Sterling Care Bel Air

Based on record reviews and interviews, it was determined that the facility failed to update a resident's discharge plan to reflect the information received from home health services referral. This was evident for a discharged resident (Resident #3) during a complaint survey.The findings include: On 10/16/2025 at 7:59 AM A review of complaint #2602798 was conducted. The review alleged that Resident #3 was discharged home on 7/22/25 without home health wound care services arrangement and as of 8/28/25 the resident had no wound care services.On 10/16/2025 at 8:20 AM A review of Resident #3 medical records was conducted. The review revealed that the resident was initially admitted into the facility on 2/3/2024 and was discharged on 8/1/2025. The records indicated that the resident had a wound on the right Below Knee Amputation (BKA) stump and received wound care services while at the facility.Further review of the records indicated that on 7/22/2025, the facility contacted a home health agency to request services for Resident #3 post discharge. On 8/1/2025 at 1:39 PM, the facility 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 complaint 302936, observation, interviews, review of resident council meeting minutes, attendance at the food committee meeting, and observations of the kitchen, it was determined that the facility failed to serve food that was attractive, palatable, matched what was on the tray ticket, timely, and at the proper temperature. This was evident for 19 (#34, #25, #18, #17, #19, #12, #13, #15, #16, #23, #10, #11, #35, #21, #31, #30, #32, #36, #5) of 19 residents interviewed or observed with the deficient practice having the potential to affect all residents. The findings include:On 8/18/25 at 10:14 AM a review of complaint 302936 was conducted and revealed concerns with meals. The complaint alleged that a resident for dinner received a scoop of mashed potatoes, string beans, and a peanut butter and jelly sandwich. The complaint alleged that the food service was contracted out and that they are not providing sufficient food. The complaint alleged that something needs to be done.On 8/18/25 at 11:30 AM observation was made of residents going into the dining room 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.

Based on observation and interviews, it was determined the facility staff failed to provide maintenance services necessary to maintain resident wheelchairs. This was evident for 15 (#25, #26, #27, #14, #12, #28, #29, #30, #19, #20, #13, #16, #33, #34, #8) of 37 residents reviewed during a complaint survey. The findings include:The following maintenance concerns were observed during the initial rounds of the facility on 8/18/25 at 7:30 AM and throughout the survey until 8/21/25.Resident #25: There was no armrest on the left side of the wheelchair and the vinyl on the right side was cracked throughout.Resident #26: The vinyl on the left wheelchair armrest was torn approximately an inch from the top of the armrest exposing yellow foam. This could be seen from the hallway.Resident #27: There was no wheelchair armrest on the right or left side of the wheelchair. Resident #27 was noted with several bruises to the resident's arms.Resident #14: There was no armrest on the left side of the wheelchair.Resident #12: The vinyl was cracked along the edge of the left wheelchair armrest, and the…

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

Based on review of complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health (Resident #7, #8, #4, #6). This was evident for 4 of 9 complaint residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to properly perform, and document neuro checks after a fall for Resident #7. A neuro check after a fall refers to a neurological assessment performed by a healthcare professional to evaluate potential brain injuries by checking a person's level of consciousness, orientation, pupil response, muscle strength, sensation, and coordination. Review of Resident #7’s medical record on 8/18/25 revealed the Resident was admitted to the facility in April 2025 for rehabilitation following a hospitalization with a diagnosis to include muscle weakness. Review of Resident #7’s medical record revealed a Change in Condition Assessment on 5/10/25 at 3:35 AM that stated “During rounds around 2 AM patient was found in the bathroom on the floor…

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 failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #4, #7 and #9). This was evident for 3 of 9 residents reviewed for complaints during a complaint survey. The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1.The facility staff documented completed assessments and medication administration of Resident #7 when the Resident was not in the facility. Review of Resident #7’s medical record on 8/18/25 revealed the Resident was admitted to the facility in April 2025 for rehabilitation following a hospitalization with a diagnosis to include muscle weakness. Review of Resident #7’s medical record revealed a Change in Condition Assessment on 5/10/25 at 3:35 AM that stated “During rounds…

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 complaint, medical record review, and interview, it was determined the facility violated the rights of a resident's representative (RP) by failing to follow the RP's wishes in where to send their loved one following their death in the facility. This was evident for 1 (#2) of 3 residents reviewed for death during a complaint survey.The findings include:On [DATE] at 10:00 AM a review of complaint 302938 was conducted. The complainant alleged that Resident #2 passed away in the evening on [DATE] and the nurse called the wrong place for Resident #2's body to be transferred. The complaint alleged that Resident #2 was to be transferred to the Anatomy Gifts Registry, however the facility called the State of Maryland Anatomy Board to pick up the resident.Review of Resident #2's medical record revealed on [DATE] Resident #2 signed that the healthcare agent's power to make decisions for the resident was effective immediately after the resident signed the form. Further review of the medical record…

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 complaint, medical record review, and staff interview, it was determined the facility staff failed to timely notify a resident's physician/nurse practitioner of a change in condition. This was evident for 1 (#6) of 9 residents reviewed for complaints during a complaint survey. The findings include: On 8/18/25 at 11:10 AM a review of complaint 302921 alleged unacceptable and negligent care provided to Resident #6 while under the care of the facility. Review of Resident #6's medical record revealed Resident #6 was admitted to the facility in December 2024 from an acute care facility with diagnoses including but not limited to generalized weakness, peripheral artery disease, COPD, slurred speech, history of falls, and hypertension. Review of a 1/10/25 at 8:58 AM eMar - Medication Administration Note documented, amlodipine Besylate tablet 10 mg. give 1 tablet by mouth one time a day for HTN (hypertension). Med not given due to low b/p (blood pressure). On 8/20/25 at 1:45 PM an interview was conducted with Nurse Practitioner #19 (NP). NP #19 stated that she did not see Resident…

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

Based on medical record review and interview, it was determined that the facility staff failed to meet professional standards of practice as evidenced by licensed nursing staff documenting assessments, administration of medications, and treatments were completed when the resident was not in the facility (Resident #7 and #9). This was evident for 2 of 9 residents reviewed during a complaint survey. The findings include: According to the American Nurses Association Standards for documentation emphasize that records should be clear, accurate and accessible is essential element of safe, quality, evidence-based nursing practice. Accurate entries must be factual and reflect the patient's status and care without errors.A violation of the American Nurses Association standards for documentation includes inaccuracies and falsification. 1.The facility staff documented completed assessments and medication administration of Resident #7 when the Resident was not in the facility. Review of Resident #7's medical record on 8/18/25 revealed the Resident was admitted to the facility in April 2025 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.

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by administering a medication not ordered by the physician (Resident #5). This was evident for 1 of 9 residents reviewed for complaints during a complaint survey. The findings include:Review of Resident #5's medical record on 8/19/25 revealed the Resident was admitted to the facility with diagnosis to include mood disorder, depression and anxiety.Further review of Resident #5's medical record revealed on 5/18/25 the Resident was seen by the Psychiatrist. Review of Psychiatry Progress Note on 5/18/25 stated depressed very anxious. A nurse's note on 5/18/25 at 9:15 PM states at 8:57 PM the psych doctor new medication and made change in psych dose as follow: Hydralazine 50 mg every 8 hours for anxiety for 14 days. Hydralazine is a medication that is used for hypertension (high blood pressure) and heart failure.During interview with the Psychiatrist on 8/19/25 at 9:02 AM, the Psychiatrist stated the medication should have been hydroxyzine…

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 documentation review, it was determined that facility staff failed to keep treatment and medication carts locked when unattended, failed to date medications when opened, discard medications/biologicals when expired, and refrigerate medication that required refrigeration. This was evident on 1 of 2 nursing units observed during random observations made during a complaint survey. The findings include:On [DATE] at 12:08 PM observation was made of an unlocked and unattended treatment cart on the Sunset Unit sitting in front of the nurse's station. The surveyor was able to open the cart and found in the top-drawer prescription creams and ointments. In the second and third drawers were dressing supplies and in the fourth drawer were prescription ointments and creams that included Diclofenac gel. In the fifth drawer was a 500 ml. bottle of Sterile water irrigation G176170 for Resident #24. There was 100 ml. left in the bottle. There was no date on the bottle as to when it 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, interview, and facility policy review, the facility failed to ensure that the garbage dumpster area was maintained in a sanitary manner to prevent the harborage of pests and rodents having the potential to affect all residents. There was garbage strewn around the dumpster on three days of the survey. Findings include: Review of the facility's policy titled, Environment, dated 09/17 and provided by the facility, revealed All trash will be contained in covered, leak-proof containers that prevent cross contamination. 7. All trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. During observation on 12/09/24 at 8:45 AM, the area around the garbage dumpster was strewn with garbage up to approximately 30 feet away from compactor along the grass by a parking area and surrounding the dumpster area. Garbage included single use disposable gloves, plastic bags, cups, lids, straws, and assorted pieces, cardboard, individual portioned food containers such as an ice cream cups opened with ice cream on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation of resident rooms and equipment and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. This was evident on 2 of 3 nursing units observed during a recertification/complaint survey. The findings include: On 12/12/24 at 11:50 AM an environmental tour was conducted related to a complaint regarding the facility not being clean and in disrepair. The following concerns were observed: In the shared bathrooms of rooms 116-118 there was toilet paper sitting on the grab bar across from the toilet. The toilet paper holder on the wall was broken off the wall. In room [ROOM NUMBER] the drywall to the right of the door inside the bathroom was pushed in from the base leaving an open gap between the base and drywall approximately 1 foot in height from the base. In the hall dining room Resident #89 was sitting in a wheelchair eating lunch. There was no armrest on the left side 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, the facility staff failed to assess and evaluate the nutrition needs of residents in a timely manner. (Resident #901, #902, #904, #906, #911, #910). This was evident for 6 of 33 complaint residents reviewed during a recertification/complaint survey. The findings include. 1. Review of Resident #902's medical record on 12/9/24 revealed the Resident was admitted to the facility on [DATE] and facility staff documented the Resident weight as 129 pounds. Review of the nutritional assessment revealed it was done on 1/27/22, 8 days after admission. The nutritional assessment stated At nutritional risk for weight loss On 2/3/22 at 2:27 PM a dietary note states Resident presents with poor intake, less than 25% of meals. Current weight is 126.2 pounds. A physician order on 2/3/22 is for weekly weights. Further review of Resident #902's medical record revealed the Resident is reweighed on 2/10/22 and the Resident's weight is 114 pounds, 15 pounds less than the Resident's weight…

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, record review, and facility policy review, the facility failed to ensure snacks were available to eight out of 33 sampled residents (Residents (R) 12, R112, R79, R106, R115, R87, R48, and R32) who desired snacks. The facility did not provide snacks to residents during the day and the evening/hours of sleep (HS) snack was not available to all residents who desired snacks. Findings include: Review of the facility's policy titled, Offering/Serving Bedtime Snacks, dated 02/23 and provided by the facility, revealed It is the practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences, and requests at bedtime on a daily basis . Snacks are readily available to residents . 1. During an interview on 12/09/24 at 2:09 PM, R12 stated he/she did not always eat what was served and would like to be able to get a snack. R12 stated he/she was not offered snacks during the day or at night. Review of the quarterly Minimum Data Set (MDS)…

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 facility policy review, the facility failed to ensure that the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to all residents. Specifically, there were accumulated food and beverage spills, crumbs, and residue on kitchen surfaces such as on carts, shelving, tables, and the inside of the microwave; there was a black/grey substance on the wall above the dishwasher; there were unlabeled food items; and unclean cups and bowls stored as clean for one of one kitchen. This created the potential for the spread of foodborne illness for 105 out of 117 residents consuming food in the kitchen. Findings include: Review of the facility's policy titled, Environment, dated 09/17 and provided by the facility, revealed All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition . All non-food contact equipment will be clean and free of debris . Review of the facility's undated policy titled, Labeling and Dating, provided by the facility, revealed, Food…

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, interviews, record review, review of the facility policy, the facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for two of twelve residents (Resident (R) 13 and R51) reviewed for enhanced barrier precautions (EBP) when providing care, and staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease on 2 of 3 nursing units. These failures could promote the spread of multi-drug-resistant organisms (MDROs) throughout the facility. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, implemented on 03/25/24, indicated, under the section Policy/Definition: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted…

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 complaint, medical records, and interview, it was determined that the facility failed to review the admission agreement, which includes a notice of the resident's rights, with a resident and/or the Resident's responsible party at the time of admission and failed to ensure the admission agreement was signed and documented (Resident #906). This was evident for 1 of 33 complaint residents reviewed during a recertification/complaint survey. The findings include: On 12/10/24 a review of complaint MD00186565 was conducted and alleged that an admissions agreement was never executed. Review of Resident #906's electronic and paper medical record failed to produce a signed copy of the admissions agreement. Further review of Resident #906's medical record revealed the Resident was admitted to the facility on [DATE] and was alert and oriented times 1. Alert and oriented times 1 means that a person knows who they are but not where they are, what time it is, or what is happening to them. On 12/10/24 at 2:05…

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 a closed medical record and staff interview, it was determined that the facility staff failed to complete a resident's discharge summary (Resident #913). This was evident for 1 of 33 complaint residents reviewed during the recertification/complaint survey. The findings include: Review of Resident #913's closed medical record on 12/9/24 revealed that Resident #913 was discharged from the facility on 12/21/23. Resident #913's electronic medical record and paper record failed to reveal a completed discharge summary from Resident #913's attending physician that included: a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-discharge medications with the post discharge medications, and a post discharge plan of care. An interview with the Director of Nursing on 12/11/24 at 4:41 PM confirmed that Resident #913's medical record did not include a completed discharge summary.

Based on complaint, medical record review, and interview with facility staff, it was determined that the facility failed to provide needed showers for residents' dependent on assistance with care. This was evident for 2 (#907, #912) of 33 residents reviewed for complaints during a recertification/complaint 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. 1) On 12/11/24 at 1:22 PM a review of complaint MD00187130 revealed an allegation that Resident #907 complained that he/she had not received regular bathing. Resident #907's medical record was reviewed and revealed the resident was admitted to the facility in April 2021 and had diagnoses which included Cerebral…

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 complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health (Resident #904, #914, #918). This was evident for 3 of 33 complaint residents reviewed during a recertification/complaint survey. The findings include: A neuro check after a fall refers to a neurological assessment performed by a healthcare professional to evaluate potential brain injuries by checking a person's level of consciousness, orientation, pupil response, muscle strength, sensation, and coordination. 1. The facility staff failed to properly perform neuro checks after a fall for Resident #914. Review of Resident #914's medical record on 12/9/24 revealed a nurse's note on 3/22/24 at 5:34 PM that stated: the writer saw resident get out of bed and sit on the floor. He/she did not hit his/her head on the floor. Head to toe assessment showed no signs of injury, resident was assisted back in bed with help of two people. Nurse practitioner and Resident representative was informed…

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 keep a resident's drug regimen free from unnecessary drugs by failing to monitor the blood pressure and heart rate prior to administering a blood pressure medication per physician's orders. This was evident for 1 (#901) of 33 residents reviewed for complaints during the recertification/complaint survey. The findings include: On 12/11/24 at 9:46 AM a review of Resident #901's medical record was conducted and revealed a physician's order for Lisinopril 20 mg (milligrams) to be given every day for hypertension. The order stated to hold the medication for a SBP (systolic blood pressure) less than 110 or HR (heart rate) below 60. The top number of the blood pressure refers to the amount of pressure in the arteries during the contraction of the heart muscle. This is called systolic pressure. Review of Resident #901's March 2022 Medication Administration Record (MAR) failed to document that the blood pressure and the heart rate were being monitored when the 8:00 AM dose of Lisinopril 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 staff interview and medical record review it was determined the facility failed to ensure that a resident's laboratory tests were completed in a timely manner (Resident #40). This was evident for 1 of 33 complaint residents reviewed during a recertification/complaint survey. The findings include: Review of Resident #40's medical record on 12/12/24 revealed on 2/24/24 at 10:49 AM STAT labs were ordered for the Resident that included a CBC (complete blood count) and a BMP (basic metabolic panel). A nurse's note on 2/24/24 at 10:13 PM stated, STAT labs ordered today, currently awaiting lab draw due to decreased blood pressure and elevated pulse. Further review of Resident #40's medical record revealed the Resident was seen by a telehealth physician on 2/25/24 at 8:25 AM and the physician documented, Patient has been having shortness of breath since yesterday. Patient is not doing well. Stat labs ordered however have not been done since yesterday. Transfer to Emergency Department. During an interview with the Assistant Director of Nursing on 12/12/24 at 12:35 PM, the ADON…

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 failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (#51, #901) of 33 residents reviewed for complaints during a recertification/complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 12/9/24 at 12:03 PM a review of Resident #51's medical record was conducted and revealed a nursing note written on 5/3/23 at 18:41 (6:41 PM) that documented Resident #51 complained of lower back pain and Tylenol was given. Review of Resident #51's May 2023 Medication Administration Record (MAR) was blank for the administration of Tylenol on 5/3/23. On 12/12/24 at 1:40 PM an interview was conducted with the Director Of Nursing (DON) and Assistant Director Of Nursing.…

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

Based on record review and staff interview it was determined the facility failed to have a process in place to ensure nursing staff were receiving competency evaluations. This was evident for 8 of 10 employee records reviewed during the survey. The findings include: On 7/2/19 at about 10:30 AM, the education records and competency evaluations were requested for Geriatric Nurse Aides (GNAs) #7, #8 and #9, #13, # 6, # 3; Licensed Practical Nurse (LPN) #15 and Registered Nurse (RN) #14. These records were randomly selected by a surveyor from a list of all nursing staff who had worked at the facility for more than a year. The term, nursing competencies, refers to routine evaluations of nursing staff capabilities and skills. At about 10:30 AM when the employee records were reviewed, documentation did not support that they received comprehensive competency evaluations over the past year as required per regulation. At 11:57 AM during an interview with the Administrator, she stated there was a plan going forward.

Based on record review and staff interview it was determined the facility failed to ensure nurses' aides received education that corresponded with annual performance evaluations. This was evident for 3 of 3 employee records reviewed. The findings include On 7/2/19 at about 10:30 AM, the education records and competency evaluations were requested for Geriatric Nurse Aides (GNAs) #7, #8 and #9. These records were randomly selected by a surveyor from a list of all nursing assistants who had worked at the facility for more than a year. At 11:57 AM, the Administrator was asked if annual performance evaluations for GNAs included regular in-service education based on the outcome of these performance reviews. She stated this had not been done but will be done going forward.

Based on observation it is determined the facility staff failed to provide Resident # 115 with the means to communicate to nursing when the Resident is in the room. This was evident for 1 out of 43 Resident investigated during the survey process. The Finding Include: The Resident is a quadriplegic due to multiple sclerosis. On 6/27/19 around 10:00 AM, while interviewing the resident during the first part of the survey, it was noted that the Resident uses a touch pad call bell in the room that enables clients with limited movement to summon help easily. Due to Resident #115's lack of mobility, the Resident uses the chin to touch the pad and summon nursing when needed. The call bell must be placed under the Resident's chin in order for the Resident to use it. The call bell was observed with the cord of the pad clipped to the Resident's left sleeve. The pad itself was lying on the sternum part of the Resident's body. When the surveyor asked the Resident how to summon the nursing staff, the Resident stated I use my chin, but I can't use it now because the pad is too far down to use it.…

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 staff interview it was determined the facility failed to ensure the medication error rate was less than 5%. Two administration errors were noted for Resident #102. This was evident for 1 of 4 residents observed while receiving medications. The findings include: On 7/2/19 beginning at 9:26 AM, staff nurse #1 was observed administering 8:00 AM and/or 9:00 AM medications to Resident # 102. She was observed applying a Lidocream Aspercream 4% patch on the resident's sternum (breastbone) and 1 on each knee. Lidocream Aspercream is used for pain and adheres to the skin when the backing is removed. Prior to placing the new patches on the resident, staff nurse #1 was observed removing patches dated 7/1 from the sternum and each knee. At about 10:30 AM, the medical record for Resident #102 was reviewed. It was noted there was the order was for Lidocream Aspercream patches 5%, not 4%. The order also stated to apply the patches in the AM and remove at bedtime. The resident received the wrong dose of medication (4% instead of 5%) and received the…

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

Based on Resident complaint and observation it was determined that the facility staff failed to maintain adequate lighting for Resident #33. This is evident during the interview/observation part of the survey. The Findings Include: On 07/01/19 around 01:35 PM while interviewing Resident #33, the Resident complained that the cord to the over bed light fixture was too short, therefore the light could not be used. Further review of the Resident's room revealed the Resident's bed to be in its highest position (resident's preference) and the pull to the fixture still could not be accessed. The maintenance manager was notified It is the facility's responsibility to ensure that Residents have access to lighting and provides Resident control.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to develop comprehensive pain care plans that included non-pharmacologic interventions for residents. This was evident for 1 (Resident #76) of 2 residents reviewed for pain. The findings include: Resident #76's medical record was reviewed on 7/1/19 at 10:42 AM. During the review, it was found that the resident had the diagnosis of a chronic pain condition and was receiving scheduled and as-needed pain mediation for the condition. The resident's medication administration (MAR) was reviewed for the months of April and May, 2019, and it was found that the resident had high utilization of the as-needed pain medication. The resident received 93 doses of the as-needed pain medication in those two months. Concurrent review of the resident's pain management consultation notes revealed that the resident had received 9 pain management consultations in 2019 at that point. Each of the consultations stated, continue supportive modalities, referring to non-pharmacologic…

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 staff interview it was determined the facility failed to ensure dependent Resident #96 received personal care in a timely manner. This was evident for 1 of 43 residents investigated during the survey. The findings include: Beginning on 6/27/19 at 10:32 AM, the medical record for Resident #96 was reviewed. According to a Minimum Data Set (MDS) assessment dated [DATE], the resident is totally dependent on staff for transfers, dressing, eating, toileting and bathing and requires extensive assistance to move about in bed. The MDS report is a comprehensive assessment of a resident's functional capabilities and helps the long-term care facility identify health problems. On 6/28/19 at 9:34 AM, Resident #96 was observed lying in bed in a sitting position with the head of the bed up. He/she did not respond when spoken to and was not observed repositioning him/herself. His/her head was turned slightly to the right and saliva was dripping out of the right side of 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.

Based on medical records and staff interview, it was determined that the facility staff failed to respond to a consultant's response from a medical appointment for Resident #115. This was evident for 1 out of 2 residents investigated for a catheter during the survey process. The Findings Include: Resident #115 is a quadriplegic from multiple sclerosis and has a supra public catheter (tube that drains urine from your bladder), because of a neurogenic bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem). The Resident has been hospitalized multiple times from urinary tract infections and sepsis (a potentially life-threatening condition caused by the body's response to an infection). The Resident saw a urologist on 5/14/19 who recommended the catheter be changed every 2-3 weeks in an attempt to cut down on the number of infections. Review of the medical records on 07/01/19 around 12:44 PM revealed that the Resident has a standing order to change the catheter once a month on the 27th of each month, along with an order to change…

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 resident medical records and interview with residents and facility staff, it was determined that the facility failed to ensure that residents with as-needed pain medication regimens received pain medication according to physician prescribed parameters. This was evident for 1 (Resident #76) of 2 residents reviewed for Pain Management. The findings include: A numeric pain scale is a common tool to evaluate a resident's perception of his or her own pain. The resident is asked to rate pain from 0 (no pain) to 10 (worst pain of your life). The American Nurse's Association defines severe pain as number 7-10 on that scale. Other references include the numbers 6-10 as severe pain. Resident #76's medical record was reviewed on 7/1/2019 at 10:42 AM. During the review, it was noted that the resident was prescribed as-needed narcotic pain medication for severe pain. Resident #76's medication administration record (MAR) was reviewed for the months of May and June, 2019. The review revealed that the resident was administered the above as-needed narcotic pain medication 36 times…

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

Based on observation, medical record review and staff interview it was determined the facility failed to ensure the medication error rate was less than 5%. Two administration errors were noted for Resident #102. This was evident for 1 of 4 residents observed while receiving medications. The findings include: On 7/2/19 beginning at 9:26 AM, staff nurse #1 was observed administering 8:00 AM and/or 9:00 AM medications to Resident # 102. She was observed applying a Lidocream Aspercream 4% patch on the resident's sternum (breastbone) and 1 on each knee. Lidocream Aspercream is used for pain and adheres to the skin when the backing is removed. Prior to placing the new patches on the resident, staff nurse #1 was observed removing patches dated 7/1 from the sternum and each knee. At about 10:30 AM, the medical record for Resident #102 was reviewed. It was noted there was the order was for Lidocream Aspercream patches 5%, not 4%. The order also stated to apply the patches in the AM and remove at bedtime. The resident received the wrong dose of medication (4% instead of 5%) and received 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.