Sterling Care Bethesda

Based on observation, medical record review, and interviews, it was determined that the facility staff failed to provide appropriate care measures to prevent complications from a hand contracture. This was evident for 1 (Resident #7) of 2 residents reviewed for mobility. The findings include:A contracture is an abnormal shortening of muscle, tendons, skin, or tissues, causing resistance to stretching. Failure to protect the palm of the hand when the hand is contracted can result in injury to the palm of the hand caused by the pressure of fingers/fingernails pressing into the palm of the hand.On 4/20/26 at 10:07 AM, the surveyor conducted an interview with Resident #7. During the interview, Resident #7 stated that he/she had a splint for his/her left hand but only used it occasionally. Resident #7 further stated that he/she sometimes needed help putting the split on. The surveyor noted that the splint was not on the Resident.On 4/22/26 at 8:16 AM, the surveyor observed that the splint was not on Resident #7 and asked if anyone had offered to put the splint on. Resident #7 answered…

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

Based on observation, interview, and record review, it was determined the facility failed to follow professional standards of practice when administering intermittent intravenous (IV) antibiotic infusions. This was found to be evident in 1 (#200) out of 1 resident observed for intravenous access care. The findings include:On 4/20/2026 at 9:15 AM, Resident #200 told the surveyor that his IV antibiotics were discontinued on Friday but his IV line was still in his left upper arm. Resident #200 showed the surveyor the IV line. The surveyor observed bloody fluid in the IV tube and on the bandage that was dated 4/10/2026.On 04/20/2026 at 9:22 AM, Registered Nurse #3 told the surveyor the IV should have been removed when the antibiotics were finished. When asked how often the dressing should be changed, she responded it should be changed every 7 days, verified that the current dressing had been on for 10 days, and stated she would remove the IV now.The Director of Nursing acknowledged the concern on 04/21/2026 at 11:58 AM.

Based on record review and interviews, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards for accuracy. This was found evident in 4 (Resident #138, #6, #4, & #8) of 51 residents reviewed during the survey. The findings include:1) On 4/20/26 at 9:41 AM, the surveyor conducted an interview with Resident #138. During the interview Resident #138 stated that he/she was admitted to the hospital due to a Urinary Tract Infection (UTI). On 4/22/26 at 9:43 AM, the surveyor reviewed Resident #138's medical record. The review revealed that Resident #138 was hospitalized in August of 2025. The discharge summary from that hospital stay recommended that Resident #138 be followed up by Urology. On further review of the medical record, it was noted that there was no urology consultation notes present. On 4/22/26 at 9:45 AM, the surveyor requested the urology consultation notes for Resident #138. On 4/22/26 at 1:41 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON stated…

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

Based on observation and interview, it was determined that the facility failed to handle soiled linen safely. This was found to be evident in 1 (Rosemary) out of 5 units observed during the annual survey. The findings include:On 04/22/2026 at 7:54 AM, the surveyor observed a linen cart in the soiled utility room with the lid off and unbagged linen overflowed onto the floor. Licensed Practical Nurse #17 stated the clothes should be bagged and thought the linen is supposed to be picked up once a week but would call for a pick up. On 04/27/2026 at 8:04 AM, the Director of Nursing acknowledged the concern regarding unbagged, soiled linen in the soiled utility room.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide 3 (R24, R25, and R26) of the 3 sampled residents' meals at the designated normal mealtimes and in accordance with their needs, preferences, and requests. The facility census was 174.Record review of the facility's dietary policy, last revised 10/2022 and titled Frequency of Meals, documented that at least three daily meals will be provided, at regular times comparable to normal mealtimes in the community. The policy described the procedures as follows:Dietary Procedures:The Dining Service Director coordinates with the residents, Administrator, and/or Director of Nursing Services to establish the meal and snack times that are comparable with normal times in the community. A schedule of meal service times will be provided to the nursing staff and available in resident/patient care areas. The Dining Services Director will ensure that each meal is served within the designated time frame unless there is an emergency or a resident's request.During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviews and staff interviews, the facility failed to provide a functional, sanitary and comfortable environment for 5(R#3, R#20, R#21, R#22 and R#23) of 5 sampled residents when a toilet had rust and black mold around the seal of toilet along with leakage with water. The facility census was 174.Findings include:Record review of facility policy Resident/Patient Room Cleaning dated 2/2025, revealed Healthcare Services Group, Inc (HCSG) is committed to providing a safe, clean, and hygienic environment for residents, staff, and visitors in accordance with regulatory guidance and industry best practices. Restrooms will be regularly cleaned and disinfected with a particular focus on disinfecting high-touch surfaces such as light switches, the wall near the toilet, trash cans, grab bars, the sink, and the toilet (including the seat and handle).Record review of facility policy Safe and Homelike Environment dated 1/2026, revealed in accordance with resident rights, the facility will provide…

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, staff and resident interviews, and record reviews, it was determined that the facility failed to treat a resident with dignity by not: 1) ensuring that Resident #429's foley drainage bag was covered; and 2) promoting an environment that enhances the quality of life. This was evident for 2 (Resident #429 and Resident #97) of 17 residents reviewed during the survey. The findings include: A foley drainage bag, or urinary drainage bag, is a medical device used to collect urine from a catheterized resident. The drainage bag is usually worn on the leg or attached to a bed. 1) During observation rounds on 2/27/25 at 10:12 am, Resident #429 was noted to have a foley catheter bag attached to his/her bed. The foley drainage bag was uncovered and contained yellow liquid. The bag was attached to the side of the bed facing the door. Resident #429's door was open, and the foley drainage bag was visible from the hallway. On 2/27/24 at 1:58 pm, the surveyor interviewed the Nursing Home Administrator (NHA). He stated that the expectation was that all foley catheters have a…

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

Based on resident record reviews and staff interviews, it was determined that the facility failed to provide residents and/or the resident's representative with an opportunity to formulate an advanced directive. This was evident for 3 (Residents #169, #85, and #173) out of 9 residents reviewed during the survey. The findings include: On 02/28/25 at 09:46 AM, Resident #169's medical record was reviewed. The medical record review revealed that Resident #169 did not have an advanced directive in place. On 02/28/25 at 10:18 AM, Resident #85's medical record was reviewed. The medical record review revealed that Resident #85 did not have an advanced directive in place. On 02/28/25 at 10:33 AM, Resident #173's medical record was reviewed. The medical record review revealed that Resident #173 did not have an advanced directive in place. On 02/28/25 at 10:38 AM, the Director of Social Services #3 was interviewed. During the interview, the Director of Social Services #3 stated that Residents #169, #85, and #173 do not have an advanced directive in place. Also, the Director of Social Services…

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

Based on observations and staff interviews, it was determined that the facility failed to provide a clean, safe, homelike environment. This was evident for 8 (Residents #51, #85, #94, #154, #90, #478, #109, and #117) out of 183 residents observed during the survey. The findings include: 1. On 2/27/25 at 8:34 AM, the surveyor observed Resident #90's room. Marring and scraping were noted on the wall behind the resident's bed. There was a large spackled area of approximately 50% of the wall that required painting. 2. On 2/27/25 at 8:37 AM, the surveyor observed Resident #117's room. There was scraping noted on the wall behind the resident's bed. 3. On 2/27/25 at 12:07 PM, the surveyor observed that Resident #478's room was dirty. The floor was dirty with food and trash around the bedside. The resident was unable to reach the trash can because it was too far away. 4. On 2/27/25 at 12:45 PM, during an interview with Resident #109, the resident reported that the faucet in the bathroom was loose and not secure. The resident further stated that the baseboard was separated from the wall. 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 resident family interviews and facility record reviews, it was determined that the facility failed to prevent residents from being physically abused. This was evident for 1 (Residents #85) out of 20 residents reviewed during the survey. The findings include: On 02/27/25 at 08:04 AM, the surveyor attempted to interview Resident #85. During the interview, the resident was non-verbal when asked questions regarding his/her stay at the facility and questions about the Facility Reported Intake MD00208175. On 02/27/25 at 10:27 AM, the resident ' s medical record was reviewed. The resident medical record review revealed that Resident #85 had a medical diagnosis of Alzheimer ' s Disease and schizophrenia. On 02/28/25 at 10:53 AM, Resident #85's daughter was interviewed. During the interview, Resident #85's daughter stated that Resident #85 was physically assaulted by a facility staff member in July 2024. On 03/03/25 at 09:36 AM, the facility's records were reviewed. The facility record review revealed that the facility's initial Facility Reported Incident and the follow-up 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 observation and record review, it was determined that the facility nursing staff failed to follow professional standards of practice when administering medications to (resident #110 and #30). This was evident during observation of medication administration. The findings include: 1) On 3/4/25 at 8:30 AM, the surveyor observed that Resident #110 refused Lidocaine Patch as ordered by the physician during medication administration. Following the medication administration observation, a review of Resident #110's March 2025 medication administration record (MAR) showed that the lidocaine patch for Resident #110 was documented as given and not refused. 2) On 3/4/25 at 8:44 AM, the surveyor observed Nurse #21 preparing 11 tablets in a medicine cup to be administered to Resident #30. Nurse #21 stated that Zinc 220mg was unavailable and could not be given to Resident #30. Following the medication administration observation, a review of Resident #30's March 2025 medication administration record (MAR) showed that Nurse #21 had documented that the resident received the Zinc. The review…

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

Based on resident and staff interviews, medical and administrative record reviews, and observations it was determined that the facility failed to address a resident's request for removal of a feeding tube. This was evident for 1 (#142) out of 4 residents reviewed for nutrition during the survey. The findings include: Tube feeding is a way to provide nutrition when you cannot eat or drink safely by mouth. There are risks associated with residents using feeding tubes for nutrition. These risks include aspiration (accidentally inhaling your stomach contents), accidental dislodgement (tube moving out of place or coming out), bleeding and perforation (hole in the wall of your bowel or intestine), infection near the site, pain, and stomach leakage to name some. Appropriate treatment and services are required to prevent complications of enteral feeding. On 02.27.25 at 09:15 AM while making clinical unit rounds the surveyor observed that Resident #142 had a feeding tube in place. Resident #142 informed the surveyor that the feeding tube was not being used for nutrition currently. 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 observations, medical record review, and interviews, it was determined that the facility staff failed to maintain a medication error rate of less than 5 percent. This was evident for 6 out of 29 opportunities observed for medication errors. The findings Include: 1) During medication observation on 3/4/25 at 8:05 AM for Resident #61, the surveyor observed LPN (Nurse Practical Nurse) Nurse#21 preparing the resident's insulin injection. Nurse #21 filled an empty insulin syringe with 30 units of insulin injection from a prefilled insulin pen. Nurse #21 went into Resident #61's room to give him/her the insulin injection. The surveyor questioned the nurse about how many units of insulin were to be given to the resident per the attending provider's order, and she reported 24 units of insulin. Due to the surveyor's intervention, nurse #21 discarded 6 units of insulin from the syringe and administered 24 units. 2) Continued observation for Nurse #21 on 3/4/25 at 8:30 AM, the surveyor observed that Resident #110 refused Lidocaine Patch as ordered by the physician during medication…

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 with facility staff and medical record review, it was determined that the facility staff failed for a significant medication error for an Insulin Dependent resident. This was evident during the review of 1 of 1 resident (Resident #61) reviewed during survey process. The Findings Include: During medication administration on 3/4/25 at 8:05 AM for Resident #61, the surveyor observed nurse #21 preparing the resident's insulin injection. Nurse#21 filled an empty insulin syringe with 30 units of insulin injection from a prefilled insulin pen. Nurse #21 went into Resident #61's room to give him/her the insulin injection. The surveyor questioned the nurse about how many units of insulin were to be given to the resident per the attending provider's order, and she reported 24 units of insulin. Due to the surveyor's intervention, nurse #21 discarded 6 units of insulin from the syringe and administered 24 units. Review of Resident #61's medication administration record (MAR) March 2025 on 3/4/25 at 10:30AM, revealed an order for a Basaglar Tempo insulin Pen…

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 interviews, it was determined that the facility failed to properly store medications, as evidenced by failing to discard expired medications. This was evident for 1 of 3 medication storage rooms observed during the survey. The findings include: An observation of the Potomac Unit medication storage room on 2/27/25 at 8:00 AM with LPN (Licensed Practical Nurse) #21 present revealed 2 bags of Intravenous drugs with expiration dates of 9/1/24, a COVID self-test kit with an expiration date of 12/20/2023, and an Insulin injection pen with an expiration date of 8/1/24. During an interview on 2/27/25 at 8:45 AM, the assistant director of nursing (ADON) said that she expected the staff to dispose of expired medications. The expired medications were removed at that time by ADON.

Based on observations and resident and staff interview, it was determined that the facility failed to provide food and drink that accommodates the resident intolerances. This was found to be evident for 1 of 1 resident (Resident #100) selected for review. The findings include: On 02/27/25 at 08:29 am during the initial observation of the unit, an interview with Resident #100 revealed that s/he is lactose intolerant and is supposed to get lactose free milk with meals. Review of the menu sheet for this resident showed Lactaid milk - 8oz, however S/he was given 2% milk which was not what was marked on his/her menu sheet. Resident #100 stated that often times the milk is incorrect. On 02/27/25 at 08:32 am GNA (Geriatric Nursing Aide) #20 was made aware of the resident receiving the incorrect milk. On 02/28/25 at 09:11 am a follow-up interview was conducted with Resident #100 and they stated the staff brought no milk this date and the milk choice on the menu sheet was crossed out. This was verified on the menu sheet by the surveyor observation. On 03/05/25 at 01:39 PM an interview 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 observations and staff interviews, it was determined that the facility failed to provide a sanitary, comfortable environment for residents, staff and public. This was evident for 1 unit out of 5 units observed during the survey. The findings include: On 2/27/25 at 7:48 AM, during observation rounds, there was a strong, ammonia urine-like odor throughout the hallways and residents' rooms on the [NAME] Unit. On 2/27/25 at 7:52 AM, Unit Manager #22 was interviewed. During the interview, Unit Manager #22 stated and agreed to the strong ammonia, urine-like odor throughout the hallways and residents' rooms on the [NAME] Unit. On 02/27/25 at 12:52 PM, the Nursing Home Administrator #1 and the Director of Nursing #2 were interviewed. During the interview, the Nursing Home Administrator #1 and the Director of Nursing #2 were made aware of the strong ammonia, urine-like odor observed throughout the hallways and residents' rooms on the [NAME] Unit. On 3/05/25 at 1:00 PM, during observation rounds, there was still a strong ammonia, urine-like odor throughout the hallways and residents'…

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, interview with residents and facility staff, and observation of facility security footage, it was determined that the facility failed to ensure that residents were free from physical abuse. This was evident for 1 (Resident #1) of 3 residents reviewed for abuse. The findings include: On 8/29/23 at 10:00 AM, facility-reported incident MD00196095 was reviewed. The facility-reported incident indicated Resident #1 alleged that, on 8/13/23, Geriatric Nursing Assistant (GNA) #3 pushed Resident #1 back into his/her wheelchair and placed hands on his/her face. The report noted that the resident had no skin impairments, pain, or discomfort following the incident. Resident #1's medical record was reviewed on 8/29/23 at 10:19 AM. The review revealed a physician's progress note dated 8/15/23 at 1:35 PM that stated the resident had an altercation, but that the resident was without pain or discomfort, denies any acute issues. No injuries from recent event. Change-in-condition follow-up assessments after the incident on 8/13/23 referred to the reason 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 surveyor observation and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food using sanitary practices in accordance with professional standards for food services safety. This was evident in the main kitchen and the second floor dining room. The findings include: 1. On 01-27-2020 at 8:30 AM, surveyor tour with the Dietary Manager of the walk-in freezer revealed a box of pork chops, a box of french bread sticks and a container of sausages opened without labels to identify when the food products were without use by dates. On 01-27-2020 at 8:45 AM, an interview with the Certified Dietary Manager revealed the identified products should have a use by date on them but they did not.2. On 01-27-2020 at 12:33 PM, surveyor observation of the lunch service of the second floor dining room revealed Kitchen Aide #2 checking temperatures of the lunch items on the dining room steam table with a thermometer. Kitchen Aide #2 did not sanitize the thermometer probe prior to inserting the probe into the various lunch items. On 01-27-2020 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 clinical record review and staff interview, it was determined that the facility staff failed to invite residents and/or their representative for interdisciplinary care conferences, and failed to review and revise residents' care plan as necessary. The finding was evident for 5 of 38 residents selected for review during the survey (#45, #78, #153, #104, #14, #37, and #137). The findings include: MDS (Minimum Data Set) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. Quarterly review assessment is an assessment due no less frequently than every 92 days. 1. On 01-28-2020 the review of Resident #45's clinical record revealed that the resident had MDS quarterly review assessments with an assessment reference date (ARD) of 06-21-2019. There was no evidence the resident's clinical record to show that the facility staff invited Resident #45 and/or the resident's representative to an interdisciplinary care conferences. 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 interview, surveyor observation, review of the clinical record and interview of facility staff, it was determined that the facility staff failed to provide timely intervention for a resident with dental problems. This finding was evident in 1 of 3 residents reviewed for the dental care area (Resident #32). The findings include: On 01-28-2020 at 8:59 AM, during resident interview, Resident #32 complained of a broken tooth on the right side which bleeds and causes pain during meals. Resident #32 stated staff were informed of complaint of the broken tooth, and advised Resident #32 that the tooth needed to come out. Review of the clinical record revealed a dental consult was ordered on 01-07-2020. As of 01-30-2020 Resident #32's tooth had not been evaluated by the dentist. A review of care plan for Resident #32 revealed that the resident had dental issue identified in August 2019 as follows: Resident has oral/dental health problems, of no upper dentures related to poor nutrition and poor oral hygiene with a goal that the resident would be free of infection, pain or…

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

Based on the review of administrative documents and interviews with residents and facility staff, it was determined that the facility failed to ensure that residents who filed written grievances were informed of the findings and corrective actions taken. This finding was evident for 1 of 1 residents (Resident #56) reviewed for the personal property care area. The findings include: On 01-27-2020 at 2:59 PM, an interview with Resident #56 revealed the resident reported missing articles of clothing and blankets to the facility staff months ago, but did not receive a response from the facility about the status of the grievance. On 01-27-2020, a review of Resident #56's inventory of personal effects dated, 06-25-2018, revealed the resident brought multiple articles of clothing and blankets into the facility. On 01-27-2020 a review of a facility grievance report dated, 08-26-19, revealed Resident #56 complained that three articles of clothing and three blankets were missing. There was no documented evidence that the facility responded to Resident #56's grievance. On 01-30-2020 at 9:20 AM,…

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, a review of clinical records, and interviews with family members and facility staff, it was determined that the facility staff failed to follow a physician's order for 1 of 38 residents reviewed during the survey (Resident #14). The findings include: 1. On 1-28-2020 at 9:00 AM, the review of Resident #14's clinical record revealed the resident had a diagnosis of pneumonia and dysphagia (dysphagia is a condition in which a person's ability to eat and drink is disrupted). Further review revealed a physician's order, dated 1-8-2020, for the resident to have nectar thick liquids and no straws with beverages. Nectar is a substance used to thicken liquids. Thickened liquids are used for individuals with dysphagia to improve the ability to safely swallow liquids to prevent aspiration, pneumonia and death. On 1-30-2020 at 9:10 AM, observation of Licensed Practical Nurse (LPN) #7 during medication pass revealed the nurse administered Resident #14 medications using water that was not thickened and with a straw. On 1-30-2020 at 10:00 AM, surveyor interview with unit…

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 record, and staff interview, it was determined that that the facility staff failed to utilize appropriate measures to prevent complication related to an indwelling catheter for 1 of 3 residents reviewed for the indwelling catheter care area (Resident #12). The finding includes: On 01-28-2020 at 3:07 PM, observation during rounds revealed Resident #12 presented with an indwelling catheter, however further observation revealed that the catheter was not anchored. Keeping the catheter anchored is necessary to prevent excessive tension on the catheter which can lead to urethral tears or dislodging of the catheter. Observation on 01-29-2020 at 9:50 AM and 4:35 PM also revealed Resident #12's catheter was not anchored. On 01-30-2020 at 2:30 PM, a review of Resident #12's the treatment administration record (TAR) revealed the charge nurse, Staff #6, had signed the TAR on 01-30-2019 which instructed facility staff to use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow . On 01-30-2020 at 2:45 PM…

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 observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that medication administration error were less than five (5) percent. This finding was evident for 3 of 25 (12%) medication administration opportunities observed during the survey. The findings include: 1. On 01-29-2020 at 9:00 AM, observation of Resident #266's 9:00 AM medication administration revealed Nurse #1 administered 960 milligrams (mg) of acetaminophen to Resident #226. Acetaminophen is a medication used to treat aches and pains and to reduce fever. On 01-29-2020 at 9:30 AM, surveyor review of Resident #266's clinical record revealed a physician's order to administer 1000 mg of acetaminophen at 9:00 AM. On 01-29-2020 at 9:38 AM, the interview with Nurse #1 revealed no additional information. On 01-31-20 at 10:00 AM, interview with the Director of Nursing revealed no additional information. 2. On 01-29-20 20at 9:00 AM, observations of Resident #266's 9:00 AM medication administration revealed Nurse #1 did not administer…

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 observations and interviews with facility staff, it was determined that the facility staff failed to ensure residents safely disposed of smoking cigarettes. This finding was evident during 1 of 4 smoking observations. The findings include: 1. On 01-28-2020 a review of the facility smoking policy revealed ashtrays and sealed, fire-safe metal containers should be used for the disposal of ashes and other smoking products. In addition, facility staff should ensure that smoking materials are extinguished before they are discarded. On 01-28-2020 at 11:10 AM, observation during the designated smoking time revealed Resident #26 was seated in the corner of the smoking patio smoking a cigarette. Furthermore, after Resident #26 finished smoking the cigarette, the resident threw the unextinguished cigarette into a grassy area where dozens of cigarette butts were lying. On 01-28-2020 at 11:15 AM, observation during the designated smoking time revealed Resident #66 finished smoking a cigarette and threw their lit cigarette into a pot of plants. The assigned smoking monitor…

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.