South Mountain Rehab Center

Based on record review and interview it was determined that the facility failed to inform and provide written information to all residents concerning their right to formulate an advance directive. This was evident for 1(Resident #68) out of 3 residents reviewed for advanced directives during a survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. On 12/10/24 at 1:06 PM, a review of the medical records of Resident #68 revealed that resident #68 had cognitive decline. Continued review failed to reveal that Resident #68 had an advanced directive. On 12/19/24 at 7:53 AM the social work assistant (SW assistant staff #12) was interviewed regarding the facilities process to inform a resident about…

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, closed record review and staff interview, it was determined that the facility failed to notify Resident #217's representative in a timely manner after a significant change occurred. This was evident for 1 out of 24 complaints reviewed during an annual certification survey. The findings include: On 12/17/24 Complaint MD00179215 was reviewed involving Resident #217. An allegation that Resident #217's family was not immediately made aware of a change in condition that occurred during the morning of 02/28/22 was investigated. Resident #217 was admitted to the facility during the afternoon on 02/25/22 with diagnoses that included an acute embolic stroke, expressive and receptive aphasia, paralysis in the extremities, a new feeding tube, and a Foley catheter. A review of Resident #217's closed medical record on 12/17/24 revealed a nurses note, dated 02/28/22 at 6:52 AM, that indicated a GNA (geriatric nursing assistant) staff member informed the charge nurse, staff member #19, that Resident #217 was observed with a large amount of emesis. Staff member #19 documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined that the facility failed to ensure the required transfer information was documented in the medical record when a resident was transferred to the hospital. This was evident for 1 (Resident #267) of 4 residents reviewed for hospitalization during the annual survey. The findings include: On 12/13/24 at 8:36 AM review of intake #MD00184369 revealed a concern regarding Resident #267's elopement from the facility and subsequent hospitalization. On 12/13/24 at 10:22 AM review of progress notes revealed a nursing note dated 10/11/2022. Review of this note revealed that Resident # 267 returned to the facility at 07:40 AM from the Hospital emergency room the morning on 10/11/22 at 7:40 AM, in a stable condition, with an abrasion on both bilateral lower extremities. Further review of the progress notes failed to reveal documentation that the resident was transferred to the hospital or the reason for the transfer. Continued review failed to reveal 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to complete Quarterly Minimum Data Set (MDS) assessments for a resident within the regulatory time frames to facilitate appropriate care planning and maintain the current assessment record. This was evident for 1 (Resident #42) in 3 residents reviewed for Resident assessments. The findings include: The Minimum Data Set (MDS) assessment is a federally mandated assessment tool that nursing home staff use to gather information on each resident's strengths and needs. The information collected is used in the resident's care planning decisions. The Quarterly assessment must be completed within 92 days of the MDS Completion Date of the last OBRA assessment. It must also be completed no later than 14 days after the ARD, which is the ARD + 14 days. The last day of the observation period is the Assessment Reference Date (ARD). This date provides a common reference point for all team members participating in the assessment. In completing…

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 submit Minimum data set (MDS) Discharge assessments as required for residents discharged from the facility. This was evident for 3 (#105, #112, #64) of 4 residents reviewed for Resident assessments. The findings included: The MDS assessment is a federally mandated assessment tool that nursing home staff use to gather information on each Resident. Discharge assessments include items for quality monitoring. Discharge assessment reporting is required for all residents in the nursing home who have been physically discharged from the facility. 1a) A record review for Resident #105 on 12/19/24 at 1:35 PM showed that the Resident was admitted to the facility in October 2024. The continued review contained a nurse's note dated 12/9/24 that stated that Resident #105 was discharged to another facility. Further review of Resident #105's MDS record showed a lack of discharge assessment for the Resident. 1b) A review of Resident #112's record contained a nurse's note dated 9/27/24 that indicated that…

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

Based on observation, record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 1 (#66) of 7 residents reviewed for position and mobility and 1 (Resident #111) of 4 residents reviewed for hospitalization. The findings include: The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. 1) An observation on 12/10/24 at 3:14 PM showed that Resident #66's fingers were bent on the right hand, pressed into his/her palm, and stated, I've not been able to move my right hand and both legs in the last year. A review on 12/18/24 at 12:10 PM showed that Resident #66 had been residing in the facility since September 2022. Diagnoses included Multiple Sclerosis (MS), with spastic paraparesis (stiffness and weakness in the legs) and Bell Palsy. A continued review contained occupational therapy (OT)…

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

Based on record review and staff interview, it was determined that the facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) form completed at the time of admission appropriately reflected the resident's diagnosis. This was true for 1 (Resident #16) of 2 PASARR forms reviewed for accuracy. The findings include: Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals with intellectual disability or a serious mental illness are not inappropriately placed in nursing facilities for long term care. The requirement ensures that all applicants receive care in the most suitable setting and are provided with all the necessary resources available. Review of Resident #16's initial nursing admission assessment on 6/20/2019 revealed a diagnosis of bipolar disorder; however, the most recent PASRR form completed on 2/14/2020 failed to reflect that resident had mental illness diagnosis on Section C. question #1. Section C of the PASRR form has questions to identify if the resident has serious mental illness and…

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 staff interview, it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan. This was evident for 3 (Residents #34, #74, and #101) of 6 residents reviewed for baseline care plans. The findings include: 1) On 12/13/24 at 10:40 AM, an interview was conducted with Director of Nursing (DON). When asked if a baseline care plan given to Resident #34 or their Representative (RP), the DON stated, I cannot provide any documentation to confirm that Baseline Care plan was given to RP or resident. On 12/13/24 12:49 PM, a review of Resident #34's medical record was conducted. Resident #34 was admitted [DATE]. No documentation of baseline care plan being given to Resident Representative or Resident in the medical record. On 12/19/2024 at 2:00 PM, the DON provided a Care Plan Conference Appointment scheduled for 10/17/2024 addressed to Resident #34. 2) On 12/17/24 at 11:20 AM, a review of Resident #74's record was conducted.…

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 pertinent document review it was determined that the facility failed to provide activities according to the resident's preferences. This was evident for 1 (Resident #91) out of 3 residents reviewed for activities during a survey. The findings include 12/11/24 at 8:49 AM Resident #91, a long-term resident of the facility, was observed lying in bed with her/his breakfast sitting on the bed side table. Further observation revealed that Resident #91 was awake and about ¼ of their breakfast was eaten. Further observation failed to reveal either music or the television (TV) being on. 12/12/24 02:45 PM An observation made in Resident # 91's room revealed the resident sitting behind the door, not visibly observing the TV, which was on a news channel. 12/17/24 at 7:54 AM Resident # 91 was observed eating in her/his room and not facing the TV. Further observation revealed a football game on the TV. On 12/18/24 several observations were made of Resident 91's room at the following times: 8:04 AM, 8:44 AM, and 12:03 PM. All these observations 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 record review, complaint MD00211139 and interviews, it was determined that the facility failed to ensure that residents received the appropriate treatment as ordered, in accordance with professional standards of practice. This is true for 2 (Resident #21 and Resident #110) of 3 residents reviewed during the survey process. The findings include: 1.)On 12/18/24 at 11:37 AM, a review of Resident #110's chart revealed that the resident's Maryland order of Life Sustaining Treatment (MOLST) revealed that the resident was on comfort care and without hospitalization. A review of complaint MD00211139 revealed an allegation that from 10/11/24 to 10/14/24, Resident #110 began experiencing seizures that worsened until death. Further review of the medical record revealed that on 07/10/24 a physician's order was placed: Midazolam HCl (PF) Injection Solution 5 MG/ML (MidazolamHCl) Inject 1 ml intramuscularly as needed for seizure activity; however, there was no documentation to indicate how often the medication could be given or what to do if found to be ineffective. A review 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.

Based on observations, record review, and interviews, it was determined that the facility failed to ensure that residents with limited range of motion received treatment and services to prevent further decline in the range of motion. This was evident for 2 (#66, #62) out of 7 residents reviewed for position and mobility. The findings include: 1) An observation on 12/10/24 at 3:14 PM showed that Resident #66's fingers were bent on the right hand, pressed into his/her palm, and had no device. The resident stated, I've not been able to move my right hand and both legs in the last year. A record review on 12/18/24 at 12:10 PM showed that Resident #66 had been residing in the facility since September 2022 and depended on the staff for assistance with his/her self-care needs due to physical limitations. The review also contained an occupational therapy evaluation dated 9/27/22- 10/17/22 that recorded that Resident #66's bilateral upper extremities were within functional limits and had no contractures. A continued review of an occupational therapy evaluation dated 9/19/23 noted an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility record review, it was determined that the facility failed to 1.) ensure that a safe designated space for smoking was maintained in various weather conditions and 2.)to carry out a physician's order to check the placement of a residents wonder guard every shift for placement. This was true for 1 of 2 resident smoking observations conducted and for 1 (Resident #91) out of 8 Residents reviewed for accidents during a survey. The findings include: On 12/11/24 at 1:03 PM, the surveyor observed Resident #16 and another resident smoking in a small, covered patio area of the [NAME] unit. The maintenance director (Staff #35) was outside with the residents at the time of the observation and assisted them with coming back inside after they finished smoking. On 12/11/24 at approximately 1:15 PM, in an interview with maintenance director, he was asked about the smoking area and he informed the surveyor that there was a designated smoking area; however, due to the rainy…

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 interviews, it was determined that the facility failed to ensure that weekly weights were obtained as ordered by the physician. This was evident for 1(Resident #24) of 6 resident records reviewed for significant weight loss. The findings include: On 12/11/2024 at 2:28 PM, a review of the Resident #24 medical records revealed that the resident had a significant weight loss (more than 20 lbs) from June to August of 2024. On 8/31/2024 weight monitoring was ordered daily for 3 days; on 9/9/2024 weekly weights were ordered. A review of the weights log revealed that on 9/1/24 resident weighed 134.6 lbs and on 12/10/24 the resident weight 124.4 which equals to 7.5% weight loss in approximately 3 months. It was noted that Resident #24 had a significant 20% weight loss over a 6 month period (June to December 2024). On 12/18/24 at 10:14 AM, Resident #24's physician orders revealed that as of 9/9/24, weekly weights were ordered; however, it was noted that there were no weights obtained in the 2nd, 3rd or 4th week of September 2024. There were also no weights…

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

Based on medical record review and interviews, it was determined that the facility failed to document the reasons for administering as-needed (PRN) pain medications and failed to document pain assessment to include the location of the pain and type of pain for a Resident reporting pain. This was evident for 1 (Resident #97) of 5 Residents reviewed for unnecessary medications review. The findings include: A medical record review for Resident #97 on 12/12/24 at 2:44 PM showed that the resident had been admitted to the facility in September 2024 with diagnoses including left hip fracture, left elbow fracture, chronic pain syndrome, and arthritis. Further review of Resident #97's medication administration record for November 2024 contained an attending provider's order for Hydromorphone 0.5mg every 12 hours as needed for pain and tramadol 50mg every 6 hours as needed for pain. A continued review showed that Resident #97 had received hydromorphone 0.5mg on 11/7/24 for a pain level of 5, 11/9/24 for a pain level of 6, and 11/11/24 for a pain level of 6 (A pain scale/level ranges from 0 to…

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

Based on record review and interviews, it was determined that the facility failed to ensure that a resident with a history of trauma received the appropriate trauma-informed care. This was evident for 1 (Resident #97) of 4 residents reviewed for unnecessary medications. The findings include: A record review contained a social history for Resident #97 dated 9/10/24, which had recorded that the resident had a history of post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). A subsequent review completed for Resident #97 on 12/12/24 at 2:44 PM, contained an attending provider's order dated 11/05/24 for an antidepressant medication to be administered to Resident #97 daily for PTSD. Further review showed a behavioral health note dated 11/13/24 that recorded that Resident #97 had a diagnosis of PTSD. However, the review failed to show what the triggers were for the traumatic event and how to mitigate or eliminate them to ensure the resident was not traumatized again. In an interview on 12/17/24 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 staff interviews, it was determined that the facility failed to have an effective system in place to ensure staff maintained current certification and or licensure. This was evident for 1(Staff #41) of 5 Certified Nursing Aide (CNA) certification records reviewed. The findings include: On [DATE] at approximately 11:20 AM, a review of Staff #41's employment record revealed that the staff was hired as a CNA. A review of Staff #41's CNA certification on the State board registry (Maryland Board of Nursing) showed that her certification expired on [DATE]. On [DATE] at 2:39 PM, a review of Staff #41 timesheet information revealed that she was working in the facility as of [DATE]. On [DATE] at approximately 2:39 PM, Corporate Nurse #6 was made aware that Staff #41's expired certification. On [DATE] at approximately 11:15 AM, in an interview with Staffing Coordinator (GNA#37), the staff was asked who was responsible for ensuring that the licenses and certification of each staff member has…

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 reviews and staff interviews, it was determined that the facility failed to keep resident's drug regimens free from unnecessary medications by failing to ensure residents received their medications according to the attending physician's orders. This was evident for 1 (Resident #97) out of 5 residents reviewed for unnecessary medications, and 1 (Resident #102) out of 5 residents observed during medication administration. The findings include: Blood pressure (BP) is often written as an upper and lower number. Systolic blood pressure (SBP) is the upper number. It measures the pressure in the arteries during heart muscle contraction. 1) A record review on 12/12/24 at 2:44 PM showed that Resident #97's diagnoses included hypertension and received Prazosin 2mg daily and metoprolol 25mg twice daily per an attending provider's orders. The order also stated to hold (not to give) the medications for SBP less than 120. A subsequent review of Resident #97's medication administration records (MARs) from November 1- December 16, 2024, showed that the resident 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 medical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regimen was free from unnecessary psychotropic medication use by failing to adequately monitor a resident for behaviors, side effects, or adverse consequences related to psychotropic medication use. This was evident for 1 (Resident #97) of 5 residents reviewed for unnecessary medications. The findings include: A record review on 12/12/24 at 2:44 PM showed that Resident #97 had been residing in the facility since September 2024. The continued review contained an order summary report that documented an attending provider's order for an antidepressant medication for Resident #97 due to depression. The review also showed that the resident was given the drug daily as prescribed from 11/6/24- 11/30/24. Further review of Resident #97's plan of care contained a care plan focus initiated on 9/12/24 for the use of an antidepressant. Interventions on the care plan included Monitor/document side effects and effectiveness [Q-every] shift, monitor/document/report [PRN-…

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 reviews, and interviews, it was determined that the facility failed to maintain a medication error rate of less than 5%. This was evident based on two errors identified out of 28 opportunities for error. The findings include: During medication administration observation on 12/13/24 at 8:53 AM, the surveyor observed a licensed practical nurse (LPN#1) pull the following medications from the medication cart for Resident #102 in a medicine cup: 1 capsule of Fenofibrate Micronized 134mg 1 tablet of Folic Acid 1mg 1 tablet of Potassium chloride 20meq 1 capsule of Hydrochlorothiazide 12.5mg 1 tablet of Lisinopril 20mg 1 tablet of Vitamin B12 1000mcg 1 tablet of Vitamin D 25mcg. The surveyor asked LPN#1 to confirm how many pills were in the medicine cup before giving them to Resident #102. She stated there were seven tablets. A review of Resident #102's December 2024 medication administration record (MAR) was completed following the medication administration. The review showed the attending provider's orders for Metoprolol 200mg and Amlodipine 5mg to be…

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 ensure that expired medications were disposed of promptly per the manufacturer's specifications. This was evident for 1 of 4 medication refrigerator storage observed. The findings include: An observation of the 2nd floor medication storage room refrigerator in the presence of Staff #49 on 12/17/24 12:45 PM revealed that Tylenol 650 mg suppository expired 7/20/2024. Staff #49 stated that it should have been discarded. Staff #49 reported the error to Staff#7, Unit Manager. On 12/18/2024 at 9:32 AM, during an interview with ADON, this surveyor mentioned the expired Tylenol suppository found on the second-floor unit. ADON stated that expectation of the nurses was to get rid of expired medications. ADON also said it is an expectation that nurses are to write the expiration dates on the medication packages so that they would know when to discard them once they were received from the pharmacy. On 12/18/24 at 10:35 AM during an interview with the ADON, this surveyor stated that the weekly storage room…

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, interviews, and record reviews, it was determined that the facility failed to have an effective process in place to ensure that adaptive devices that were recommended by therapy were provided to a resident. This was evident for 1 (Resident # 5) observed during the dining observation portion of the recertification survey. The findings included: On 12/10/24 at 12:21 PM, an observation was made in the Manor unit dining hall. The observation revealed a puddle of liquid on the floor under Resident #5's chair. Further observation revealed the same liquid on the table dripping onto the floor. The observation failed to reveal whether any adaptive devices were provided to the resident. On 12/11/24 at 8:39 AM a second observation was made in the Manor unit dining hall. Resident #5 was observed at the table with a puddle of white liquid under his/her chair. Further observation revealed a tipped-over cup of milk. Observation failed to reveal any adaptive devices were provided to the resident. On 12/11/24 at 12:06 PM a third observation was made in the Manor unit dining…

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 reviews and interviews, it was determined that the facility failed to complete the resident matrix accurately. This was evident in 2 of 3 resident matrix reviewed during the survey. The findings include: The resident matrix is a form that is completed by the facility. The form lists the resident's name, room number and have columns numbered 1 through 20 that are marked with the resident's corresponding care categories. All information entered into the form should be verified by a staff member knowledgeable about the resident population. Information must be reflective of all residents as of the day of survey. On 12/10/24 after entrance to the facility at approximately 9:30 AM, multiple staff members had confirmed, including the Director of Nursing (DON), that the facility was not in an outbreak and no resident was infected with COVID. During the initial team meeting on 12/10/24 at 1:42 PM, the survey team had identified and discussed discrepancies with the resident matrix, including Resident #77 and #88, that were marked as having COVID infections. Resident #88 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 observations, interviews, and records review, it was determined that the facility failed to ensure staff use appropriate infection control practices. This was evident for 1 (Resident #38) of 1 resident reviewed for tube feeding and 1 out of 2 medication administrations observed and has the potential to affect all residents in the facility. The findings include: 1) PEG: A percutaneous endoscopic gastrostomy (PEG) is a surgery to place a feeding tube. These feeding tubes are often called PEG tubes or G tubes. Feeding tubes, or PEG tubes, allow you to receive nutrition through your stomach. This type of feeding is also known as enteral feeding or enteral nutrition. Resident #38 was a newly admitted resident of the facility. A quick review of his/her medical records indicated that the resident was admitted with a peg tube for nutrition. On 12/10/24 at 3:20 PM, a Licensed Practical Nurse (LPN #1) was observed accessing Resident #38's peg tube. LPN #1 was not wearing appropriate personal protective equipment (PPE). A sign posted on the resident's door was also observed that…

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 interviews, it was determined that the facility failed to have documented evidence that all nurses' aides received 12 hours of training that included abuse prevention and Dementia management, annually and training needed to provide competent care. This was evident for 5 (GNAs #25, #37, #39, #41, and #50) of 5 randomly selected nursing staff reviewed for competencies. The findings include: Nursing competence is defined by the American Nurses Association as an expected level of performance that integrates knowledge, skills, abilities, and judgment. On 12/13/24 at 10:24 AM in an interview with GNA #25, the GNA was asked if she has received training and competency to perform personal care to the residents and she said yes. However, she was unable to report when the training was last completed. She said it has been a while, I don't remember to be honest. On 12/19/2024 approximately 11:20 AM, the surveyor requested staff files for 5 staff members and the staff files received were incomplete. A review of the staff records revealed that there was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to void an older MOLST form located in a resident's active medical record. This was evident for 1 (Resident #112) of 2 residents reviewed for Advance Directives during an annual recertification survey. The findings include: A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used to document a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. Instructions for completing a Maryland MOLST require that a Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) accurately and legibly complete the form and then sign and date it. Voiding the Form: to void this medical order form, a physician or nurse practitioner shall draw a line through the sheet, write VOID in…

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 and staff interview, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect multiple residents. The findings include: 1. On 10/28/2019 at 12:45 PM, in room [ROOM NUMBER], one of four window shades is missing the adjustment rod to open and close the blind. 2. In room [ROOM NUMBER], 2 of the 4 closet doors are in disrepair. The third closet door has duct tape and does not close all of the way. The fourth closet door does not close and is seated crocked and in disrepair. These items were brought to the attention of the facility environmental services manager.

Based on reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to conduct a yearly performance review on 3 of 5 geriatric nursing assistants for the year of 2018. The findings include: On 08/28/19, a review of 5 random geriatric nursing assistants (GNA) for yearly performance appraisal revealed that 3 of the 5 GNA's had not had a yearly appraisal for the year 2018. Review of GNA #1's records revealed that GNA #1's performance appraisal was not conducted in 2018. Review of GNA #2's records revealed that GNA #2's performance appraisal was not conducted in 2018. Review of GNA #3's records revealed that GNA #3's performance appraisal was not conducted in 2018. In an interview with the Director of Nursing (DON) on 11/01/19 at 10:25 AM, the facility DON confirmed that GNA #1, GNA#2, and GNA #3 were not given a performance appraisal for the past 12 months in 2018.

Based on observation, it was determined the facility staff failed to properly store medications. This was observed once during an annual recertification survey. The findings include: An observation was made on 10/28/19 at 12:53 PM on the 300 wing at the nursing station. The surveyor observed one of two unattended and unlocked medication carts. A medication cart holds the medications for the residents residing on the 300 wing. No nursing staff members were attending to the medication cart at the time of the observation. The nursing unit manager was immediately made aware of finding and locked the open medication cart.