Lorien Nsg & Rehab Ctr Belair

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, it was determined that the facility staff failed to develop and initiate comprehensive person-centered care plans for residents residing in the facility. This was evident for 4 (# 70, #46, #54, #90) of 42 residents reviewed during a 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. Minimum Data Set (MDS) is a standardized assessment tool that is used to evaluate the health status and functional capabilities of residents, and to help nursing home staff identify health issues. 1) On 6/3/2024 at 11:45 AM, a review of Resident #70's clinical records revealed the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not limited to adjustment disorder with mixed Anxiety and Depressed Mood, Unspecified Dementia, unspecified severity, without…

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

Based on observation, interview, and record review it was determined the facility failed to ensure Resident #68 had access to their call bell to call for staff assistance. This was evident for 1 out of 4 residents reviewed for environment. The findings include: During surveyor's initial tour of the facility on 5/28/24 at 10:28AM, Resident #68 was observed to be laying in bed with their call bell on the floor out of reach behind their bed. On 5/28/24 at 10:29AM the surveyor requested a dual observation with Licensed Practical Nurse (LPN) #35 who observed and upon interview, they confirmed the location of the call bell. The surveyor observed LPN #35 pick the call bell off of the floor and give it to Resident #68 and clipped the call bell cord to their bed. On 6/10/24 at 12:35PM the surveyor conducted review of the medical record for Resident #68 which revealed the following information included in the care plan interventions dated 3/5/24: keep call bell in reach and encourage me to use it for assistance and have commonly used articles within reach.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to 1) ensure a second certification of incapacity was obtained, 2) ensure that residents were provided information regarding advanced directives, and 3) obtain Advanced Directives from residents/resident's family. This was evident for 3 (Residents #54, #90, and #112) out of 7 residents reviewed for advanced directives during the recertification survey. The findings include: An advanced directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under the State law (whether statutory or as recognized by the State courts) relating to the provision of health care when the individual is incapacitated. 1) On [DATE] at 9:57AM the surveyor observed the Maryland Order for Life Sustaining Treatment (MOLST) form in the paper chart of Resident #90 and noted that under the certification section, it was marked as the resident or authorized decision maker having declined to discuss 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 review and staff interview it was determined the facility failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#86) of 6 residents reviewed for hospitalization during a recertification survey. The findings include: In an initial interview with Resident # 86 on 5/28/2024 at 11:14 AM, the resident stated that s/he was sent to the hospital over a week ago for low blood level. When asked if s/he was notified in writing the reason for the transfer, Resident #86 state s/he was told verbally about the reason for the transfer but was not given anything in writing. On 5/30/2024 at 11:45 AM, a review of nurses' progress notes revealed the following documentation dated 4/30/2024 at 23:37 (11:37 PM): Note Text: Resident admitted to UCMC (Upper Chesapeake Medical Center) per [staff name] for symptomatic anemia and GI bleed. Change in condition documentation (SBAR) dated 4/30/2024 at 17:09 (5:09 PM) revealed Resident #86 was transferred to the hospital.…

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 notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 2 (#86, #104) of 6 residents reviewed for hospitalization during a recertification survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1) In an initial interview with Resident # 86 on 5/28/2024 at 11:14 AM, the resident stated that s/he was sent to the hospital over a week ago for low blood level. When asked if s/he was notified in writing the reason for the transfer, Resident #86 stated s/he was told verbally about the reason for the transfer but was not given anything in writing. Resident #86 added that s/he knew they were holding their bed but did not know for how long. On 5/30/2024 at 11:45 AM, a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#70) of 42 residents reviewed during a recertification survey. The findings include: 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. On 6/3/2024 at 11:45 AM, a review of Resident #70's clinical records revealed the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not limited to adjustment disorder with mixed anxiety and depressed mood, unspecified dementia,…

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 resident and staff interviews and medical record review, it was determined that the facility failed to revise care plans after a resident sustained an injury after a fall. This was evident for one resident (Resident #95) out of 42 residents reviewed for care plan timing and revision. The findings include: Resident #65 has been at the facility for a month to get short-term rehab for a respiratory infection. On 05/29/24 at 11:07 AM, an Interview with a resident (#95) revealed that the resident sustained Fracture after a fall in the facility on 05/16/24. The resident was sent to the Hospital and returned to the facility on 5/26/2024. On 06/06/24 at 10:05 AM Record review revealed that the risk for falls care plan was Initiated on 05/02/2024 with the goal will have no falls through the review period. The resident sustained injury after a fall on 05/16/24, and after returning from the Hospital, the resident's care plan goals and interventions were not revised until 06/05/2024 to provide appropriate care after injury. On 06/04/24 at 08:27 AM, an Interview with Nursing 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 observation, interview and record review, it was determined that the facility failed to have a resident's hearing aids accessible to the resident. This was evident for 1( Resident #46) of 1 resident reviewed for management of their hearing aids. The findings include: Minimum Data Set (MDS) is a standardized assessment tool that is used to evaluate the health status and functional capabilities of residents, and to help nursing home staff identify health issues. On 05/29/24 at 09:08 AM, Resident #46 was observed having difficulty hearing the surveyor while being interviewed. He/she was also observed not wearing hearing aids on both ears. No hearing aids were seen within the resident's reach or elsewhere in the room. On 05/29/24 at 09:08 AM, Resident #46 stated that his/her hearing aids were in the room somewhere but that he/she was not sure where they were. He/she expressed that he/she likes wearing hearing aids because it helps him/her hear better. He/she added that he/she feels discouraged not hearing…

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

Based on interview and record review it was determined the facility failed to: 1) ensure timely and necessary care was provided to a resident, including following medical orders, staff communication regarding resident needs, oversight, assessment and action by staff trained and allowed within the scope of practice for care of resident tube feeding equipment and appropriate documentation of care concerns, and 2) ensure that there were accurate physician orders for resident care. This was evident upon surveyor's review of two facility self reported incidents (MD00205639 & MD00205866) regarding Resident #3, and one resident (Resident #71) of three residents reviewed for rehabilitation services. The findings include: 1.) On 5/28/24 the surveyor began review of two facility self-reported incidents concerning the care of Resident #3. On 6/3/24 at 12:55PM the surveyor conducted a review of the medical record which revealed the following care information for Resident #3 which included the following: turn and reposition every 2 hours and as needed while in bed, turn q2hr and PRN pillows-…

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

Based on observation, interview, and record review it was determined that the facility failed to ensure that residents received respiratory care consistent with professional standards of practice. This was evident for 2 (#44, #86) of 2 residents reviewed for respiratory care during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Oxygen therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider. 1) On 5/28/24 at 10:53 AM Resident #44 was observed in bed with oxygen tubing lying next to the bed. The oxygen tubing was connected to a wall oxygen outlet and was set at 1.5 liters. The connected humidification water bottle was empty and undated, and the oxygen tubing was also undated. When asked, the resident explained that they used oxygen all of the time but must have taken the tubing off sometime during…

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 staff failed to ensure that pharmacist recommendations were acted upon and documented in the resident's medical record. This was evident for 1 (#2) of 5 residents selected for Unnecessary Medications Review during a recertification/complaint survey. Findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. Resident #2's medical record was reviewed on 5/31/2024 at 11:37 AM. Resident #2 was admitted to the facility on [DATE]. Monthly medication regimen review with consultant pharmacist recommendation to physician was not readily found in Resident #2's medical…

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

Based on interviews and record reviews, it was determined that the facility failed to monitor and document residents' needs for the use of PRN (as needed) psychotropic medication. This was evident for 1 (Resident #112) of 5 residents reviewed for unnecessary medication during the annual survey. The findings include: Clonazepam is a psychotropic medication used to treat seizures, panic disorder and anxiety. On 5/31/24 at 9:22 AM, a review of Resident #112's medical records revealed that the resident was prescribed Clonazepam routinely for panic disorder 2 times per day, at 4 PM and 8 PM, and was also prescribed a PRN dose that could be given once per day if needed for panic disorder that was not managed with the routinely scheduled doses. Further review of Resident #112's Medication Administration Record (MAR) showed that the resident received 5 PRN doses of Clonazepam in May 2024: 5/14/24 at 2:48 PM, 5/18/24 at 12:01AM, 5/19/24 at 1:56 PM, 5/21/24 at 8:36 AM, and 5/26/24 at 1:45 PM. However, there was no documentation of the resident's behavior that described the need for any 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.

2) During surveyor's record review of the medication administration audit report on 6/3/24 at 12:55PM the surveyor observed the following documentation in the medical record signed off by LPN #31 for the following care for Resident #3: On 5/12/24 at 1:58AM LPN #31 documented the following care occurred at 1:57AM: Assessment of the enteral tube for proper placement prior to each feeding, flush, or medication administration. On 5/12/24 at 1:58AM LPN #31 documented the following care occurred at 1:57AM: Check enteral tube for residual every shift/if 150ml or over, hold feeding for 1 hour and recheck: If residual 100ml or over, notify MD-document amount in ml every shift document amount. On 5/12/24 at 1:58PM LPN #31 signed off on enteral tube water flushes. On 5/12/24 at 2:02AM LPN #31 signed off on every shift monitoring of a pressure relief mattress for proper function. On 5/12/24 at 2:02AM LPN #31 signed off on an assistive device: wedge for repositioning in bed every shift and for pressure relief when in bed every shift. On 5/12/24 at 2:02AM LPN #31 signed off on elevation/floating…

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

Based on observation, record review, and interview it was determined the facility staff failed to 1) ensure proper hand hygiene while performing dressing changes. This was evident for 2 observed dressing changes for residents #44 and #54 conducted during the infection control facility task investigation. 2) perform handwashing before and after gloving. This was evident for one (Resident #567) of 6 residents reviewed for Infection Prevention and Control. The findings include: A pressure ulcer, also known as a pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. A nephrostomy tube is a thin, flexible catheter that is surgically inserted and drains urine from the kidney into a bag outside the body. 1)On 5/28/24 10:54 AM in an interview with Resident #44, the resident said they had a sore on their backside. On 5/30/24 at 1:14 PM a review of Resident #44's medical records revealed documentation that the resident had multiple pressure ulcers which required daily dressing changes. On 6/03/24 at 10:05 AM 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 interview and record review it was determined the facility failed to ensure an allegation of neglect and an investigation of neglect were timely reported. This was evident for 1 (MD00205866) out of 6 facility reported incidents reviewed during the facility's recertification survey. The findings include: On 5/28/24 the surveyor began review of a facility reported incident (MD00205866). On 5/31/24 at approximately 10:27AM the surveyor conducted an interview with the facility Administrator who reported the following information regarding the facility's process for the reporting of allegations of abuse and neglect: Supervisors report to us and we act on and start investigation immediately, we talk to residents, we determine if it is something we need to report, determine if it is a care concern or a customer service issue, or something that looks like it could be abuse or neglect, and investigation along the lines of abuse is reported to OHCQ within 2 hours of us getting notified. On 5/31/24 at 12:41PM the surveyor observed the following documented in the facility's initial…

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 complaint intake review, medical record review, and staff interview it was determined that the facility failed to document the transfer of a resident in the medical record including the reason for the transfer. This was evident for 1 (#166) of 3 residents reviewed for discharge. The Findings include: Resident #166's closed medical record was initially reviewed on 6/5/24, in relation to complaint intake MD00206001. Resident #166 was admitted to the facility on [DATE]. Per the census tab in the electronic health record (EHR) revealed the resident was discharged on 3/7/23. There was not a discharge note to indicate the reason for the discharge, or information of how, or when the resident left the facility. Under the evaluations tab in the EHR was an in Progress discharge instructions document without indication as to who was provided the instructions. The Director of social services (staff #21) was interviewed on 6/5/24 at 1:30 PM. Upon identification of the resident in question she did a custom search of…

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

Based on record review and interview it was determined that the facility failed to allow residents the right to have a dignified existence by failing to answer call lights in a timely manner. This was evident for 3 (#30, #43, and #42) of 41 residents reviewed during the survey. The findings include: 1) A review of the facility reported incident #MD00193246 on 4/4/24 at 10:24 AM revealed Resident #30 had reported an allegation of abuse on 6/9/23 because when s/he put his/her call light staff had not responded. A review of the call light response times included in the investigation filed revealed that the resident had waited 30 - 50 minutes for staff to respond to his/her call light between the dates of 6/1/23 - 6/7/23. A review of Resident #30's medical record on 4/4/24 at 9:00 AM revealed an admission assessment dated 5/2023 that documented the resident was able to use the toilet for urination and bowel movements. The care plan for Activities of Daily Living (ADL - everyday task that people do to care for themselves, such as eating, toileting, bathing, dressing, etc.) initiated 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 medical record review of a complaint and a facility reported incident, review of medical records and interview with staff, it was determined that the facility failed to ensure that a resident was free from mental and physical abuse. This was evident during the review of 2 of 23 (#21 and #22) residents reviewed for abuse. The findings include: Review of the facility reported incident #MD00196006 and related complaint #MD00196058 on 4/3/24 at 10:44 AM revealed a concern regarding GNA staff # 17. According to the incidents, GNA #17 on 8/24/23 Resident #21 reported that s/he used the call bell for assistance to use the bathroom. S/he reported that after a long time GNA #17 came in and threw the call bell at Resident #2. GNA #17 then yelled at Resident #21 not to press the button again. According to the investigation and report Resident #21 reported that s/he was fearful following that incident and would not use the call bell for the remainder of the shift for any assistance. Review of the medical record for Resident #21 on 4/5/24 at 9:00 AM revealed that s/he had mixed…

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 conduct a thorough investigation of an allegation of neglect to determine the root cause and implement a plan of correction. This was evident for 1 (#30) of 23 residents review for abuse. The findings include: On 4/4/24 at 10:24 AM a review of the facility's investigation for facility reported incident # MD00193246 revealed that Resident #30 had reported an allegation of neglect on 6/9/23. The allegation stated that the resident felt neglected because staff do not respond to the call light. A review of the facility's call light audit revealed that during the 7 days that were reviewed the resident had waited 30 - 50 minutes for call light response. However, these extended wait times were during all 3 shifts. Further review of the investigation revealed that facility staff had interviewed each Geriatric Nursing Assistant (GNA) who had been assigned to the resident during the long call light response times. However, they failed to interview the nurses and other GNAs assigned to the unit to determined…

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 the facility failed to provide incontinent care for dependent residents. This was true for 2 out of 2 (resident # 6 and resident # 39) residents reviewed for Activities of Daily Living for dependent residents. Findings include: 1. A medical record review was conducted on 4/3/24 at 10:49 AM. Medical record revealed on 12/18/21, resident # 6 complained to the social worker about a GNA #21. The resident stated that GNA #21 changed him/her at 4 PM on 12/17/21. At 7 PM, resident called the GNA to change him/her again. GNA stated they would be right back but never showed up again. Resident was finally changed at 3 AM by the nurse staff # 4. On 12/19/21 GNA # 21 was called in to speak with the Administrator about the incident that took place with resident # 6 over the weekend. The nursing home administrator took GNA # 21 off the schedule for neglect and reported GNA #21 to the Board of Nursing. 2.On 4/5/24 at 8:26 AM a review of medical records indicated resident # 39 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 chart review and interviews with the DON (Director of Nursing), the facility failed to ensure residents receive care, consistent with professional standards of practice, to prevent pressure ulcers. This was evident for 1(resident #39) out of 1 resident investigated for wounds. Findings include: On [DATE] at 8:26 AM a medical record review was completed for Resident #39, who was admitted to this facility for rehab therapy. When resident # 39 was admitted to the facility there were no wounds on their sacrum according to the admission assessment. On [DATE], a new open area was found on Resident 39's sacrum with a red wound bed; new orders were given for Splurge with Rotifer dressing daily. At the time the wound was discovered, nursing failed to obtain wound measurements for the new area on the sacrum. On [DATE], the wound was described as larger with foul smelling drainage and a dark brown in color. The surrounding area was red. There were still no measurements of the wound recorded. The physician…

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

Based on record review and staff interview it was determined that the facility failed to ensure that nursing assistants were competent and had the skill set needed to care for the residents. This was evident for 1 (#) of # nursing assistant staff reviewed. The findings include: On 4/8/24 at 9:48 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) present a review of Geriatric Nursing Assistant (GNA) Staff #22's employee file. There was no evidence that the facility had determined the level of competence of Staff #22 to ensure she had the skill set to care for the residents. The DON and NHA reported they would check and report back to the surveyor. On 4/8/24 at 2:30 PM the NHA and DON reported that there was no additional paperwork for Staff #22 other than what had been provided to the surveyor. The Human Resources Director was asked to provide Staff #22's hire date and termination date. On 4/9/24 at 7:15 AM the paperwork was provided and according to the hire letter Staff #22 was hired 10/2022 as a nursing assistant in training as she had not been issued her GNA…

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 complaints, facility reported incidents, interviews, and employee files, it was determined that the facility failed to ensure that geriatric nursing assistants (GNA) had the required 1. abuse training and 2. competencies to provide safe and proper care to residents in the facility. This was determined during the review of 1 (GNA #17) of 9 employee files. The findings include: 1. Review of the employee file of staff GNA #17 on 4/4/24 at 12:20 PM revealed that she had not completed her annual abuse training since 2020. The Director of Nursing (DON) and Administrator were interviewed on 4/4/24 at 12:25 PM regarding the surveyors' findings of the lack of abuse training. They were not aware that the training was not up to date at that time, additionally, they were newly getting acclimated to the facility and had the employee immediately removed and reported to the board. The employee's file was reviewed secondary to allegations of abuse and neglect on 8/24/23. The Administrator and DON implemented education and inservices to the other employees related 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 interview, it was determined the facility staff failed to clearly identify target symptoms for the administration of psychotropic medications and establish a plan for the ongoing monitoring of those symptoms for Residents (# 9 and #15). This was evident for 2 of 5 residents selected for review of unnecessary medication and 2 of 38 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to clearly identify target symptoms for the administration of psychotropic medications and establish a plan for the ongoing monitoring of those symptoms for Resident #9. Medical record review for Resident #9 revealed on 11/20/18 the physician ordered: Risperdal .25 milligrams (mgs) by mouth every morning for bipolar. On 1/8/19 the physician ordered: Risperdal .5 mg in morning for anxiety. Risperdal is used to treat certain mental/mood disorders. Risperdal belongs to a class of drugs called atypical antipsychotics. It works by helping to restore the balance of certain natural substances in the brain. 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 medical record review and staff interview it was determined that facility staff failed to provide dental services to a resident with a broken tooth for Resident (#26). This was evident for 1 of 2 residents selected for review of dental services and 1 of 38 residents selected for review during the annual survey process. The findings include: Resident #26's medical record was reviewed on 5/13/2019. Medical record review revealed a Change of Condition note dated 1/3/2019 that reads: Resident c/o (complained of) tooth pain, evaluated mouth and found upper left bicuspid tooth broken. No evidence of a subsequent dental evaluation was identifed in continued review of Resident #26's medical record. The Director of Nursing was interviwed on 5/15/2019 at 12:35 PM and confirmed that facility staff had failed to ensure that Resident #26 received dental services after he/she was identified with a broken tooth.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, it was determined the facility staff failed to 1. update a resident's care plans to properly indicate a resident's up to date wishes, and 2. void older MOLST forms located in a resident's active medical record. This was evident for 2 (Resident #31 and #41) of 5 residents reviewed for Advance Directives during an annual recertification survey. The findings include: 1. Review of Resident #31's medical record on [DATE] revealed an Advance Directive care plan, dated [DATE], instructing the nursing staff to follow Resident #31's surrogate decision maker's wish that Resident #31 is to be a No CPR, Do Not Resuscitate and Do Not Intubate. Further review of Resident #31's active MOLST form, dated [DATE], revealed Resident #31 surrogate decision maker had decided that Resident #31 is to be a Full Code. 2. Review of Resident #41's medical record on [DATE] revealed 3 different MOLST forms with 3 different dates ([DATE], [DATE], [DATE]) of when each of the MOLST forms went into effect. During…

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

Based on record review and interview, it was determined the facility staff failed to provide abuse updated training to a Geriatric Nursing Assistant, failed to provide in-service abuse training to all staff and failed to notify the physician and family member of the alleged abuse in a timely manner for Resident #12. This was evident for 1 of 1 resident selected for abuse investigation and 1 of 38 residents selected for review during the annual survey process. The findings include: Medical record review during the investigation of facility reported incident: MD00133011 revealed Geriatric Nursing Assistant #18 reported to have seen facility staff #19 aggressively push the arm of Resident #12 into his/her lap on 10/30/18 while pushing the resident in the wheelchair. Further investigation revealed facility staff #18 failed to report the alleged allegation of abuse/rough care to the administrative staff until 10/31/18. Facility staff #18 stated he was afraid to report the incident. Once the allegation of abuse/rough care was provided to the administrative staff, GNA #19 was removed from…

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/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 (Residents #41 and #112) of 38 residents reviewed during an annual recertification survey. The findings include: 1. Review of the medical record for Resident #41 documented that the resident was transferred to an acute care facility on 2/8/19, 4/2/19, and 4/29/19. There was no documentation found in the medical record that the resident or family was notified in writing of the transfer to the emergency department. In an interview with the Director of Nursing (DON) on 5/15/19 at 9:00 AM, the DON stated there is no documentation the resident nor the resident's family received notification of Resident #41's transfers to the hospital. 2. Review of the medical record for Resident #112 documented that the resident was transferred to an acute care facility on 10/6/18. There was no documentation found in the medical record that the resident 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.

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 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 #41 and #112) of 38 residents sampled for investigations. The findings include: 1. Review of the medical record for Resident #41 documented that the resident was transferred to an acute care facility on 2/8/19, 4/2/19, and 4/29/19. An interview with the facility Director of Nursing (DON) on 5/15/19 at 9:00 AM confirmed the facility did not give Resident #41 a copy of the facilities bed hold policy with each of these hospitalizations. 2. Review of the medical record for Resident #122 revealed the resident was transferred to an acute care facility on 10/6/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. On 5/13/19 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical record and staff interview, it was determined the facility staff failed to develop a baseline care plan for Residents (#211, #23 and #112). This was evident for 3 of 38 residents selected for review during the survey process. The findings include: A care plan is an outline of nursing care showing all the resident's needs and the ways of meeting the needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the patient. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care. 1. Medical record review revealed for Resident #211 that he/she was admitted from the hospital on 4/30/19 with a recent fall and multiple fractures of the ribs. Further medical record review revealed the facility staff failed to initiate a care plan to address pain management and non-pharma logical interventions for resident #211. Interview with the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to implement comprehensive care plans for Resident #9 to address bladder incontinence and to address pressure ulcer for Resident #112. This was evident for 1 of 1 resident selected for review of bladder incontinence and 1 of 3 residents selected for review of pressure ulcer during the survey process and 2 of 38 residents selected for review during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of…

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

Based upon medical record review and staff interview it was determined that facility staff failed to update a resident's care plan to reflect the resident's need for two caregiver assistance with bed mobility. This was evident for 1 of 38 residents ( Resident #261) reviewed during survey investigation. The findings include: Resident #261's medical record was reviewed on 5/10/2019. This review revealed a Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 5/4/2018. The MDS is a complete assessment of the resident that provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident and to modify the care plan based on the resident's status. Resident #261's MDS Assessment is coded to reflect that the resident requires extensive assistance and the aid of two persons for bed mobility. Bed mobility refers to how a resident changes position in bed. Resident #261's careplan was reviewed on 5/10/2019. The care plan is a detailed written guide that is customized to address a resident's unique needs. 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 observation and interview, the facility staff failed to fail to apply Ted stockings for Resident #34 and failed to have two staff participation to reposition Resident #16. This was evident for 2 of 38 residents during the investigative portion of the survey. The findings include: 1. Medical record review for Resident #34 revealed on 3/20/2019 the physician ordered: Teds stockings, knee high apply in AM remove in PM. TEDS stockings lower your chances of getting deep vein thrombosis (DVT), a kind of blood clot, and other circulation problems after surgery. Surveyor observation of resident #34 on 5/9/19 at 1:02 PM and on 5/9/19 at 8:30 AM, revealed the resident sitting in his/her wheelchair in the room; however, the facility staff failed to apply the TEDS stockings. On 5/13/19 at 9:00 AM the Director of Nursing was informed that the facility staff failed to apply Ted stockings as ordered by the physician. 2. The facility nursing staff failed to follow a resident's care plan and obtain enough assistance to prevent a resident from receiving a skin tear during care. During an…

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

Based on observation, medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressure ulcers to (Resident #34). This is evident for 1 of 3 residents selected for review of pressure ulcers and 1 of 38 residents selected for review during the survey process. A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), and Stage IV (full thickness skin loss with extensive damage to muscle, bone, or tendon). The findings included: Resident #34 was admitted from the hospital on 3/20/19 without any pressure ulcers. Review of Resident #34's medical record revealed a BRADEN scale assessment for predicting pressure sore risk. The Braden Scale is 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of a medical record, and staff interview, it was determined the facility failed to 1. obtain enough staff assistance to protect a resident from falling, and 2. provide a resident with supervision to prevent the resident from falling. This was evident for 2 (Resident's #23 and #112) of 7 residents reviewed for accidents during an annual recertification survey. The findings include: 1. In an interview with Resident #23 on 5/9/19 at 9:51 AM, Resident #23 stated a facility GNA (geriatric nursing assistant) dropped me after I was admitted to the facility. A review of Resident #23's ADL care plan revealed that Resident #23 is totally dependent upon staff for all transfers which was updated on 10/1/18. Review of Resident #23's medical record revealed nursing documentation indicating that on 10/18/18 at 10:28 AM, Resident #23 had to be eased to the floor during a transfer. In an interview with staff member #14 on 5/15/19 at 9:15 AM, staff member #14 stated s/he was taking care of Resident #23…

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

Based on record review it was determined that the facility staff failed to thoroughly assess and intervene when Resident #9 was noted with a decrease in urinary continence. This was evident for 1 of 1 resident selected for review of urinary continence and 1 of 38 residents selected for review during the annual survey. The findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment 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 provide 1:1 assistance to Resident #213. This was evident for 1 of 6 residents selected of nutrition and 1 of 38 residents selected for review during the survey process. The findings include: Medical record review for Resident #213 revealed on 2/16/19 the physician ordered 1:1 assist with all meals. The resident had a diagnosis that included but not limited to dysphagia. Dysphagia is the medical term used to describe difficulty swallowing. Dysphagia includes difficulty starting a swallow and the sensation of food being stuck in the neck or chest. Surveyor observation of Resident # 213 on 5/8/18 at 8:45 AM revealed the resident sitting in his/her wheelchair eating breakfast; however, no staff member in the room to assist or observe the resident. Interview with GNA #11 on 5/14/19 at 8:30 AM revealed that Resident #213 is a set-up only (opening the milk and condiments container) sometimes and that he/she is independent in eating. Interview with the Director of Nursing on 5/14/19 at 10:17…

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

Based on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication for Residents (#211) and failed to thoroughly document a pre or post assessment of pain while administering pain medication to Resident (#62). This was evident for 2 of 5 residents selected for review of pain during the annual survey and 2 of 38 residents selected for review during the annual survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. 1. Medical record review for Resident #211 revealed…

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

Based on observation and interview, it was determined the facility staff failed to ensure that medications were properly secured, thoroughly labeled with residents' name, and dated when the medication was open. This was evident for 1 of 4 medication carts and 2 of 3 treatment carts observed during the annual survey process. And the facility nursing staff failed to properly store and secure medications in failing to maintain a treatment cart locked. The findings include: Observation of the medication carts and treatment carts on 5/15/19 at 12:30 PM revealed the following: 1. Humalog pen with no name to determine which resident it was to be administered to and no date to indicate when it was open on Treatment cart #1. Humalog (insulin lispro) is a short-acting type of insulin. Insulin helps to control blood sugar levels in diabetes mellitus. 2. Humalog pen with no date to indicate when it was open and the name of the resident to be administrated to was discharged from the facility. 3. Humalog pen with no date to indicate when it was open. 4. Systane eye drops with no name to determine…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood test as ordered for Resident (#9). This was evident for 1 of 38 residents selected for review of laboratory results in the survey sample. The findings include: Medical record review for Resident #9 revealed on 10/3/19 the physician ordered: CBC, CMP, Vitamin D and Depakote level every 3 months. A complete blood count (CBC) is a test that measures the cells that make up the blood: red blood cells, white blood cells, and platelets. A complete blood count (CBC) is a blood test used to evaluate overall health and detect a wide range of disorders, including anemia, infection and leukemia. The comprehensive metabolic panel (CMP) is a frequently ordered panel of 14 tests that gives a healthcare provider important information about the current status of a resident's metabolism, including the health of the kidneys and liver, electrolyte and acid/base balance as well as levels of blood glucose and blood proteins. Abnormal results, and especially combinations of abnormal…

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

Based on observation and interview, it was determined the facility staff failed to maintain confidential information-HIPAA related to Resident (#312). This was evident for 1 of 38 residents selected for review during the annual survey. The findings include: The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule is the first comprehensive Federal protection for the privacy of personal health. The HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patients' rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections. Protected…

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, observation, and staff interview it was determined that the facility staff failed to ensure documentation of the use of a hand roll was recorded completely (#33). This was true for 1 out of the 38 residents reviewed as part of the survey process. The findings include: Resident #33 was observed on 5/9/19 at 11:50 AM to be without a hand roll. A review of the clinical records revealed that on 8/15/18 the primary physician wrote an order to Apply small foam red roll to left hand 4 hours (or as tolerance) everyday. Monitor skin and pain. For contracture mgmt. The resident also has a care plan which instructs staff to place a roll in the left hand. The Director of Nursing (DON) was interviewed on 5/13/19 at 12:11 PM. The findings were discussed. The DON returned at 1:24 PM on 5/13/18. She confirmed that the roll is being placed in the resident's hand, but staff are not documenting it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, it was determined the facility staff failed to promote an environment that decreased the potential of transmission of communicable diseases or infections for Resident (#26). This was evident for observations of dining in the restorative dining room [ROOM NUMBER] out of 10 residents observed for dining and 1 out of 38 residents selected for review of infection control during the survey process. The findings include: Observation of lunch in the restorative dining room on 5/9/19 at 12:20 PM revealed facility staff #3 assisting Resident 26 with his/her lunch. It was noted at that time, the facility staff used bare hands to apply mayonnaise to the sandwich. It was further noted during the observation, facility staff #4, also used bare hand food contact to apply lettuce and tomato to the sandwich and cut it for Resident #26. Interview with the Director of Nursing on 5/15/19 at 1:30 PM confirmed the facility staff failed to promote an environment that decreased the potential for…

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