Carriage Hill Bethesda

Based on resident medical record review and interview, it was determined that the facility failed to ensure that medications were administered as ordered. This was evident for 1 (#50) of 1 resident reviewed for significant medication errors during the annual survey. The findings include:1.During review of Resident #50's medical record on 03/23/2026 at 9:10 AM revealed that on 10/06/2025 the physician ordered Acetaminophen Oral Tablet 500 MG (Acetaminophen) give 2 tablet by mouth every 8 hours as needed for moderate pain do not give more than 3g within 24 hours. On 02/19/2026 the physician ordered Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) give 2 tablet by mouth three times a day for pain. Review of March 2026 Medication Administration Record revealed Resident #50 received the 3 times a day Acetaminophen and received as needed Acetaminophen totaling 4000 mg which exceeds 3g (3000 mg) on 03/05 and 03/17. During an interview on 03/23/2026 at 10:00 AM with staff #2, Resident #50's March 2026 Medication Administration Records were reviewed with surveyor. Staff #2 agreed…

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

Based on observation and staff interview, it was determined the facility failed to procure, store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food safety, thereby placing residents at risk for foodborne illness and contamination. This deficient practice was identified during the annual survey and had the potential to affect all residents receiving meals prepared by the dietary department.Findings include:On 3/18/26 at 9:00 AM, an initial tour of the facility kitchen was conducted in the presence of the Certified Dietary Manager. Observation of the dietary department revealed multiple breaches in sanitary food handling, storage, and environmental cleanliness, including:-Seven pre-poured syrup containers were observed stored on a visibly soiled utility table and were not labeled or dated, preventing identification and safe use.-A large plastic container of salad dressing was observed open and unlabeled in the walk-in refrigerator, failing to ensure proper food identification and protection from contamination.-Opened…

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

Based on observation and staff interview, the facility failed to: 1. Maintain proper infection control practices to prevent the potential for cross-contamination by storing soiled linen in the same room as clean linen. This was evident in 1 (first floor) of 1 linen storage areas observed during environmental rounds and has the potential to affect all residents who rely on clean linen for care and services on the first floor.2. Maintain an infection prevention and control practice to provide a safe and sanitary environment in laundry service area. This was evident by 2 of 4 laundry service areas observed during the annual survey. Findings include:1. During observation rounds conducted on 3/18/26 at approximately 9:00 AM, a room labeled bath was observed to contain three large trash cans filled with soiled linen. In the same room, two carts containing clean linen were also stored. The co-mingling of soiled and clean linen in the same area has the potential to result in cross-contamination and does not align with accepted infection prevention and control practices. During an interview…

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

Based on observations and interviews with facility staff it was determined the facility failed to ensure that a resident has access to a phone and a working television (TV) remote control in their room. This was found to be evident for 1 (#109) of 62 residents reviewed during the facility's annual Medicare/Medicaid survey.Findings include:Intake # 2959654 was reviewed on 3/20/26 for multiple concerns. One of the concerns was that resident # 109 did not have a phone in the room and that the television remote control was not working.An observation was made on 3/26/26 at 10:45 AM; there was one phone jack observed on the wall between Resident #109's bed and the roommate. There were two staff that came into the room upon surveyor request for dual observation. Staff #34, a Geriatric Nurse Assistant (GNA) and staff #35 a Registered Nurse (RN). Staff #35 confirmed that there was only one phone jack in the room and the only phone line is connected to Resident #109's roommate. The nurse (#35) confirmed that Resident #109 does not have a personal phone or a facility provided phone in 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 observation, resident interviews, and staff interviews, it was determined that the facility failed to maintain a sanitary, pest-free environment to ensure residents reside in a safe and comfortable setting. This deficient practice affected 1 out 2 floors reviewed during the annual survey. Findings include: 1. During observation rounds conducted on 3/18/26 at approximately 8:00 AM, several residents reported the presence of ants in their rooms. Residents stated that the issue had previously been reported to maintenance; however, the concern remained unresolved at the time of observation. During an interview with nursing staff, it was revealed that the facility utilizes a TELS (electronic maintenance request) system in which staff input maintenance concerns, generating a work order slip for the maintenance department. There was no evidence provided that the reported pest concerns had been addressed in a timely manner. During follow-up observation rounds on 3/19/26 at approximately 11:00 AM, this surveyor observed ants present in multiple resident rooms on the 1st 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 administrative record reviews and staff interviews it was determined that the facility failed to provide evidence that part-time and PRN geriatric nursing assistants (GNA) received education on abuse prevention, neglect, and exploitation training annually. This was evident for 7 (#17, # 21, #22, #24, #30, #39, #40) of 8 GNA employee and education files reviewed during the annual survey. The findings included:On 03/25/2026 at 02:09 PM the surveyor interviewed the assistant director of nursing (ADON) and staff educator, staff #8 regarding the annual clinical training requirements of the geriatric nursing assistants (GNAs). The ADON stated that she works closely with the HR director regarding ensuring that employees are up to date with their competency training annually. The surveyor inquired whether the annual training provided was different for PRN, agency, and Full time GNA staff. The ADON responded yes. The human resources director, staff #9 also stated that part-time and PRN GNAs are not required to demonstrate compliance with annual clinical training by facility.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 employee human resource records, education training records, spreadsheets, and interviews it was determined that the facility failed to have a system in place to ensure that PRN and part-time geriatric nursing assistants (GNAs) received at least 12 hours of clinical in-service training annually. This was found to be evident for 7 (#17, # 21, #22, #24, #30, #39, #40) of 8 part time or PRN GNAs employee files and educational files reviewed during the annual survey.Findings include:On 03/25/2026 at 02:09 PM the surveyor interviewed the assistant director of nursing ADON and staff educator, staff #8 regarding the annual clinical training requirements of the geriatric nursing assistants (GNAs). The ADON stated that she works closely with the HR director, staff #9 in regard to ensuring that GNA employees are up to date with their annual clinical competency training. The surveyor asked the ADON whether the annual training provided was different for PRN, agency, and Full time GNA staff. The ADON responded no.The surveyor asked whether the requirements for compliance with…

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 complete and transmit the Minimum Data Set (MDS) assessments. This was evident for 27 (Residents #4, #6, #9, #11, #22, #23, #30, #32 #46, #62, #64, #65, #71, #72, #76, #78, #81, #87, #91, #93, #94, #95, #96, #99, #101, #102 and #109) of 33 residents reviewed for resident assessments during the annual survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. Nursing homes are required to submit the Omnibus Budget Reconciliation Act (OBRA)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility failed to ensure a safe environment. This was found to be evident during random observations conducted of the facility's environment during the recertification survey. This deficient practice has the potential to affect all Residents. The findings include: According to the Centers of Medicare and Medicaid Services the acceptable water temperature for nursing homes and facilities serving residents should be thermostatically controlled to a maximum of 120 degrees Fahrenheit at the fixture, ensuring hot water is at least 100 degrees Fahrenheit. During random observations conducted on 1/10/15 at 7:15 AM the surveyors obtained hot water temperatures with a calibrated handheld thermometer for the following Resident bathroom sinks: room [ROOM NUMBER] temperature was 125 degrees Fahrenheit , room [ROOM NUMBER] temperature was 123 degrees Fahrenheit, room [ROOM NUMBER] temperature was 121 degrees Fahrenheit, room [ROOM NUMBER] temperature was 123…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview and record review, it was determined that the facility failed to ensure a homelike environment for residents and accommodate the needs of residents. This was found to be evident for 8 (Resident #209, #210, #212, #213, #215, #216, #217, and #357) out of 15 Residents reviewed for homelike environment and accommodation of needs. The findings include: 1) During random observations conducted on 01/15/25 at 11:29 AM, the Surveyors observed multiple environmental concerns in resident rooms. The following were observed: a. room [ROOM NUMBER] stained ceiling tiles in the bathroom and by the window, b. room [ROOM NUMBER] no bathroom call bell pull cord and a hole in the wall behind bed A, c. room [ROOM NUMBER] wall paper had peeled from the bathroom wall, d. room [ROOM NUMBER] no bathroom call bell pull cord and a plastic bag that covered the smoke detector, e. room [ROOM NUMBER] no bathroom call bell pull cord, f. room [ROOM NUMBER] ceiling tile stained in resident room above…

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 complete comprehensive MDS (Minimum Data Set) assessments within the required timeframe. This was evident for 6 (Resident #4, #6, #11, #71, #94, and #405) out of 34 Residents reviewed for resident assessments during the annual survey. The findings include: 1) Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. According to CMS guidelines, an MDS annual assessment must be completed…

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 complete the Quarterly MDS (Minimum Data Set) assessments within the required timeframe. This was evident for 18 (Residents #9, #11, #22, #30, #32, #46, #62, #64, #65, #76, #78, #81, #87, #96, #99, #101, #102 and #109) of 33 residents reviewed for resident assessments during the annual survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. According to CMS guidelines, an MDS Quarterly assessment must be completed within 14 days of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review it was determined that the facility failed to provide an invitation to residents for care plan meetings, failed to provide residents with care plan meetings and failed to revise resident care plans. This was found to be evident in 5 (Resident #1, #58, #62, #158 and #164) out of 10 Residents reviewed for care plan timing and revision. The findings include: Care Plan meetings are meetings with a team of care providers (attending physician, a registered nurse, nursing assistant dietary services, resident, and the resident ' s representative if applicable) to ensure the plan is continually adjusted to meet the changing needs or concerns of residents. Care Plan meetings are to be held quarterly. BIMS uses a scoring system that is a number between 0 and 15 that indicates a resident's cognitive health in a long-term care facility. The BIMS score is used to help identify early signs of cognitive decline and the need for further evaluation. Scores: 13-15: Intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews and interviews, it was determined that the facility failed to ensure that medical records maintained for residents reflect an accurate representation of the care and services provided across all disciplines and failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) order form. This was evident for 8 (Resident #94, #158, #166, #255, #256, #455, #1 and #10) out of 74 residents sampled during the annual survey. The findings include: 1) On 01/14/2025 at 12:38 PM, the Director of Nursing (DON) stated that the activities staff keeps activity logs for residents under the plan of care (POC) Task section in Point Click Care (PCC), the electronic health record. On 01/14/25 at 1:19 PM, a review of the POC Task documentation provided by the facility administrator showed that Resident #94 participated in activities for two days, 11/18 and 11/19, in November 2024. December 2024 and January 2025 activity documentation was requested, however no…

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

Based on observations and interviews it was determined that the facility failed to ensure the dignity of the residents as evidenced by the nursing staff not knocking on resident room door before entering resident room, and nursing staff not wearing a name tag. This was found to be evident for 2 (Resident #35 and #58) out of 3 residents reviewed for dignity and resident rights. The findings include: During an interview with Resident #35 on 1/8/2025 at 10:05 AM the surveyor observed the Geriatric Nursing Assistant (GNA) #15 enter Resident #35's room without knocking on the resident room door. The surveyor interviewed GNA #15 and asked what the expectation was when entering a resident room. GNA #15 stated that staff were to knock on the resident room door prior to entering the resident room. GNA #15 acknowledged that she did not knock on Resident #35's door before entering the room and that she was sorry that she did not knock on the resident door. During the tour of Nursing Unit 2 at 12:55 PM am on 1/13/2025, the surveyor observed Geriatric Nursing Assistant (GNA) #17 in the hall at…

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

Based on record review and interview, it was determined the facility failed to ensure a resident was free of neglect. This was found to be evident for 1 (Resident #165) out of 1 Resident reviewed for neglect during the recertification survey. The findings include: According to the Centers for Medicare and Medicaid Services Activities of Daily Living (ADLs) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. A review of complaint MD00191143 submitted to the Office of Health Care Quality was conducted on 01/14/25 at 7:22 AM. The complaint reported a concern that the facility did not provide Resident #165 ADL care during an entire shift, as a result the resident's was extremely upset because his/her gown and bed linen were soaked in urine. During a record review conducted on 01/14/25 at 8:13 AM revealed a health status note from Licensed Practical Nurse (LPN) # 27 dated 4/15/2023 03:27. The note stated Resident has [Resident gender pronoun] call light on upon arrival. 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 a review of facility-reported incident investigation, record review and interview, it was determined that the facility failed to thoroughly investigate an allegation of abuse. This was evident for 1 (Resident #358) of 11 residents reviewed for abuse during the recertification survey. The findings include: On 1/15/2025 at 3:40 PM, a review of facility-reported incident MD00189545 revealed that on 3/1/2023, Resident #358's family member reported that about 2 weeks prior, Resident #358's Geriatric Nurse Assistant (GNA) hit him/her in the back of the head 5 times. He/she stated that he/she did not report the incident at the time because he/she did not want to get anyone in trouble. On 1/15/2025 at 4:03 PM, a review of Resident #358's medical record indicated a BIMS score of 10 of 15, moderate impairment (Brief Interview for Mental Status, BIMS, is a screening tool used to assess basic cognitive function in patients in long-term care facilities.) Further review of the facility's investigation revealed that Resident #358 was interviewed, and he/she denied being hit by the GNA 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 record review and interview, it was determined that the facility failed to accurately code the resident's discharge status on the Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #152) of 4 residents reviewed for hospitalizations during the survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. On 1/10/25 at 12:18 PM, a record review of Resident #152 revealed a discharge date of 10/08/2024. The Discharge summary dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to develop and implement a comprehensive care plan for constipation, the use of intravenous (IV) fluids for hydration and Activities of Daily Living (ADLs) for dependent resident. This was evident for 3 (Resident #12, #355 and #356) out of 13 residents reviewed for care planning during the recertification survey. The findings include: 1) A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 1/08/25 at 8:19 AM, Resident #355 stated that he/she was constipated from 12/29/2024 and nothing had been done until 1/2/2025. He/she added that the facility staff gave him/her a medication that resulted in diarrhea and vomiting. On 1/14/25 at 3:08 PM, a review of Resident #355's medical record revealed the following medications for bowel regimen: - Colace Oral Capsule 100 MG (Docusate Sodium) Give 2 capsules by mouth at bedtime 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, clinical record review and staff interviews, it was determined that the facility staff failed to provide an ongoing activities program to meet the needs and preferences of residents. This was evident for 1 (#94) of 4 residents reviewed for activities during the survey. The findings include: Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities. On 01/09/2025 at 09:41 AM, an observation was made of Resident #94 sitting in a wheelchair in the hallway across from the nurses' station. On 01/10/2025 at 11:14 AM Resident #94 was observed again sitting in a wheelchair in the hallway across from the nurses' station. The resident was not observed participating in any activities. On 01/10/2025 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 record reviews and interviews, it was determined that the facility failed to follow up on recommendations for specialty consultations for residents. This was evident for 1 (Resident #12) of 1 resident reviewed for consultations. The findings include: On 01/10/25 at 7:10 PM a review of Resident #12's clinical record revealed that the resident was admitted to the facility on [DATE]. On 10/12/24 the resident was transferred to the hospital for unresponsiveness. On 10/16/24 Resident#12 was readmitted to facility with a primary diagnoses of New Onset Seizure. The resident's Discharge summary dated [DATE] requested an appointment be made with a Neurologist within 4 weeks of discharge. Further review of the resident's clinical record revealed the Physicians and Nurse Practitioners progress notes stated as follows: - 10/16/24 at 17:04 Physician (Re-admission): Per discussion with neurology, the patient will need to be seen in the near future for follow-up (appointment has to be made by family/staff) - 10/25/24…

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 interviews it was determined that the facility failed to follow appropriate respiratory care and services. This was found to be evident in 1 (Resident #145) out of 1 Resident reviewed for respiratory care and services. The findings include: On tour of the Nursing Unit 1 on 1/8/2025 at 10:39 AM the surveyor observed an oxygen humidifier bottle and oxygen tubing attached to the oxygen concentrator in Resident #145's room without a date on the humidifier bottle and the tubing. In addition, the surveyor did not observe an oxygen usage sign on the Resident room door or on the doorframe of the Resident #145's room. The surveyor conducted a record review of Resident #145's medical record on 1/10/2025 at 8:15 AM. The medical record review revealed that Resident #145 had current physician orders for oxygen and an order to change the oxygen tubing and humidifier bottle every Monday on the night shift. Further review of the medical record revealed that Resident #145 had a care plan for oxygen therapy related to respiratory illness. In addition,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to discontinue a medication in a timely manner as ordered by the attending physician. This was evident for 1 (Resident #73) of 2 residents reviewed for unnecessary medications. The findings include: Resident #73 was admitted to the facility on [DATE] with diagnoses including Cognitive Communication Deficit, Major Depressive Disorder and Psychosis. On 01/13/25 at 07:40 AM a review of Resident #73's clinical record revealed that the Licensed Pharmacist on 09/11/2024 made a recommendation to the physician to discontinue the medication, Oxycodone PRN (as needed) because it was not utilized by the resident. On 09/17/2024 the physician reviewed the recommendation and ordered Oxycodone PRN be discontinued. Further review of the clinical documentation revealed that the facility failed to follow up on the physician's order to discontinue the medication on 09/17/2024. On 11/12/2024 the Licensed Pharmacist again issued a recommendation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review it, was determined that the facility staff failed to promptly provide or obtain/schedule for dental services. This was found to be evident for 1 (Resident #1) out of 3 residents reviewed for dental services during an annual survey. The findings include: During a floor rounding, on 01/07/25 at 01:09 PM, Resident #1 stated I had my teeth problem and a cap fell out and it hurts, I told the staff first when I was admitted . Record review, on 01/13/25 at 02:48 PM, revealed that Resident #1 was admitted on [DATE] to this facility with the diagnoses of severe protein-calorie malnutrition and encephalopathy. On 10/20/24 an initial dental assessment was done by the Social Worker Staff #2. Under The Minimum Data Set (MDS) section L0200, the assessment code was Yes to a broken or loose-fitting tooth (chipped, cracked, uncleanable or loose). The Minimum Data Set (MDS) is a standardized assessment tool that measures health status in nursing home residents. MDS assessments are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to 1) ensure a diet met the need of the resident and 2) provide a resident with a lunch meal to accompany resident on scheduled days of dialysis to an outpatient dialysis center. This was found to be evident in 2 (Resident #58 and #169) out of 5 residents reviewed for food and nutrition services. The findings include: 1) A review of complaint MD00205719 submitted to the Office of Health Care Quality was conducted on 01/16/25 at 7:00 PM. The complaint reported a concern that the facility did not provide Resident #169 the low-fat low residue diet that the Resident's medical condition required. On 01/16/25 at 7:10 PM a review of Resident #169's hospital Discharge summary dated [DATE] stated a low fiber low insoluble residue diet, avoid all coffee, and dairy. On 01/16/2025 at 7:46 PM review of Resident #169's Physician order showed the following diet orders: order dated 05/02/24 Regular diet Mechanical Soft texture, Regular/Thin consistency; order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review it was determined that the facility failed to adhere to menus and food provided to residents in accordance with resident preferences. This was found to be evident for 3 (Resident #255, #357, and #455) out 21 Resident's reviewed for food and dining during the survey. The findings include: 1) During an observation conducted on 01/13/25 at 9:33 AM the Surveyors observed Resident #455's breakfast tray and meal ticket. The breakfast meal ticket stated juice, hot or cold cereal, scrambled egg, biscuit gravy, biscuit, coffee and milk 2%. The Resident's breakfast tray had scrambled egg, 1 piece of toasted bread cut diagonally into 2 pieces, one 4 oz orange juice and 1 bowl of hot cereal. The breakfast tray did not have a biscuit, biscuit gravy, coffee, or milk. During an interview conducted on 01/13/25 at 9:34 AM, Resident #455 stated that since admission the meal trays had not matched the meal tickets. The Resident stated that he/she was concerned that the facility…

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

Based on surveyor observation during the initial kitchen tour it was determined that the facility staff failed to properly store items in a manner consistent with regulatory requirements. The facility prepares all meals in one centralized kitchen. The findings include: On 02-11-2020 at 9:13 AM, an initial tour conducted with the certified dietary manager (CDM) revealed a large container of mayonaisse which was over 3/4 utilized in the walk in refrigerator with no date as to when it had been opened. In addition there were several bags of vegetables in the walk in freezer which also were not labeled and dated. A dry food storage container of flour was observed with the hand scoop handle touching the flour inside the container. On 02-11-2020 at 11:55 AM surveyor observation of tray line a check of the temperature of the milks stored in the refregerated cooler at the end of the tray line revealed a temperature of 47.8 degrees Farenheit instead of the required 40 degrees Farenheit.

Based on surveyor review of the clinical record and staff interview, it was determined that the facility staff failed to develop a baseline care plan pertinent to the needs of the resident within 48 hours of admission. This finding was evident for 1 of 3 residents reviewed for the pain management care area (Resident #08). The findings include: On 02-11-2020, review of the clinical record revealed Resident #08 was admitted to the facility after surgical repair of a fractured right hip. The resident has a history of osteoporosis and pathological fractures of the hip (fractures caused by disease, not injury). Further review of the clinical record revealed a baseline care plan initiated for Resident #08 which identified a skin concern related to surgical repair of the right hip (incision). The baseline plan of care failed to address the pharmacological pain regimen, presence of pain, location of pain or characteristics of pain. Non-pharmacological pain management interventions were also absent from the baseline plan of care. On 02-12-2020 at 2:15 PM, 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.

Based on surveyor review of the clinical records and facility staff interviews it was determined that the facility staff failed to develop a comprehensive resident centered care plan. This finding was evident for 1 of 22 residents (#26) selected for review during the survey. The findings include: 1. On 02-14-2020, surveyor review of the clinical records for Resident #26 revealed the resident was receiving a psychotropic medication (any medication capable of affecting the mind, emotions or behavior) to treat anxiety. Further review of the clinical records for Resident #26 revealed there was no care plan to address the use of the psychotropic medication to treat anxiety. On 02-14-2020 at 11:40 AM, surveyor interview with the director of nursing (DON) and the unit manager for the second floor revealed no additional information.

Based on surveyor observation, the review of the clinical record and staff interviews, it was determined that the facility staff failed to provide appropriate equipment or services to prevent further decrease in range of motion. This finding was evident in 1 of 3 residents selected for review for the limited range of motion care area (Resident #14). The findings include: On 02-11-2020 at 8:50 AM during initial screening rounds, Resident #14 was noted with significant contractures of the bilateral upper extremities. Contractures are shortening and hardening of muscles, tendons or other tissue often leading to deformity and rigidity (stiffness) of joints. On 02-12-2020 at 11:20 AM a second observation revealed Resident #14 with bilateral arms tightly contracted against the body. Review of the clinical record revealed Resident #14 was referred to occupational therapy (OT) for evaluation of bilateral hand and elbow contractures. The OT evaluation skilled treatment details, dated 08-28-19, assessed Resident #14 with severe contracture of left elbow and hand, moderate to sever contracture…

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

Based on surveyor observation and review of the clinical record, it was determined that the facility staff failed to properly secure an indwelling catheter to prevent urinary catheter associated complications. This finding was evident in 1 of 3 residents reviewed for the indwelling catheter care area (Resident #157). The findings include: On 02-11-2020 at 8:23 AM, Resident #157 was observed lying supine (face upwords) in bed with a foley catheter drainage bag observed at the bedside. Further observation revealed the catheter tubing was not secured in a manner to prevent accidental removal, and/or reduce trauma to the urethra and bladder by preventing excessive pull or traction. On 02-11-2020 at 4:10 PM Resident #157 was again observed with the catheter tubing unsecured. On 02-12-2020 at 10:24 AM the Unit Manager accompanied surveyor to observe catheter tubing of Resident #157. The observation revealed a catheter drainage bag containing urine lying on the floor, and the catheter tubing was not secured. On 02-12-2020 at 2:30 PM surveyor observation of Resident #157 revealed 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 surveyor observation, review of the clinical records, staff interview, it was determined that the facility staff failed to administer drugs that are labeled in accordance with acceptable standards of practice, and with Federal laws. This finding was evident for 1 of 22 residents selected for investigation during the survey (Resident #08). The findings include: On 02-11-2020 at 10:00 AM, surveyor observed Resident #08 with two bottles of pills and one unlabeled box of medication on the bedside table in the resident's room. At 10:10 AM, CMA Staff #06 entered the room and informed Resident #08 it was time to take his/her medication. CMA Staff #06 exited the room to retrieve a medication cup, then picked up the unlabeled box of Rytary (a medication for the treatment of Parkinson's Disease) and assisted Resident #08 in putting the capsules into the medication cup. Resident #08 then swallowed the administered capsules given by CMA Staff #06. On 02-11-2020 at 10:30 AM, review of the clinical record for Resident #08 revealed instructions to the pharmacy DO NOT SEND PROFILE ONLY,…

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.