed, and four staff members (Staff #19, #51, #52, and #53) out of five reviewed during this recertification/complaint survey.The findings include:A COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease.1) On 12/05/25 at 11:34 AM, the surveyor randomly selected five residents to review their immunization records. The review revealed that Resident #89, who was admitted in October 2025, did not have a COVID-19 vaccination record on file.In an interview on 12/08/25 at 8:54 AM, the Director of Nursing (DON), who also serves as the Infection Preventionist,…

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

Based on observation and interview it was determined the facility failed to ensure residents had access to call bells. This was evident for 1 (Resident #12) resident observed during the surveyor's initial tour of the facility during the recertification survey.The findings include:Keeping the call bell within reach is a fundamental nursing standard of practice for patient safety, especially fall prevention, ensuring patients can summon help for needs like toileting, water, or repositioning, reducing risks from altered mobility or medication side effects, and improving satisfaction by providing timely assistance and patient empowerment. This involves ensuring the device is accessible (e.g., below grab bars in bathrooms, not obstructed), functional, and that patients know how to use it, with staff regularly checking and responding promptly to these signals. Upon the surveyor's initial tour on 12/1/25 at 11:20 AM, the call bell for Resident #12 was observed to be inaccessible, on the floor and behind the resident's bedside table. On 12/1/25 at 11:25 AM in an interview with Registered…

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

Based on reviews of the facility investigation and other pertinent information, reviews of a closed medical record, and staff interview, it was determined that the facility 1) failed to report allegations of possible abuse to the local police within 2 hours when a resident (# 255) was identified with an injury of unknown source (fracture). and 2) failed to notify the state agency within 2 hours of a potential abuse/neglect incident. This was evident for 4 (Resident # 69, # 54 and # 10, #255) of 9 residents reviewed for abuse during the recertification survey. The findings include: 1. A review of the facility abuse policy on 04/16/24 revealed under Section V. Reporting, any witnessed or suspected violations involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of resident property, must be reported immediately to the employee's supervisor. Under Section P. indicated that: Local law enforcement agencies will be notified as appropriate. Under Section VIII. Abuse Coordinator Procedures: K. Should the investigation reveal that abuse,…

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

Based on observations and interviews with facility staff, it was determined that the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors. This was evident for 2 (Watersedge and Sudbrook) of 4 units in the facility reviewed for staffing information. The findings include: On 4/4/24 at 8:18 AM, the surveyor did not observe staffing information posted on the Watersedge unit. On 4/4/24 at 8:30 AM, the survey team did not observe staffing information posted on the Sudbrook unit. In an interview with Geriatric Nursing Assistant (GNA #12), they stated even though it [staffing information] was not posted, we know who our residents are for the day because we always have the same schedule. On 4/15/24 at 11:20 AM, the survey team did not observe staffing information posted on the Sudbrook unit. In an interview with Licensed Practical Nurse, (LPN #28), when asked where staffing information was posted, they stated it was in here [a binder inside the nurse's station]. LPN #54 made a copy of the staffing information and posted…

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

Based on observations and staff interviews it was determined the facility failed to: 1) store food in accordance with professional standards for food safety; 2) ensure that staff are preparing food under sanitary conditions; and 3) ensure that appropriate testing supplies were not outdated to evaluate the safe operation of the facility kitchen dishwasher. This was evident during the kitchen observation of the recertification survey. The findings include: 1) An initial tour of the facility kitchen was completed on 04/04/2024 at 08:00 AM with Dietary Manager staff (#7) and the following was observed. Review of the following items failed to reveal an expiration date: One can of medium sliced beets One can of lightly seasoned tomato sauce Several (amount) spice containers of spices One gallon container of deluxe style mayonnaise One gallon container of ranch dressing. Additionally, the following items were found to be expired: Three containers of Thickened Orange Juice from concentrate moderately thick honey consistency had an expiration date of 09/24/2023. Two containers of Redi-Shred…

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

Based on administrative and medical record reviews and staff interview, it was determined that the facility failed to: 1) accurately maintain medical records for a resident (# 19); and 2) maintain a completed copy of an investigation into an allegation of staff to resident abuse; 3) provide complete access to closed resident electronic medical records; and 4) identify and maintain accurate electronic medical records by having nursing staff members signing off resident care that was performed by the assigned staff member. This was evident for 8 of 8 records reviewed for accuracy of medical records during an recertification survey. The findings include: 1) Review of resident (#19) medical record on 04/10/2024 at 3:30 PM revealed residents (#19) current care plan had a focus area stating that resident (#19) was at risk for wandering and elopement related to his/her medical diagnosis of Alzheimer Dementia. This focus area was initiated on 07/26/2022 and last revised on 01/18/2024. On 04/10/2024 at approximately 4:00 PM the Director of Nursing staff (#2) provided the survey team with a…

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

Based on administrative record review and interviews with facility staff it was determined the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program in place to address identified quality deficiencies. This was found to be evident during the facility's survey. The findings Include: During the facility's current survey conducted on April 4, 2024, thru April 18, 2024, deficient practice was identified in the following areas: Quality of Care with one example of a resident (# 17) who did not receive pain medication with a suspected fracture, Supervision of residents with a history of wandering, Functioning call bell system and Neglect and Abuse allegations. An employee (# 85) was terminated in December 2023 for not following protocols for providing Activities of Daily Living (ADL's) assistance to a resident (#1). During an interview with the DON on 4/18/24 at 10:00 AM she was informed that the facility provided the survey team with attendance sheets for monthly meetings conducted by the Quality Assurance (QA) committee for December 2022, January…

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

Based on administrative record review and interviews with facility staff it was determined the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least on a quarterly basis to address identified concerns and evaluate the effectiveness of their action plan. This was found to be evident during a review of the facility's Quality Assurance Performance and Improvement (QAPI) meeting attendance sheets during the survey. Findings include: The survey team requested copies of the QAPI monthly attendance sheets for January 2023 thru February 2024 on 4/18/24 at 10:00 AM. The facility provided copies of QAPI attendance sheets for the following months: December 2022, January 2023, February 2023, April 2023, June 2023, January 2024, and February 2024. During an interview with the DON on the same date at 11:00 AM she was asked how often the QAPI committee members meet to address all identified concerns that are brought before the team, and she stated that stated that the standard for the internal team members is that they are to meet monthly. She went on 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 observations and interviews it was determined the facility failed to maintain a working call bell system. This was evident for 1 resident (#5) out of 7 residents and 2 rooms (#113 and #127) out of 6 rooms during the survey. The findings include: During observation rounds on 04/05/2024 at 9:20 AM on the facility's first floor nursing station, Meadowood, call lights were noted to be going off. The call lights were observed for approximately 25 minutes. This surveyor observed the nurses' station on Meadowood for possible staff, no one was present at that time. The monitor for the call lights at the nursing station read system failure for Rooms #113 and #127. During an interview and observation on 04/05/2024 at 9:51 AM resident (#5) call bell was pressed by this surveyor and call bell did not work. During an interview on 04/05/2024 at 10:00 AM Regional Administrator staff (#9) was made aware of the above observations by this surveyor. Staff (#9) stated that he would check into the call bell system right away.

Based on observations, resident and staff interviews , and record reviews, it was determined that the facility failed to treat residents with respect and dignity in an environment that promotes enhancement of quality of life. This was evident for 3 (Resident #55, #81, #84) out of 4 residents reviewed for dignity during the recertification survey. The findings include: 1. During observation rounds on 4/4/2024 at 8:30 am, the surveyor observed 2 urinals on the floor in resident #55's room. An empty urinal was laying on the floor against the wall closest to the entrance of the room. Another urinal with amber colored fluid was observed laying in between the bedside table and the wall. The resident was yelling for the nurse stating, I need a razor to shave my face. During an interview on 4/4/2024 at 8:32 am with Resident #55, s/he stated that the nurse came to empty the urinal and placed the urinal on the floor. During an interview on 4/4/24 at 8:40 am with Licensed Practical Nurse (LPN) staff # 10, she stated she didn't know who put the urinals on the floor. During a follow-up…

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

Based on administrative and medical record review, and interviews with facility staff it was determined the facility failed to keep a resident safe from neglect when an employee failed assist a resident with Activities of Daily Living (ADL) as required. This was found to be evident for 1 (Resident #1) of 9 residents reviewed for abuse during the survey. Findings include: Intake MD00200445 was reviewed on 4/16/24 at 4:00 PM for allegations of resident neglect. According to the intake report, Geriatric Nurse Assistant (GNA # 85) placed resident # 1 dinner tray in his/her room on the bedside table across the room and out of the resident's reach. Further review of the facility's investigation found a notice of Corrective Action Form dated 12/14/23 indicating the following: GNA # 85 did not follow proper protocol for providing a meal to the resident and did not assist the resident with ADL's as requested by the resident. The facility spoke with the employee on 12/19/23 about termination and sent a letter. An interview was conducted with the DON on 4/16/24 at 5:00 PM and she stated 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 administrative and medical record review and interviews with facility staff, it was determined the facility failed to complete a thorough investigation into abuse allegations for a resident with an injury of unknown origin. This was found to be evident for 1 (Resident # 1) of 9 residents reviewed for abuse during the survey. Findings include: Intake # MD00199866 was reviewed on 4/15/24 at 9:00 AM for allegations of abuse for an injury of unknown origin. Review of the facility's investigation revealed resident # 1 was admitted with the following but not limited diagnosis: Osteoarthritis (Degenerative Joint Disease). According to the investigation on 11/23/23 the resident's assigned GNA (Geriatric Nurse Assistant) stated that at approximately 8:00 PM while providing care, she noticed that the resident right lower leg was swollen and rotated outward. The nurse confirmed this finding after her assessment and the resident was sent to the emergency room for further evaluation. The resident returned with diagnosis of fracture of right tibia and fibula. An interview was conducted…

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 medical record review and interviews it was determined the facility failed to provide a resident and his/her representative a complete summary or complete written summary of the resident's initial baseline care plan. This was evident for 1 resident (#17) out of 53 residents reviewed during the survey. The findings include the following: A facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility and any updated information based on the details of the comprehensive care plan, as necessary. Review of resident #17's medical record on 04/08/2024 at 01:45 PM revealed that resident (#17) was admitted to the facility on [DATE] and there was no evidence or documentation found that resident (#17) or his/her…

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 administrative and medical record review, and interviews with facility staff it was determined the facility failed to develop a care plan for a resident at risk for wandering. This was found to be evident for 1 (Resident # 73) of 7 residents reviewed for accidents during the facility's survey. Findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident care. MD00172344 was reviewed on 4/10/24 at 10:30 AM for allegations that Resident # 73 was observed out of the building in the adjacent parking lot. Further review of the resident medical record on the same date at 11:15 AM revealed the resident has the following but limited diagnosis: Vascular Dementia (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Review of a wandering assessment that was done on 5/18/21 upon admission, indicated a score of nine (9). A score of 9 indicates…

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

Based on record review and interview with facility staff, it was determined that facility nursing staff failed to follow professional standards of nursing when documenting medications. This was evident for 1 of 9 residents (Resident #260) reviewed for abuse. The findings include: It is the standard of nursing practice to document administered medications immediately after administration. Failing to do this results in an inaccurate record where it cannot be determined when a medication was actually given and has the potential to result in medication errors (such as a resident receiving a dose twice, or two doses of a medication being given too close in time). On 4/8/24 at 8:39 AM, review of the facility's investigation packet for MD00199456 revealed a written statement from Geriatric Nursing Assistant (GNA #5) dated 11/11/23 that stated while they were giving out breakfast, they noticed Resident #260's right wrist was swollen, and immediately reported it to the charge nurse [LPN #48]. On 4/10/24 at 8:21 AM, review of the medical record revealed a Progress Note written by LPN #48…

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 reviews of a closed medical record and staff interview, it was determined that the facility nursing staff failed to update a resident's physician prescribed wound care treatment orders after the facility wound consultant updated the treatment orders after a weekly assessment. This was evident for 1 (Resident #257) 4 residents reviewed for pressure ulcers during the recertification survey. The findings include: Review of Resident's #257's closed medical record on 04/09/24 revealed that Resident #257 was admitted to the facility on [DATE]. Resident #257 was seen by the facility wound consultant on 09/26/23 and was identified with a left heel deep tissue injury and a bilateral sacrum wound. The wound consultant noted Resident #257's wounds to be chronic and require continued topical wound dressing therapy. The wound consultant gave orders instructing the nurses to apply a betadine dressing to the left heel and apply medihoney, calcium alginate and a foam dressing to the bilateral sacrum wounds daily.…

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 administrative and record review it was determined the facility failed to provide adequate supervision for residents at risk for wandering. This was found to be evident for 2 (Resident # 73 and # 54) of 10 residents reviewed for wandering during the facility's survey. Findings include: 1. Intake MD00172344 was reviewed on 4/10/24 at 10:30 AM for allegations that resident # 73 was observed outside of the building in the adjacent parking lot. On 4/10/24 a review of resident # 73's medical record revealed the resident has the following but not limited diagnosis: Aphasia (a language disorder caused by damage in the brain that controls language expression and comprehension) following nontraumatic intracranial hemorrhage and Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following nontraumatic intracerebral hemorrhage affecting left non-dominant side. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information…

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

Based on record review and interview it was determined that facility staff failed to notify the provider when a resident reported that their pain medication was ineffective. This was evident for 1 (#26) of 3 residents reviewed for pain management. The findings include: A medical record review for Resident #26 6/25/24 at 12:25 PM revealed the resident was recently diagnosed with a liver mass. The physician documented that the condition can be painful and ordered the resident to have hydromorphone (an opioid to treat pain). Review of the physician's orders revealed the resident had an order for hydromorphone 2mg give 1 tablet every 4 hours for pain levels of 4-6 and a second order for hydromorphone 2 mg give 2 tables every 4 hours for pain levels of 7-10. During an interview with Resident #26 on 06/26/2024 at 9:21 AM s/he reported that s/he was in constant pain. The resident went on to report that s/he had pain medication earlier this morning when the pain level was at an 8, however his/her pain level was still at a 6. When asked the resident stated that the nurse had not returned 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 reviews and staff interviews, it was determined that the physician or medical director did not address the pharmacist medication regimen recommendation. This was evident for 1(Resident #26) of 5 residents reviewed for medication regimen reviews. The findings include: On 4/12/24 at 11:00 am, the surveyor reviewed the monthly Pharmacist Medication Regimen Review (MRR) for October of 2023 for Resident #26. On the October 2023 MRR there was a recommendation by pharmacist #81 to draw a Thyroid Stimulating Hormone (TSH) lab and Thyroxine (T4) lab that was ordered but not completed. The TSH lab test measures the level of the thyroid stimulating hormone in the blood and the T4 lab measures the amount of thyroxine, a thyroid hormone, in the blood. There was no action or note in the medical records by the physician or medical director addressing the pharmacist's recommendation. On 4/12/24 at 2:58 pm, an interview was conducted with the Director of Nursing (DON). The DON stated that they were unable to locate a response from the physician or a follow-up pharmacy review…

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 observations it was determined the facility failed to provide resident (#41) with an accurate menu of meals being served and offering resident (#41) food preference choices as well as other alternative food options. This was evident for 1 resident (#41) out of 53 residents reviewed during the survey. The findings include: During an interview on 04/05/24 at 11:09 AM resident (#41) stated that the facility gives him/her what they want to give him/her, there are no menus given to him/her and he/she does not have any choices when it comes to the food. Resident (#41) stated the facility just puts the tray in front of you and if you do not like it then you get nothing else offered to you. During an interview on 04/10/24 at 11:15 AM Dietary Manager staff (#7) stated that the facility is on week 2 of their menu cycle, menus are to be reviewed with the resident by the facility caregivers and each resident has a menu in their room with an alternative menu to choose from if resident does not want what is being served for that meal. Staff (#7) also stated that staff are…

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

Based on interview and observation it was determined the facility failed to provide resident (#41) with drinks that are consistent with resident needs as stated on his/her meal ticket. This was evident for 1 resident (#41) out of 53 residents reviewed during the annual survey. The findings include the following: During an interview on 04/10/2024 at 12:10 PM resident (#41) stated and pointed out they do not send what is on my paper that I am supposed to get, and this happens all the time, referring to the meal ticket that was placed on resident #41's meal tray. During a dining observation on 04/10/2024 at 12:10 PM it was observed that residents #41's meal ticket stated that he/she should receive a total of 8 oz of apple juice and resident (#41) only received one 4 oz. container of apple juice on his/her tray. On 04/10/2024 at 12:15 PM Dietary Manager staff (#7) was made aware of the above findings and resident (#41) was given another 4 oz container of apple juice on his/her tray to drink.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of employee files and online sources and interviews with facility staff, it was determined that the facility failed to ensure Geriatric Nursing Assistant (GNA) staff had active, current certification. This was evident for 1 of 5 GNAs (GNA #11) reviewed for staff qualifications during the survey. The findings include: The Maryland Board of Nursing (MBON) is the agency charged with the regulatory oversight of the practice of nursing in the State. The MBON's mission is to preserve the field of nursing by advancing safe, quality care in Maryland through licensure, certification, education, and accountability for public protection. All nursing assistants must be certified in order to work. The primary source verification of certification status is found in the Look Up A License feature of the MBON website. This secure program is updated daily. On [DATE] at 1:07 PM, review of the Look Up A License feature on the MBON website showed the certification status for GNA #11 as non-renewed and with an…

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

Based on observations and interviews it was determined that the facility staff failed to maintain infection control practices as evidenced by having uncovered linen carts, a pillow and two pads for side rails on the floor in the linen closet, and the soap and hand sanitizer dispensers were empty in the Soiled Utility Room on the unit Sudbrook. This deficient practice was evident for one linen closet and one utility room observed during the survey. The findings include: On 04/17/24 at 9:38 am the surveyor and Infection Preventionist/Educator #6 opened the door to the linen closet on Waters Edge Unit and observed the linen was not covered and a pillow and a box of gloves were on the floor inside the linen closet. Infection Preventionist/Educator #6 verbalized the linen cart is not removed from the closet. The cart is brought upstairs, and the linen cart is refilled. On 04/17/24 at 9:47 am the surveyor observed two blue side rail pads on the floor in the linen closet on Sudbrook. Infection Preventionist/Educator #6 verbalized they should not have been on the floor. On 04/17/24 at 10:01…

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 it was determined that the facility staff failed to notify maintenance personnel of maintenance problems on the unit Sudbrook. The deficient practice was evident on 1 unit. The findings include: On 04/17/24 at 9:38 am while the surveyor was on the unit Sudbrook with Infection Preventionist/Educator #6 the surveyor attempted to turn the light on in the linen closet and the light did not come on. On 04/17/24 at 9:49 am while on the unit Sudbrook near the nursing station, the surveyor observed the right side of the food cart open, and the trays were exposed. The surveyor attempted to close the door several times to no avail. During an interview with Licensed Practical Nurse #28 he/she verbalized the staff should have reported the issue to the kitchen immediately. The aides and nurses collected the trays and put them on the cart. When Dietary Aide #67 reached the unit to retrieve the food cart the surveyor asked if he/she was aware the right door did not close Dietary Aide #67 reported Certified Dietary Manager #7 was made aware of the problem on the…

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

Based on review of facility policy and employee files and interviews with facility staff, it was determined that the facility failed to ensure staff participation in mandatory abuse training. This was evident for 1 of 5 Geriatric Nursing Assistants (GNA #43) reviewed for abuse training during survey. The findings include: On 4/16/24 at 10:43 AM, review of the facility's policy entitled, Residents/Patient Rights- Abuse, Neglect, Mistreatment or Misappropriation of Resident/Patient's Property, revealed, All employees, including management staff and volunteers, will receive training upon orientation and annually. On 4/16/24 at 2:46 PM, review of employee files revealed GNA #43 was hired on 6/23/23 and did not reveal documentation of participation in any type of abuse training. On 4/17/24 at 1:30 PM, the facility provided a copy of GNA #43's printed Relias transcript of completed online trainings. The document entitled, Training Hours, revealed GNA #43 did not participate in any type of abuse training. Furthermore, review of the Reporting Abuse Training Attendance Sheet conducted 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 the review of employee records and staff interview, it was determined that the facility failed to provide documentation that a Geriatric Nursing Assistance's (GNA) was given abuse training at least once every 12 months. This was evident for 1 of 4 GNA employee records (Staff #25) reviewed during the sufficient and competent nursing staffing task during the recertification survey. The findings include: A review of facility reported incident MD00198544 on 04/09/24 revealed an allegation Resident #259 was the victim of staff to resident verbal abuse on 09/30/23. The surveyor was unable to review the facility investigation due to staff being unable to locate the investigation documents. A review of Staff member #25's employee records failed to reveal that Staff member #25 was provided abuse training one year prior to the alleged 09/30/23 incident. Further review of Staff member #25's educational records revealed that Staff member #25 received Recognizing, Reporting, and Preventing Abuse training last on 08/30/2022. In an interview with the facility director of nurses (DON) 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 of medication pass and interview, it was determined the facility staff failed to obtain a medication error rate less than 5% (Residents #22, #16 and #20). This includes 3 out of 6 residents observed for medication pass, 21 errors out of 35 opportunities with a medication error rate of 62.86%. The findings include: The facility uses an Electronic Medical Record (EMR) for the administration and documentation of medications for administration to the residents. The physician's orders for the medications are entered the EMR with the times of medication administration. During medication observation, the computer will display yellow for the medication to be administered in that time frame. Any medication outside the time frame of administration will be gray. When gray, the facility staff is not able to document administration since it is not in the ordered time frame. Medications must be given within a ½ hour of the time that is listed on the medication log. This means that you have ½ hour before the medication is due, and ½ hour after it is due to administer 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 the facility staff failed to ensure residents' dignity was maintained. This was evident for 4 out of the 34 residents reviewed as part of the survey: The findings are: 1. This surveyor observed on 6/18/19 at 8:12 AM one resident eating breakfast while the other two residents at the table were waiting for their food. Two tables over and closer to the unit entrance there are two breakfast trays. One is in front of a resident who is eating from the breakfast tray and the other is in front of an empty chair. A resident was brought over at 8:14 AM and began eating. A second tray was placed in front of one of the residents at the first table at 8:27 AM. The third resident was moved to different table and served a tray at 8:30 AM. The Director of Nursing was interviewed on 6/20/19 at 11:31 AM. She said she would address the issue with her staff. 2. Resident #26 was observed sitting in the common area in his/her Geriatric chair on 6-17-19 at 9:50 AM and 6-18-19 at 8:30 AM. Resident #26 is totally dependent on the 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 medical record review and interview, it was determined the facility staff failed to void an older MOLST form located in a resident's active medical record for Resident (#73) and failed to ensure an advance directive which allowed for medical decisions was in place for Resident (#129). This was evident for 2 of 5 residents selected for review of advance directives and 2 of 38 residents selected for review during the annual survey process. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. Advance directives only apply to health care decisions and do not affect financial or money matters. The Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a resident's or Power of Attorney…

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 staff interview, it was determined the facility failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Resident #97) of 3 residents reviewed during an annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #97's medical record on 6/17/19 revealed Resident #97 was admitted to the facility on [DATE]. Review of the medical record failed to reveal documentation that a copy of the baseline care plan was provided to Resident #97 or Resident #97's responsible party within 48 hours after admission. In an interview with the facility Social Worker on 6/20/19 at 8:30 AM the facility Social Worker confirmed the facility staff did not supply Resident #97 nor his/her responsible party with a copy of the baseline…

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, observation and medical record review the facility staff failed to provide all treatments and services as ordered by the physician for Residents (#22 and #76). This is evident for 2 out of 2 residents selected for review during the investigation stage of the survey process. 1. A review of Resident #76's clinical record revealed that the resident's primary physician wrote an order for the resident to receive Boost Breeze (a nutritional supplement) 8 ounces one time a day and document the percentage of the supplement consumed each time. A review of the Medication Administration Record for March, April, May and June of 2019 revealed that nursing staff has not documented the amount consumed as ordered. The Director of Nursing was interviewed on 06/19/19 at 09:47 AM. She confirmed that the nursing staff did not document the amount of Boost Breeze consumed. 2. Surveyor observation of medication pass on 6/18/19 at 8:20 AM revealed facility staff #3 failed to administer medications in accordance with the standard of practice. Medications (oral) are delivered by pharmacy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to perform and/or document weekly skin and wound assessments for a Resident (#43) with a pressure ulcer. This was evident for 1 out of 6 residents selected for review during the investigation stage of the survey process. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). Resident #43 was admitted from the hospital on [DATE], without any pressure ulcers. Reviewed of Resident #43's medical record revealed a BRADEN scale assessment for predicting…

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

Based on record review, observation and staff interview, it was determined the facility staff failed to ensure that the resident's environment was free from potential accidents (#77). This was evident for 1 of 38 residents selected for review during the annual survey process. The findings include: Surveyor interview with Resident #77 on 6/17/19 at 12:00 PM revealed the resident indicated there was medication at the bedside. Surveyor observation of Resident 77's room on 6/18/19 at 1:50 PM and 6/19/19 at 9:15 AM revealed the resident had a meter dose inhaler at the bedside. The ProAir inhaler multi-dose inhaler was noted at the bed side. ProAir inhaler is used to prevent and treat wheezing and shortness of breath caused by breathing problems (such as asthma, chronic obstructive pulmonary disease). Further record review revealed no evidence that the resident was assessed to determine the ability to use the inhaler or a physician's order allowing the resident the ability to administer self-medications. Interview with the Director of Nursing on 6/20/19 at 1:00 PM confirmed the facility…

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

Based on record review, observation and interview, it was determined the facility staff failed to apply 1/4 side rails to a resident's bed (#86) as ordered. This was evident for 1 of 38 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #86 revealed on 1/29/19 the physician ordered: 1/4 side rails as enablers for turning and repositioning. A side rail is structural support attached to the frame of a bed and intended to prevent a patient from falling. Bed rails include any combination of partial or full rails (e.g., one-side half-rail, one-side full rail, two-sided half-rails or quarter-rails, rails along the side of the bed that block three-quarters to the whole length of the mattress from top to bottom, etc.). The potential for serious injury is more likely from a fall from a bed with raised side rails rather than from a fall from a bed where side rails are not used. Surveyor observation of Resident #86 on 6/17/19 at 1:00 PM, 6/18/19 at 1:45 PM and 6/19/19 at 9:15 AM revealed the resident in bed; however, 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, it was determined the facility staff failed to properly store medications. This was observed once during an annual recertification survey. The findings include: An observation was made on 06/19/19 at 12:55 PM on the second-floor rehabilitation unit. The surveyor observed an unattended and unlocked treatment cart. The treatment cart held schedule II narcotic medications for the resident's residing on the second-floor rehabilitation unit. No nursing staff members were attending the medication cart at the time of the observation. The charge nurse was immediately made aware of the observation.