Roland Park Rehabilitation And Healthcare Center

Based on observations and interviews it was determined that the facility failed to dispose of garbage and refuse properly. This finding was found to be evident in review of the outside dumpster area during the annual recertification survey. The findings include: The surveyor toured the outside dumpster area at 1:17 PM on 4/16/2026 with the Floor Technician in attendance. There were 2 dumpsters for trash and garbage and 1 dumpster for recyclables. Outside of the trash dumpster was multiple pieces of trash lying on the ground, a bag of trash behind the dumpster and the trash dumpster was not closed with the attached lid on top of the dumpster. The Licensed Nursing Home Administrator (LNHA) was notified of the concern with the outside dumpster area at 1:50 PM on 4/16/2026. At 6:45 AM on 4/17/2026 the surveyor followed up on the outside dumpster area with the Housekeeping Manager in attendance. Observed on the ground outside the dumpster was multiple pieces of trash, an empty large can of beans, empty juice cups, plastic gloves, and paper towels. At 8:45 AM on 4/17/2026 the Licensed…

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 surveyor record review it was determined that the facility failed to maintain an accurate medical record for a Resident. This finding was found to be evident in 1 (Resident #27) out of 1 Resident reviewed for Resident records.The findings include:Anticoagulants or blood thinners are medications that prevent blood clots from forming or growing by inhibiting clotting factors. The primary side effect of anticoagulants is increased bleeding, requiring careful monitoring. Minimum Data Set (MDS) Assessment is a standardized, federally mandated clinical assessment tool used in Medicare/Medicaid- certified nursing homes to evaluate Resident functional capabilities, health needs, and preferences. The MDS assessment drives care planning, quality monitoring, and reimbursement, with assessments conducted upon admission, quarterly, annually, and upon significant status changes. The MDS assessment is completed by licensed health care professionals in nursing homes. Data is submitted electronically to state databases.Care Plan is a written document that outlines a person's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and surveyor record reviews it was determined that the facility failed to have a physician order for a Resident to receive Hospice care. This finding was found to be evident in 1 (Resident #73) out of 2 Residents reviewed for Hospice Services.The findings include:Minimum Data Set (MDS) Assessment is a standardized, federally mandated clinical assessment tool used in Medicare/Medicaid- certified nursing homes to evaluate Resident functional capabilities, health needs, and preferences. The MDS assessment drives care planning, quality monitoring, and reimbursement, with assessments conducted upon admission, quarterly, annually, and upon significant status changes. The MDS assessment is completed by licensed health care professionals in nursing homes. Data is submitted electronically to state databases.Care Plan is a written document that outlines a person's care needs and how they will be met. The care plan includes health information related to medical history, current treatments, medications,…

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

Based on staff interviews, review of pertinent documentation including the facilities Quality Assurance and Performance Improvement (QAPI) policy, and survey findings, it was determined the facility staff failed to 1.) track performance to ensure improvements are realized and sustained and 2.) failed to conduct at least one Performance Improvement Plan/Project (PIP) annually that focuses on problem prone areas identified by the facility through data collection and analysis. This was evident during review of the facilities Quality Assurance program.Findings include:1.) On 04/20/2026 at 11:11 AM, the Director of Nursing (DON), Staff #3, and the Assistant Director of Nursing (ADON), Staff #4, were interviewed regarding responsibility for the QAPI meeting and its operational process. Both stated that they are jointly in charge of QAPI. Staff #4 (ADON) further specified that all departments meet monthly and submit data for the QAPI meeting.When Staff #4 ADON was asked how data collected from QAPI meetings are regularly reviewed, analyzed, and acted upon, they responded by citing examples…

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 with facility staff, it was determined that the facility failed to ensure that the environment of resident care was maintained in a manner that minimized the potential spread of infection as evidenced by an unwrapped toilet tissue roll placed on top of the red sharps bio-hazard container. This was evident for 1 (Resident #8) of 64 residents investigated during the annual survey.The findings include:On 04/14/2026 at 8:33 AM during the initial observation, an unwrapped roll of white toilet tissue was observed in Resident #8's bathroom sitting on top of the red sharps container. On 04/14/2026 at 8:46 AM the unwrapped toilet tissue in Resident #8's bathroom was shown to Staff #36, Licensed Practical Nurse, LPN. Staff #36, LPN stated they would call housekeeping to dispose of the tissue on top of the sharps container.On 04/14/2026 at 9:04 AM the Director of Nursing, (DON) was made aware of the issue and verbalized understanding that unwrapped tissues on the sharps container was an infection control issue. Housekeeping later removed the tissue.

Based on observation and staff interviews, it was determined that the facility failed to have call bells within reach of a dependent resident. This was evident for 1 (Resident #12) of 1 resident reviewed for language and communication during the annual survey.The findings includeOn 4/14/2026 at 11:07 AM Resident #12 was observed in a wheelchair sitting to the right side of the bed. The bed was between the wheelchair and the nightstand. The call bell was tucked away on the top drawer of the nightstand to the left and away from residents reach. The resident is alert and oriented. In his neck is a trach stoma, a surgical opening on the neck to facilitate breathing. An oxygen (o2) humidifier was attached to the trach site. The resident can only mouth words and has weaknesses to the right side. The surveyor requested to speak with the resident's nurse.On 4/14/2026 at 11:22 AM In an Interview with the residents nurse a License Practical Nurse (LPN) #25. She was asked how the resident calls for help and she said that resident can use the call bell. She was asked where the call bell was,…

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

Based on observation and interview, it was determined that the facility failed to ensure residents and staff had a safe and comfortable environment. This was evident for 1 of 1 observation made in the facility laundry room.The findings include:On 04/17/2026 at 7:59 AM, an observation of the laundry room revealed a dryer closest to the wall in the laundry room, which had an exterior piece at the bottom that was leaning against the dryer.When the surveyor moved the exterior piece, it revealed parts of the dryer that lay below the area where items are placed to dry. Further observation of the laundry room revealed a portion of the wall to the right of the door prior to walking into the dirty laundry room from the clean laundry room which had a horizontal shaped hole in the wall, approximately 8 inches long and 2 inches wide.On 04/17/2026 at 8:03 AM, an interview with Laundry Aide (Staff #35) revealed she started at the facility about a month ago and the hole in the wall and lower part of the dryer noted above had been like that since she started.On 04/17/2026 at 10:03 AM, the surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and interview with staff it was determined the facility staff failed to provide a safe, clean, comfortable, and homelike environment for residents. This was evident for 1 (Room # 209) of 3 resident rooms observed during review for Safe/Clean/Comfortable/Homelike Environment. The findings include:An interview on 2/20/26 at 11:00 AM, with Resident #2 in room [ROOM NUMBER] for complaint #2682305 revealed the facility's staff failed to ensure a sanitary and safe interior environment.The following was observed by the surveyor. The curtains had red and brown spots scattered throughout the curtains.The floors had paper trash, food and were dirty in appearance throughout.The bedside commode that was over the toilet had brown materials in all the crevices and on the seat of the commode. The bathroom had a strong smell of urine and Feces.On 2/20/26 at 11:30 AM, Administrator was made aware of the findings.On 2/20/26 at 1 PM another observation of the room revealed that the curtains had been…

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 a complaint 2748952 regarding a planned discharge, it was determined that the facility failed to provide the receiving facility with a comprehensive discharge summary of the residents stay in the facility. This was evident for 1 of 1 resident (11) reviewed for discharge.The findings include:Review of the complaint 2748952 on 2/23/26 revealed concerns related to the receiving facility not being given a discharge summary from the discharging facility and in addition not receiving all the residents' medications as discussed in pre-discharge planning according to the receiving facility. During an interview on 2/24/26 with the discharging nurse, LPN #3 revealed that she was not familiar with what to do with discharges, she wasn't sure of the process with narcotics and didn't send any with the resident to the receiving facility. She stated that she sent all the non-narcotic medication with [resident], but she wasn't clear on how to discharge a resident. The DON and ADON were then interviewed regarding the discharge with Resident # 11. In the miscellaneous section…

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

Based on record review and interview, it was determined that the facility failed to refer residents to the appropriate state-designated authority for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination. This was evident for 1 resident (Resident #2) of 1 residents reviewed for PASSAR during the complaint survey.The findings include:Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.On 2/20/26 at 11:00 AM, a review of Resident #2's records revealed a PASSAR Level I screening form dated 10/12/23 which indicated that the resident should have been referred for a Level II evaluation. No Level II PASSAR…

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 failed to develop and implement a process to determine if residents with a history of trauma received the appropriate trauma informed care. This was evident for 1 (#5) of 2 residents reviewed for trauma informed care.The findings include:On 2/19/26 at 8am, a review of complaint 2689128 which reported that resident #5 alleged that Resident #10 enter the room around 7 pm and grabbed both of resident's hands and was punched in the face about five time.A medical record review for Resident #5 on 2/19/26 at 8:30AM, revealed the resident was admitted to the facility on [DATE]. Further review revealed no evidence that a trauma informed assessment or care plan had been completed to ensure the resident received trauma informed care after the incident.On 2/19/26 at 9 AM, an interview with Resident #5 revealed that Resident #5 was tearful and stated that I'm in fear, and afraid to go to sleep at night. I'm scared when the perpetrator walks in the…

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

Based on medical record review and interview with facility staff, it was determined that the physicians failed to have their notes in the medical record timely after seeing the resident. This was evident for 1 of 1 (#10) Residents reviewed during a complaint survey.The findings include:Review of the medical record for Resident #10 on 2/19/26 at 9:30 AM revealed multiple visits and completions of psychiatric evaluation and consultations by a psychiatric NP, staff #8. However, a closer review of these assessments noted that the completion date and the uploaded date into the miscellaneous section of the resident's medical record were not the same, sometimes with a month in between evaluation and upload date. This concern was reviewed with the facility NHA on 2/20/26 at 8:49 AM. The NHA reported that Resident #10 was visited by the psychiatric NP multiple times after an incident that occurred on 12/6/25. These notes included visits on 12/23/25, 1/2/26 and 1/22/26 that were not on Resident #10's record during review the day prior on 2/19/26. He was notified of the regulatory concern at…

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

Based on record review and staff interview, it was determined that facility staff failed to complete a facility assessment with all the information as required. This was evident during the extended survey review. The findings include:During review of the facility assessment, secondary to completing the extended survey, it was determined that the facility assessment provided revealed what the facility offers, however it is not based on a 'facility assessment.'At entrance to the facility on 2/19/26 a resident matrix was requested and provided. On this matrix it notes a resident with a tracheostomy. Record review on 2/20/26 at 1:00 PM revealed that this Resident #12, also has a gastrostomy tube in place for nutritional support. However, review of the facility assessment failed to show that any current residents are in need of tracheostomy or gastrostomy support, only that the facility 'offers' those services. Additionally, it notes that they have 'supportive care' for behavioral/mental health providers. It does not say who, therefore the qualifications are not there-i.e. NP, Dr, SW,…

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 employee files and interviews with facility staff it was determined that the facility failed to employee staff with active professional licenses relevant to their hired job descriptions. This was evident during the review of 1 of 2 employee files, (Staff #7)The findings include: On 2/20/26 at 8am, the surveyor reviewed complaint #2682305 which alleged that Register Nurse (Staff) #7 was employed as a Supervisor RN at the facility without an active license from 12/5/22 to 8/30/23. The state of Maryland's Board of Nursing (MBON) does not recognize staff #7 license due to graduation from a program that is not recognized and approved by the Board.A record review on 2/21/26 at 9:30 AM, of staff #7's personnel file, showed staff #7's RN license was issued in Virginia only (compact designation) on 10/18/22 from [NAME], FL 33610. Staff #7 RN license was suspended in Virginia on 3/13/23. Staff #7's personnel file also listed his/her primary address as Maryland.On 2/24/26 8:54 an interview with the Human…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations it was determined that the facility failed to maintain a safe, sanitary, comfortable, and functional environment for the residents in room [ROOM NUMBER].The findings include:An interview on 2/20/26 at 11:00 AM, with Resident #2 in room [ROOM NUMBER] for complaint #2682305 revealed the facility's staff failed to ensure a safe interior environment.On 2/20/26 at 1Pm, a tour of room [ROOM NUMBER] with the Maintenance Director revealed unattended maintenance needs: The grab bar in the bathroom next to the toilet was not firmly attached to the wall.The floor tile to the bathroom was missing and cracked. This made it difficult for the residents to roll in and out of the bathroom using a wheelchair or walker.The cable cover plate was not attached to the wall.The ceiling had evidence of water damage with marked brown areas.The nightstand had a broken handle.room [ROOM NUMBER] has damaged walls with peeling paint and scrapes throughout greater at the head of the beds. Cross reference F 584.

Based on surveyor review of a facility reported incident and facility staff interview, it was determined that the facility failed to immediately report an incident of alleged abuse by a resident to the Office of Health Care Quality. This finding was evident for 1 (Resident #62) of 4 residents selected for an abuse investigation. This finding is related to facility reported incident # MD00214230. The findings include: On 03/24/25 at 11:13 AM surveyor review of the facility reported incident revealed that Resident #62 alleged Geriatric Nursing Assistant (GNA), Staff #19, sent him/her a text message on 11/10/24, threatening to poison him/her. Further review of the alleged incident revealed that during the previous survey at the facility, Resident #62 reported this alleged incident to a surveyor from the Office of Health Care Quality (OHCQ) on 1/29/25. The surveyor immediately relayed the allegation to the Director of Nursing (DON). An interview was held with the Administrator on 3/25/25 and 3/26/25 which revealed no new information.

Based on review of a facility reported abuse allegation and interview it was determined that the facility failed to maintain documentation that alleged abuse was thoroughly investigated. This was evident for 1 of 3 facility reported incidents reviewed during the survey. This finding is related to facility reported incident # MD00214230. The findings include: On 03/24/25 at 11:13 AM surveyor review of the facility reported incident revealed that Resident #62 alleged Geriatric Nursing Assistant (GNA), Staff #19, sent him/her a text message on 11/10/24, threatening to poison him/her. An interview was held with the Director of Social Services, Staff #8, on 03/24/25 at 12:26 PM. Reviewed the investigation file with SSD. The SSD confirmed that he was one of the staff members who investigated the incident. However, there was no evidence found in the facility's investigation file related to the allegation of abuse by Resident #62. On 3/25/25 8:30 AM surveyor interview with the Nursing Home Administrator (NHA) revealed no new information.

Based on record review and resident and staff interviews, it was determined that the facility staff failed to report a threat of physical violence against a resident as required. This was evident for 1 (#39) of 53 residents reviewed during the survey. The findings include: A complaint alleging that a staff member attempted to poison Resident #39 was investigated on 1/29/25 at 8:03 AM. A review of Resident #39's medical record included a plan of care developed on 9/13/24 for behavioral problems as evidenced by blocking staff access to other residents, verbal aggression to staff and fabrication of care issues. Social Services progress notes revealed that the facility addressed the residents' concerns, but were not able to substantiate the attempted poisoning allegations and offered the resident a room change to another unit. On 1/29/25 at 12:45 PM, the Administrator provided a Service Comment Form, dated 10/10/24, which described the actions taken to address the residents concerns and included The resident was offered a room/unit change, and s/he declined. As a precaution, the accused…

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 staff, it was determined that the facility staff 1) failed to prevent further potential exploitation while an investigation was in progress, and 2) failed to have evidence that all alleged violations are thoroughly investigated. This was evident for 2 facility reported incidents reviewed for 1 (#11) of 53 residents reviewed during the survey. The findings include: 1) Facility Reported Incident (FRI) #MD00197317 was reviewed on 1/27/25 at 11:17 AM. The report indicated that Resident #11 alleged that Staff #12 a Geriatric Nursing Assistant (GNA) took his/her wallet, which contained $15.00, while making his/her bed on 9/21/23. The facility reported the incident, conducted an investigation, was unable to substantiate the allegation, and submitted their final report to the state on 9/27/23. The facility's report and investigation documentation failed to reveal that Staff #12 was suspended pending the outcome of the investigation. Staff schedules revealed that Staff #12 worked 7AM-3PM on 9/21/23. The Administrator was asked to provide evidence…

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 a complaint, staff interview and medical record review, it was determined that the facility failed to adequately prepare a resident for discharge. This was evident for one resident during the review of 1 of 3 complaints regarding discharges. (Resident #23) The findings include: Review of the complaint #MD00203025 on 6/10/24 at 9:45 AM revealed concerns regarding Resident #23's discharge planning and preparation nor was the resident provided their personal belongings prior to the discharge. A review on 02/02/25, of the discharge that occurred on 2/01/23 and the completed paperwork revealed that Resident #23 had not signed any discharge paperwork, including the discharge instructions/post discharge plan review, and the resident property list. The discharge paperwork did not include wound care for the resident. The facility DON was interviewed on 02/04/25 at 9 AM. The facility process on discharge was reviewed. She stated that the staff are to review the discharge planning and have the resident sign it and then it is scanned into the computer. Additionally, this…

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

Based on medical record review and staff interview, the facility staff failed to address a resident's concerns (resident # 49) of not being able to see from glasses received from a contracted provider in 8/2024. This was evident for 1 of 53 residents reviewed during a complaint survey. The findings include: On 1/27/24 at 1:00pm, Ombudsman #3 reported that resident #49 complained that he/she was unable to see from glasses they received from the facility's vision vendor in 8/2024. Ombudsman #3 stated that he/she explained the resident's concerns in an email to the Director of Nursing (DON) in 11/2024. Resident #49 stated that he/she hasn't received new glasses as of 1/2025. Review of resident #49's medical records on 1/28/25 at 10:30am revealed that the resident had a optometry exam on 8/12/24 and received glasses as a result of the optometry exam. The resident received new glasses on 8/20/24. Interview with the Director of Nursing (DON) on 1/28/25 at 11:00am revealed that DON was unaware of resident #49's issues with his/her glasses. The surveyor pointed out that ombudsman #3…

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 surveyor observation and staff interview, the facility staff failed to provide supervision to prevent an accident when the facility staff failed to remove low-hanging extension cords from the 3rd floor ceiling. This would affect all residents and visitors on the back of the 3rd floor unit. The findings include: On 1/24/25 at approximately 10:30am, a surveyor touring the 3rd floor unit observed extension cords connected to temporary lights hanging from the ceiling tiles at the back of the unit. The surveyor observed that the extension cords were hanging low enough to hinder any resident or visitor walking in the area adjacent to rooms [ROOM NUMBERS]. Interview with the Director of Nursing (DON) on 1/24/25 at 11:00am revealed the facility's 3rd floor back unit sustained a water leak at 1/10/25 at approximately 5:00pm. The water leak affected the back end of the 2nd and 3rd floors. Interview with the DON, Administrator and the Maintenance Director on 1/24/25 at 2:00pm revealed the water leak from the…

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

Based on medical record review and interviews, it was determined that the facility failed to implement physician care orders for a resident admitted with a colostomy. This was evident for 1 (#41) of 3 residents reviewed related to a complaint about colostomy care. The findings include: On 1/24/25 at 2:43 PM, a review of the medical record for Resident #41 revealed that s/he was admitted to the facility post colostomy (a surgical procedure that creates an opening (stoma) in the abdomen through which waste from the large intestine (colon) can be discharged into a bag) at the beginning of May 2024. Further review on 1/28/25 at 9:36 AM failed to reveal any orders in place for the care and treatment of the ostomy from 5/29/24 -7/18/24 during the resident's intermittent stay in the facility when the resident went to the hospital and returned to the facility. This concern was reviewed with the facility DON and the Regional DON on 1/28/25 at 1:07 PM. No further documentation that care was provided to the survey team that Resident #41 received care for their ostomy between 5/29/24 and 7/18/24

Based on resident interview, it was determined that the facility failed to ensure residents have a choice in recreational activities. This was true for 5 (#4, #9, #26, #50, and #64) out of the 7 residents representing the resident council. The findings include: This surveyor interviewed 7 residents representing the Resident Council on 3/1/20 at 1:30 PM. Five of the residents stated that if they want to go outside for fresh air in the courtyard, they need to ask for permission and request a staff to accompany them. If one is not available, then they cannot go out. Evidence to dispute the residents' allegation was not provided prior to exit.

Based on staff interview and observation, it was determined the facility staff failed to promote care for residents in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality by labeling residents as feeders on a posted staffing board. This occurred on 1 of 2 nursing unit staffing boards. The findings included: On 3-1-2020 at 9:50 AM, the posted staffing board on the second floor nursing unit had written, Feeders: 201(2), 202(2), 204(1), 209(1), 210(1), 212(2), 216, 225(2), 230(1). The use of the undignified term feeder was confirmed with the Night Supervisor #3 at 9:50 AM on 3-1-2020.

Based on medical record review and interview, it was determined that the facility staff failed to notify the residents or responsible party in writing of the reason for Residents (#87, and #102) transfer to the hospital. This was evident for 2 of 6 resident reviewed for hospitalization during the annual recertification survey.The findings include: 1. Review of the medical record for Resident #87 revealed the resident was transferred to an acute care facility on 1/11/2020. There was no documentation found in the medical record that the resident, and or the resident's responsible party was given written notice in a language and manner that they understand. On 03/02/20 11:27 AM, the Director of Nursing was made aware there was no documentation found in the medical records that the residents, and or the resident's responsible party was given written notice in a language and manner they understand. This finding was confirmed by the Director of Nursing. 2. Closed record review conducted on 3/3/2020 at 1:02PM revealed the facility failed to send a notice of resident #102's transfer 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 medical record review and staff interview, it was determined the facility failed to notify the resident or the resident's responsible party in writing of the facilities bed-hold policy before transferring them to the hospital. This was evident for 2 (Residents #87 and #102) of 6 residents sampled for investigations. The findings include: 1. Review of the medical record on 3/1/2020 at 12:30 AM, for Resident #87 documented that the resident was transferred to an acute care facility on 1/11/2020. An interview with the facility Director of Nursing (DON) on 03/02/20 11:27 AM, confirmed the facility did not give Resident #87 a copy of the facilities bed hold policy. 2. Closed record review conducted on 3/3/2020 at 1:02PM revealed the facility failed to send a notice of resident #102's transfer to the hospital. Interview with the Director of Nursing (DON) on 3/3/2020 at 1:13 PM revealed the facility was aware of the requirements of transfer notices but the facility had yet to comply with this policy.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, it was determined that the facility staff failed to accurately transcribe a written physician order (Resident #1). This is evident for 1 of 3 resident's selected for infections review during the annual survey. The findings include: On 2-24-2020, Resident #1 returned from a Vascular Surgery appointment with new orders for the care of their right heel wound. The orders said to discontinue the wound vacuum dressing to the right heel and wear protective boots at all times. The right heel wound care was 1. every other day cleanse wound with [NAME] or other wound cleanser x 5 minutes. 2. Apply endoform to wound and cover with gauze to anterior and posterior ankle prior to wrapping with kerlix. Anterior ankle gauze is for protection. 3. Doctor to schedule split thickness skin graft week of March 9, 2020. Office will call facility with date/time/details. 4. Please draw CBC and CMP (lab tests) prior to procedure. The facility staff did not discontinue the…

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

Based on record review, observation and interview, it was determined the facility staff failed to have the appropriate interdisciplinary team members attend a Resident's care plan meeting (#304) and failed to maintain a fluid restriction as ordered by the physician for Resident #35. This was evident for 2 of 4 residents reviewed for nutrition during the annual survey. The findings include: 1. Resident #304 was admitted to the facility with a feeding tube placed into the stomach for nutrition because the resident was unable to swallow. Resident #304 received all food in liquid form and fluids through this tube. On 8-6-19, a care plan meeting was held with Resident #304's family and the facilities social worker, nurse and the Director of Rehabilitation. The facility dietitian did not attend the care plan meeting, therefore, nutritional needs were not addressed. The Director of Nursing confirmed on 3-5-2020 at 11:00 AM that the dietitian did not attend the care plan meeting to address Resident #304's nutritional needs. 2. The facility staff failed to maintain a fluid restriction as…

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

Based on medical record review and interview, it was determined the facility staff failed ensure a resident was free from un-necessary medication by failing to discontinue the medication Lorazepam as ordered by the Physician for Resident (#77). This was evident for 1 of 53 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to discontinue the medication Lorazepam as ordered by the Physician for Resident (#77). Medical record review on 03/04/20 at 10:22 AM, for Resident #77 revealed on 1/9/20, the physician ordered Lorazepam (Ativan) x 14 days. This medication is used to treat anxiety. Lorazepam belongs to a class of drugs known as benzodiazepines, which act on the brain and nerves (central nervous system) to produce a calming effect. Further record review revealed the medication Ativan was noted on the Medication Administrator record for the months of January 23rd through March 4th, 2020. However, the facility staff did not document the administration of the medication pass the 14 days. After surveyor intervention, 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 observations and staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on both resident care areas 2nd and 3rd floors of the facility. The findings include: On 8/17/2018 at 4 PM, an environmental tour was conducted with the Maintenance Director (Staff #16) to share observations of the survey team. The Maintenance Director took notes along the way. The following concerns were identified: In room [ROOM NUMBER], one of the side nightstands was missing a drawer. Multiple staples were observed in the wall along wall paper seams. A long gouge/gash and dirty spots were found in the wall paper along the accent wall of the room. In the restroom of room [ROOM NUMBER],there were two stained ceiling tiles. The maintenance director indicated that there was ccasional leakage from the floor above. In room [ROOM NUMBER], 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 staff interview, it was determined the facility failed to develop comprehensive person-centered care plans with goals that were measurable. This was evident for 3 (#3, #51, and #54) of 27 residents investigated. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1. Review of the medical record for Resident #3 on 8/20/18 revealed a care plan At risk for behavior symptoms r/t Dementia and cognitive impairment with the goal will reduce risk of behavioral symptoms. The goal was not measurable. 2. Review of the medical record for Resident #54 on 8/20/18 revealed a care plan at risk for loss of range of motion r/t disease process, left hand contracture with the goal will exhibit no decline in ROM (range of motion) within confines of disease processes. The goal was not measurable. Review of the care plan is at risk for alteration in skin integrity related to: contractures, impaired mobility, and incontinence had the goal…

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

Based on medical record review and staff interview, it was determined the facility failed to evaluate resident care plans. This was evident for 4 (#3, #51, #54, and #89) of 54 residents investigated during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1. Review of the medical record for Resident #3 on 8/20/18 revealed a care plan At risk for behavior symptoms r/t Dementia and cognitive impairment with the goal will reduce risk of behavioral symptoms. An 8/7/18 care plan progress note documented that a meeting was held and who attended. It summarized that the resident did not attend group activities, wandered about unit and was unable to focus in group and that resident appeared content at times and at other times may become tearful. The note stated remains on psych caseload for management of medications, mood and behaviors. Resident remains at cognitive and emotional baseline with no new concerns. There was no evaluation of the goal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility documentation review, it was determined the facility failed to discard medications/biologicals after the expiration date. This was evident for 3 of 5 medication carts observed on 1 of 2 nursing units. The findings include: Observation was made, on [DATE] at 12:38 PM, of Medication Cart #2 on the second- floor nursing unit of (1) box of Assure Dose for Glucose Monitoring; Lot #05186A with an expiration date of 10/17. Also observed was Resident #85's Humalog 100U/1ml insulin vial which was opened on [DATE]. According to the manufacture's website, Humalog Insulin should have been discarded after being opened for 28 days. Staff #5 was with the surveyor during the observation. Observation was made, on [DATE] at 12:43 PM, of Medication Cart #3 on the second-floor nursing unit of (2) Glucose control Solutions G3 2.5 ml., Lot #16816063102 with an expiration date of [DATE] and (1) Glucose control solutions Lot #16816073102/202 with an expiration date of [DATE]. There was…

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

Based on review of facility Quality Assurance & Assessment (QA&A) activities, previous survey results, and interview with facility staff, it was determined that the facility failed to remain free of repeat citations from previous surveys. This failure to remain free of repeat citations is evidence that the facility's efforts to correct citations have not been effective. This was true for 5 of 18 (F584, F609, F641, F656, & F812) citations assessed on this annual recertification survey. The findings include: The facility received repeat citations from their January, 2016 and May, 2017 annual recertification surveys for 1. maintaining a clean, safe, and homelike evironment; 2. timely reporting of abuse; 3. development of comprehensive care plans; 4. accuracy of assessments; and 5. sanitary procurement, storage, preparation, and serving of food. All five of these citations were being cited under analogous F tags under the new survey process. Because the ongoing review of the above concerns by the quality assurance committee failed to correct ongoing deficiencies, the facility was cited…

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, interviews,and facility investigation it was determined that the facility failed to keep a resident free from verbal abuse as evidenced by reports of a resident being verbally abused by a staff member. This was evident during the review of facility reported incident MD00127467. The findings include: Review of Resident # 400's medical record on 8/21/18 at 10am revealed multiple co-morbidities including Bipolar Disorder and Opioid Dependency. Investigation Report, dated 6/1/18, revealed that, on 6/1/18 at 11:45am, a representative from I Care transportation witnessed a GNA (Geriatric Nursing Assistant) speaking inappropriately to resident # 400, while waiting to transport the resident to an appointment. On 6/1/18 at 3:10pm, the representative from I Care transportation returned resident #400 from his/her appointment and reported to nurse # 7 and the Unit manager #13 that he/she witnessed a GNA using foul language while in the residents' room this morning. The facility identified the GNA as (Staff #2). Review of the facility investigation revealed a written…

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 and review of the facility investigation, it was determined that the facility staff failed to report an allegation of verbal abuse immediately. This was evident during the review of facility reported incident MD00127467. The findings include: Review of Resident # 400's medical record, on 8/21/18 at 10am, revealed multiple co-morbidities including Bipolar Disorder and Opioid Dependency. Investigation Report, dated 6/1/18, revealed that, on 6/1/18 at 11:45am, a representative from I Care transportation witnessed a GNA (Geriatric Nursing Assistant) speaking inappropriately to resident # 400, while waiting to transport the resident to an appointment. On 6/1/18 at 3:10 pm the representative from I Care transportation returned resident #400 from his/her appointment and reported to nurse # 7 and the Unit manager #13 that he/she witnessed a GNA using foul language while in the residents' room this morning. The facility identified the GNA as (Staff #2). Review of the facility investigation on 8/21/18 at 11:am revealed that GNA #1 (Geriatric Nursing…

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

Based on clinical record review and staff interview, it was determined that the facility staff failed to initiate a significant change MDS assessment for (Residents #112). This was evident for 1 out of the 7 residents reviewed. A significant change in status assessment is a comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either a major improvement or decline. When a resident is enrolled is a hospice program a significant change in status assessment. The findings include: Review of Resident # 112's medical records on 8/21/18 at 10am, revealed that the resident was admitted to hospice services on 6/1/18. Further review of the medical record revealed that the facility staff failed to initiate a significant change MDS assessment regarding the resident's change in condition. During interview with the MDS Coordinator (staff # 3) on 8/21/18 at 12pm, s/he stated the resident was not receiving hospice services; therefore, a significant change MDS was not needed. Interview with the…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#107) of 5 residents reviewed for accidents and 1 (#65) of 3 residents review for dental services. The findings include: 1. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #107's medical record on 8/20/18 revealed that the resident had a fall on 5/11/18. The progress note, dated 5/11/18 at 20:33, (8:30 PM) stated, Resident alert and oriented x 4. Found by GNA sitting on bathroom floor beside toilet. Assessed by this writer, no injury nor c/o pain. Asked by this writer, why he 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 medical record review and interviews with staff, it was determined that the facility staff failed to provide a resident with a copy of his/her baseline care plan. This was evident for 1 (#207) of 1 residents reviewed for care plan. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: Resident #207's medical record was reviewed on 8/16/18 at 10:09 AM. The record revealed that the resident was admitted on [DATE] and that a baseline care plan was created on that date as well. During an interview on 8/16/18 at 10:35 AM, Staff #11 was asked what the facility provided to the resident when the baseline care plan was completed. He/She indicated that the facility would provide a copy of the resident's medication list and a copy of the care plan. If the resident/representative did not attend the meeting, the copies would be physically delivered to the resident, or mailed to the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, it was determined the facility failed to follow physician's orders and the care plan for potential for altered skin integrity for a resident who was totally dependent on staff for all mobility needs and by failing to administer routine medication for pain and anticogulation as per the resident's plan of care and physicians orders. This was evident for 1 (#54) of 5 residents reviewed for positioning and for 1 (#207) of 4 residents reviewed for pain management. The findings include: 1. Review of Resident #54's medical record on 8/20/18 revealed August 2018 physician's orders for Medi-Boots to bilateral feet at all times which was initially ordered on 5/26/17. Medi-Boots are protectors for the heels to protect against pressure ulcers. Review of Resident #54's care plan at risk for alteration in skin integrity related to: contractures, impaired mobility and incontinence, which was initiated on 5/27/17, had the intervention float heels as able.…

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, it was determined that the facility staff failed to serve food in a sanitary manner. This was observed during 1 of 3 dining observations. The findings include: Observation was made, on 08/15/18 at 12:05 PM, in the second-floor dining room of a Geriatric Nursing Assistant (GNA) setting up the lunch tray for Resident #67. The GNA (staff #15) was observed to use his/her bare fingers to pull bread out of a plastic bag for resident #67. At 12:08 PM, a nurse (staff #5) was observed to pull cookies out of a plastic bag with his/her bare hand for resident #67. On 8/17/18, administrative staff were informed of the observations of bare hand touching of food, empathizing that employees should prevent contact of ready-to-eat food with their bare hands.

Based on medical record review, observation and staff interview it was determined the facility failed to accurately document in resident medical records as evidenced by licensed nursing staff signing off that treatments were implemented when the treatments were observed not implemented. This was evident for 1 (#54) of 5 residents reviewed for positioning, 1 (#207) of 7 residents reviewed for medication review, 1 (#58) of 8 residents reviewed based on facility complaints, and for 1 of 1 resident reviewed for hospice care. The findings include: 1. Review of Resident #54's medical record, on 8/20/18, revealed August 2018 physician's orders for Medi-Boots to bilateral feet at all times which was initially ordered on 5/26/17. Medi-Boots are protectors for the heels to protect against pressure ulcers. Observation was made on 8/20/18 at 3:05 PM of Resident #54 receiving care by 2 Geriatric Nursing Assistants (GNAs). The resident's incontinence brief was changed, and the resident was positioned on his/her back with a sheet covering the resident. The resident did not have anything on 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.