Hammonds Lane Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to ensure a resident who requires dental services on a routine or emergent basis receives necessary or recommended dental services in a timely manner. This was evident for 1(Resident #41) reviewed for dental services.The findings include: On 8/18/2025 at 11:10AM, during a review of Resident #41's electronic medical record, the Surveyor discovered the resident's last dental examination was 9/26/2024. Further review revealed a dental note dated 9/26/2024 which stated Not a candidate for surgical extractions or xrays in the facility and remaining teeth have poor prognosis due to periodontal disease, caries, and retained roots. Action required by nursing home staff: Monitor teeth for signs/symptoms of problems; Patient would benefit [from] referral for panoramic xray and extraction with nitrous/IV sedation. Patient at risk for dental infection. Provider continue peridex swabs 2x a day for periodontal disease.On 8/18/2025 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.

Based on observation and interview with staff, it was determined that the facility failed to ensure face masks were included Personal Protective Equipment (PPE) inside the PPE carts outside residents' rooms. This was evident for 3 PPE carts on the C wing and 4 PPE carts on the A wing. The findings include: Personal protective equipment (PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. PPE includes, but not limited to, gloves, masks, safety goggles, and gowns. On 8/14/2025 at 8:30AM, during a tour of the C wing nursing unit, the Surveyor observed 3 PPE carts along one side of the hallway. Each cart failed to have face masks inside. On 8/14/2025 at 8:33AM, during a tour of the A wing nursing unit, the Surveyor observed 4 PPE carts along one side of the hallway. Each cart failed to have face masks inside. On 8/14/2025 at 10:19AM, the Surveyor conducted an interview with the Infection Preventionist (IP) #25. The Surveyor was informed that the expectation was for all PPE…

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 staff and residents, the facility failed to ensure residents have an enclosed closet space protected from casual access from others by having a closet door. This was found to be evident for 2 out of 21 resident rooms observed during the annual survey.The findings include: On 8/15/2025 at 8:25AM, during a tour of the A wing nursing unit, the Surveyor observed that Resident #41 and Resident #57 did not have closet doors, and their personal belongings were visible. On 8/15/2025 at 8:30AM, an interview conducted with Resident #57 revealed that the closet door had been taken off the hinges months ago because the door was loose and posed a safety issue. The resident was informed that the door would be replaced, and the resident would get a curtain to cover their exposed belongings in the meantime. The resident stated that it never happened and felt uncomfortable with his/her personal belongings exposed to whoever entered the room. On 8/18/2025 at 8:20AM, the Surveyors conducted an environmental tour of the A wing, B wing, and C wing nursing units…

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 of facility staff it was determined the facility failed to ensure effective pest control as flying gnats and flies were observed throughout the building. This was found to be evident during the survey.The findings include: On 8/14/2025, during a tour of A wing nursing unit between 8:30AM and 10:20AM, the Surveyor observed the following concerns:1.) In room [ROOM NUMBER]A-1 and 2, multiple gnats were noted flying around the room.2.) In room [ROOM NUMBER]A-2, multiple gnats observed on used tissues sitting on Resident #1's bedside table.3.) In room [ROOM NUMBER]A-1 and 2, gnats and flies observed flying around the room. Resident #2 stated that the gnats and flies have been an issue within the facility.On 8/14/2025 at 10:25AM, while walking down C wing hallway towards the conference room, the Surveyor observed gnats flying.On 8/15/2025, during a tour of the A wing nursing unit at 8:15AM through 9:40AM, the Surveyor observed the following concerns:1.) In room [ROOM NUMBER]A-1 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 observations and interviews with facility staff it was determined the facility failed to: 1.) administer medications as ordered by the physician, for 4 of 4 residents (#97, #58, #213, #365) observed during a medication administration and record review; 2.) document a resident (#68) was receiving oxygen therapy and; 3.) document interventions taken when a resident's (#88) tracheostomy tube became dislodged. This was evident for 6 of 6 medical records reviewed for professional nursing documentation during the facility's annual Medicare/Medicaid survey. Findings include: 1a.) A medication observation was made on 6/1/23 at 10:30 AM and Licensed Practical Nurse (LPN) #40 was administering medications to Resident #97. She administered 9:00 AM medications to the resident at 10:30 AM. The computer screen was highlighted pink in color. LPN# 40 explained that when the computer screen highlights a pink screen it means the medications are late. LPN #40 went on to say that a yellow screen appears when 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 pertinent facility documents and interview with facility staff, it was determined that the facility failed to have a facility assessment that was accurate and complete including information relevant to the needs of the residents the facility serves. The findings include: On 06/20/23 at 11:30 am the surveyor reviewed the Facility Assessment which revealed the Guest Service Director, Assistant Director of Nursing, admission Director and the Maintenance Director had incorrect names listed and were not the current staff. This was confirmed by the list of key personnel provided by the facility staff. Further review of the provided facility assessment failed to reveal any of the required information related to the numerical staffing needs of the facility based on the facility assessment to ensure enough qualified staff are available to meet each resident's needs. During an interview with the Nursing Home Administrator on 6/20/23 at 11:45 am while reviewing the facility assessment she revealed that it was difficult to understand. She further revealed that the facility is…

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, record revies and interviews of facility staff it was determined the facility failed to: 1.) document that daily activities were provided to residents (Resident # 9 and # 60) and 2.) document medical information in a resident's medical record (Resident #25, #211, #365). This was evident for 5 out of 90 residents reviewed during a facility's annual survey. Findings include, 1. Observations were made of resident # 9 and # 60 on 5/16/23 at 9:55 AM and 5/17/23 at 9:40 AM and there were no activities observed taking place. An interview was conducted with the Recreation Director (RD)# 21 on 5/23/23 at 1:30 PM and she was made aware that no activities were observed for resident # 60 and resident # 9 and asked about specific activities that are done with the residents. She stated that resident # 60's family likes to attend activities in the evening with the resident. She further stated that one on one activities are provided for residents who are unable to attend activities and that documentation…

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 make sure the residents on Unit C had their call bells within reach to call for assistance. This deficient practice was evident in 2 of 4 (#47 & #48) residents observed on Unit C during the annual survey. The findings include: On 05/16/23 at 9:40 am during the initial walk through of the facility, the surveyor observed Resident #48's call bell on the floor and Resident #47's call bell under the bed. LPN #10 confirmed the surveyor's findings at 9:43 am. After surveyor intervention LPN #10 provided both residents with their call bells. On 06/20/23 at 5:47 PM during an interview with LPN #10 he/she stated at the beginning of the shift during rounds the nurses make sure the residents have their call bell. Throughout the day the nursing staff checks to make sure they have their call bells.

Based on family interview, ADL record review, and staff interviews it was determined that the facility staff failed to ensure a resident's desire to have scheduled showers of two per week honored by the facility. This was true for 1 out of 2 (#261) residents reviewed for choices. The findings include: Complaint MD00184959 and facility reported incident MD00185236 were reviewed on 06/06/2023 and 06/07/2023. According to the reports, the complainant and the facility reported incident alleged Resident #261 did not have any showers for 9 days after admission and then only had 2 showers. A phone interview was conducted with the complainant on 06/05/2023 at 9:50 AM and he/she stated that Resident #261 was at the facility for 9 days before anyone gave her/him a shower and that the resident never received twice weekly showers. A review of the Annual Minimum Data Set (MDS) assessment, a part of the comprehensive review of a resident's care, completed on 10/10/2022 revealed that under Section F 400 Interview for Daily Preferences, the resident stated that showers were very important. 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 medical records and interview it was determined that the facility failed to maintain a resident's privacy as evidenced by a Nurse Practitioner discussing a resident's medical diagnoses in a hallway. This deficient practice occurred in 1 of 1 (#98) resident's reviewed for privacy practices during the annual survey. The findings include: On 5/16 at 11:00 am during the surveyor's initial screening, Resident #98 reported on 5/12/23 while in the hallway with Occupational Therapist(OT) #12 he/she saw Nurse Practitioner (NP) #45 and mentioned pain control. Resident #98 reported that NP #45 openly said Resident #98 had a substance abuse and alcoholism in the hallway. On 05/24/23 at 10:56 am during an interview with OT #12 he/she told the surveyor while taking Resident #98 to the therapy gym the resident spoke to NP #45 about his/her pain and NP #45 did openly mention Resident #98's medical history in the hallway. On 05/26/23 at 11:47 am during an interview with NP #45 who reported Resident #98 approached him/her about pain management which is a complex health situation. NP #45…

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, the facility failed to provide residents with housekeeping services that promote a comfortable and homelike environment. This was evident for Unit C and room [ROOM NUMBER]A-1 observed during the facility's annual survey. The findings include: On 5/17/23 at 8:00 AM, the surveyor smelled strong smells of human waste during the initial tour of Unit C. On 5/17/23 at 11:30 AM, the surveyor continued to smell the strong smells of human waste in another visit to Unit C. On 5/17/23 at 10:30 AM, the surveyor observed the floor in room [ROOM NUMBER]A-1 littered with trash from breakfast. The surveyor informed LPN #4 of the trash on the floor of room [ROOM NUMBER] A-1. LPN #4 stated that he/she would have staff clean the area. On 5/17/23 at 12:00 PM, the surveyor observed the floor of room [ROOM NUMBER]A-1 was still littered with trash from breakfast. On 5/17/23 at 12:30 PM, the survey team interviewed the Administrator regarding housekeeping services in the 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 administrative and medical record review and interviews with facility staff it was determined the facility failed to prevent verbal abuse by an agency staff member towards a resident. This was found to be evident for 1 of 26 (Resident # 37) residents reviewed for abuse during the resident's annual Medicare/Medicaid survey. Findings include: MD00193103 was reviewed on 6/16/23 at 10:30 AM for allegations of abuse. According to the facility's investigation, on 6/2/23 at approximately 12:45 PM, Geriatric Nurse Assistant (GNA) #67 was overheard by another GNA cursing at Resident #37. Further review of the facility's investigation and a statement by GNA #18 revealed that while she was in the hallway assisting with passing lunch trays, she saw GNA #67 begin to walk out of the resident room. She further stated that she heard Resident #37 yell, get out, and GNA #67 then turned around and walked to the curtain and replied with an [expletive] you, to the resident, and then walked out of the room. Review of GNA #67's statement on the same date revealed that he was passing drinks 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on administrative review and interviews with facility staff, it was determined the facility failed to: 1.) report to the proper authority to include the police department, that staff used another staff license to work at the facility and 2.) notify the state agency when a resident (R#309) eloped from the facility. This was found to be evident during a review of the facility's investigation of facility reported incidents and 1 of 19 residents reviewed for accidents during the facility's annual Medicaid/Medicare survey. Findings include: 1. Intake MD00186016 was reviewed on 5/25/23 at 9:30 AM for allegations that staff worked as imposters by using other staff licenses while working at the facility. A review of the facility's investigation, and a copy of the timeline that was provided by the Administrator revealed that on 10/8/22 Staff # 55, an unlicensed staff, worked at the facility as Geriatric Nurse Assistant (GNA) #43. An interview was conducted with the Administrator, #1 on 5/25/23 at 2:00 PM and she…

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 to medical record review and interviews it was determined that the facility failed to complete thorough investigations when investigating facility reported incidents. This deficient practice was evident in 2 of 8 facility reported incidents involving Residents #92 and #310) reviewed during the annual survey. The findings include: 1. On 06/06/23 at 8:26 am, review of the Facility Reported Incident MD00191413 revealed Resident #92's family member sent an email to the facility Complaint mailbox on 04/15/23 at 8:32 am. A review of the facility's investigation revealed there was no documentation to verify the resident's concerns were addressed or invalid. On 06/06/23 at 9:39 an during an interview with Director of Nursing (DON) #2 she provided a statement from Resident #92 dated 04/20/23 that indicated that when the resident was initially admitted his/her dressing wasn't being changed unless he/she asked for it to be changed and he/she wasn't getting pain medication on time. He/she didn't have any concerns during the time of the interview because everything was rectified. When…

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

Based on medical record review and interview with staff it was determined the facility staff failed to notify the resident and/or the resident's representative(s) of a hospital transfer and the reason for the transfer in writing. This was found to be evident for 1 (Resident # 62) of 3 residents reviewed for hospitalization during the annual survey. The findings include: Review of Resident #62's medical record on 5/23/23 at 10 am, failed to reveal a written hospital transfer for 1/17/22. On 5/23/23 at 3:30 pm during an interview with the Director of Nursing, she stated she could not locate a hospital transfer documentation for Resident #62 for the hospital transfer on 1/17/22; however, the Director of Nursing was able to present the Bed Hold Notice of Policy & Authorization.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to provide a completed bed hold policy notice to the resident or resident representative (Resident # 25). This was evident in 1 of 1 resident reviewed during the facility's annual survey for care planning. Findings includes: Review of Resident #25's medical records on 5/18/23 at 9:18 am revealed the resident was admitted to the facility on [DATE] for rehabilitation and on 10/13/22 the resident was transferred to the hospital. Further review of Resident #25's medical records on 5/24/23 at 12:30 pm revealed the transfer documents included a bed hold document that did not indicate the number of hospital and/or therapeutic leave days remaining for Resident #25's Medicaid account. Review of Resident #25's medical records on 5/24/23 at 12:45 pm revealed the resident received assistance from Medicaid from admission on [DATE] to 10/13/22 (date of his/her transfer to the hospital for emergency treatment). During an interview with the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1.) accurately code for falls this was evident for 2 (Resident #52, #263) out of 2 for falls and 2.) accurately code: Hearing, Speech and Vision. This was evident for 1 (R#90) out of 1 reviewed for Hearing, Speech and Vision and 3.) accurately code hospitalization. This was evident for 1 (R #107) our of 5 reviewed for hospitalization during the survey process. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The MDS provides a comprehensive assessment of the resident's functional capabilities and helps nursing home staff identify health problems. It is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term…

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 staff failed to implement patient centered care plans for: 1.) residents who received oxygen therapy (#47, #68, #88), 2.) use of a Wander Guard (#309) and 3.) ensure that a resident's pain care plan was followed for pain management. This deficient practice was evidenced in 5 (#47, #68, #88, #309 & 219) resident records reviewed for oxygen therapy, use of a Wander Guard, and Activities of Daily Living (ADL's) during the investigation stage of the facility's annual Medicare/Medicaid survey during the annual survey. The findings include: 1. During the initial screening of the residents on 05/16/23 and 05/17/23, surveyor observed Resident #68 and #88 receiving oxygen therapy. Resident #47 had oxygen tubing on the bed and the oxygen machine was on 2 liters. On 05/22/23 at 1:57 pm Director of Nursing (DON) # 2 provided the surveyor with a care plan for respiratory complications for Resident #68. Oxygen use was an intervention, but the resident did not have a resident centered care plan 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 medical record review and interviews it was determined that the facility failed to ensure that the nursing staff was competently trained to care for residents who had a tracheostomy. The deficient practice was evident in 1 of 1 (Resident #88) residents who resides in the facility with a tracheostomy. The findings include: On 05/30/23 at 1:00 pm a review of the Resident #88's electronic medical record (EMR) revealed the resident was sent to the hospital on [DATE] for a tracheostomy dislodgement. On 05/30/23 2:29 pm review of the nurse's employee record who was assigned to Resident #88 when the tracheostomy became dislodged revealed an agency nurse was assigned to the resident. Director of Nursing (DON) #2 made the surveyor aware they facility did not have documentation to support the nurse was competently trained to care for a resident with a tracheostomy tube. On 06/02/23 at 8:58 am during an interview with Director of Nursing #2 she/he reported there was no specific training for tracheostomy care 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 medical record review and interview it was determined that the facility failed to: 1.) have a system in place to identify potential drug diversion as evidenced by failure to ensure Controlled Drug Administration Records were kept in a manner that an accurate reconciliation could be completed and failed to have an effective system in place to ensure nursing staff signed that the controlled drug count was correct at the time the count occurred. This was found to be evident for 1 of 8 (Resident #60) residents reviewed for narcotics and 1 out of 6 medication carts reviewed and 2.) the facility contracted pharmacy delivery company failed to deliver a resident's medication without informing the facility of the cancellation of the medication delivery (Resident #213). This was evident for 1 of 10 residents reviewed for activities of daily living during a facility recertification survey. The findings include: 1. On 5/31/21 at 1 pm review of Resident #60's medical record revealed the resident was admitted 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 review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure a resident's drug regimen was free from unnecessary drugs. This was evident for 1 of 66 residents (Resident #365) reviewed during a facility's recertification survey. The findings include: Review of the facility incident report MD00187644 reported Resident #365 requiring Narcan (medication that reverses opioid overdose symptoms) administration when he/she was found unresponsive. Medical record review for Resident #365 on 5/26/23 at 1:45 pm revealed the resident was admitted to the facility on [DATE] for rehabilitation for a right leg fracture. Continued review of Resident #365's medical record revealed facility nursing staff administered Narcan to the resident after an opiate overdose on 1/10/23. Resident #365 was ordered to have a 15 mg Oxycodone tablet every 4 hours for a pain score of 6-10 as needed (resident reporting extreme pain) since 12/22/22. Further review of 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 observations and interview with facility staff it was determined that the facility failed to: 1.) properly store resident's medications and facility supplies in accordance with currently accepted professional standards. This was evident in 1 out of the 4 medication storage rooms within the facility and; 2.) ensure that expired medications were disposed of properly. This was found to be evident for 1 resident (#2) when 3 medication carts were reviewed for narcotic reconciliation during the facility's annual Medicare/Medicaid survey. The findings include: 1. On 05/31/23 08:55 AM during observation rounds of the Medication Storage room on Unit B wing revealed the following: a. One package of Safe Step Huber Needle Set, facility supply, was found in the upper cabinet over the sink with an expiration date of 11/28/22. b. Two tabs of Colchicine 0.6mg were found lying in the top drawer of a cabinet with an expiration date of 12/01/22 with no resident's name on medication. c. One Albuterol Inhaler was found on the countertop in the Medication Storage room for Resident #408. 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 medical record review and interview it was determined that the facility failed to meet the needs of the residents regarding the timeliness of providing laboratory services. This was evident for 1 resident out of 66 (Resident #7) residents reviewed for during the annual survey. The findings include: On 5/30/23 at 3 pm a review of the Residents #7's medical record revealed a physician order dated 4/17/23 at 2:43 pm to obtain a HGBA1c. A Hemoglobin A1C (HGBA1c) test is a blood test that measures your average blood sugar levels over the past 3 months and is used to determine and/or manage diabetes. Further review of the medical record failed to reveal that the lab was obtained. On 5/30/23 at 4 pm during an interview with the Director of Nursing, she stated that the HgA1c was not obtained as ordered by the physician on 4/17/23. After surveyor intervention, the physician was notified and the lab was obtained on 5/31/23.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with facility staff it was determined the facility failed to maintain infection control practices: 1.) in room [ROOM NUMBER] and of Resident #103's room as well as in 3 (#47, #48, & #77) of 4 resident's observed for infection control practices; and 2.) contain soiled linen on Unit B at the point of collection. This was evident for 1 of 3 units observed during observation rounds of the annual Medicare/Medicaid survey. Findings include: 1. An observation was made on 5/16/23 at 7:45 AM while touring the building and noted on the floor in room [ROOM NUMBER], was a dried dark red substance, and a large number of crumbs surrounding the bed. The Geriatric Nurse Assistant (GNA) # 3 was made aware at that time as she was in the hallway near the resident room. An observation was made on 5/17/23 at 11:00 AM of resident # 103's room and there were a large amount of crumbs and medicine cups noted on the floor. An observation was made on 5/19/23 at 1:15 PM of Resident #103's room and there…

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 with facility staff it was determined the facility failed to ensure that residents were offered a pneumococcal and influenza vaccine. This was found to be evident for 3 (Resident #111, #25 and #108) of 5 residents reviewed for immunizations during the facility's annual Medicare/Medicaid survey. Findings include: A review of resident # 111's medical record on 5/31/23 at 10:00 AM for immunizations revealed the resident did not have documentation of a pneumococcal or influenza vaccination. A review of resident # 25's medical record on 5/31/23 at 10:00 AM for immunizations revealed the resident did not have documentation of a pneumococcal or influenza vaccination. A review of resident # 108's medical record on 5/31/23 at 10:00 AM for immunizations revealed the resident did not have documentation of a pneumococcal or influenza vaccination. During a meeting with the DON on 5/31/23 at 11:35 AM she stated that resident # 111 and resident # 108 did not receive an Pneumococcal Vaccine. She further stated that resident # 25 refused all vaccinations…

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 maintain an effective pest control program as evidenced by numerous alive ants and multiple spiders seen in resident's rooms. This deficient practice has the potential to affect resident who reside on C-Wing. The findings include: On 05/25/23 at 10:23 am while the surveyor was speaking with Resident #19 in his/her room, the surveyor observed a dead ant on the resident's fitted sheet. RN #24 verified Resident #19 had a dead ant on the anterior left side of the fitted sheet near the pillow. There were multiple live ants and two alive spiders in Resident #19's room near the trim by the window. Resident #19 verbalized frequently seeing ants in the room. On 05/25/23 at 10:30 am observations made of multiple live ants near the window and on the air conditioner unit in room [ROOM NUMBER] C. There were a cluster of dead ants under the air conditioner unit. A spider web was in the corner of the bathroom with a live spider inside. On…

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

Based on observation and interviews of facility staff it was determined that food service employees failed to ensure that equipment was maintained and food was stored properly to reduce the risk of foodborne illness. The findings include: On 1/03/2019 at 9:26 AM surveyors toured the facility main kitchen with the food service manager. The following observations were made: 1. A cardboard box of green peppers and a cardboard box of wrapped boneless beef rounds were observed on the floor of the walk in refrigerator. 2. Cardboard boxes containing dry food goods were observed stored on the floor of the dry goods storage room and not on the available shelving in the room. On 1/09/2019 at 7:45 AM surveyors toured the facility main kitchen with the food service manager. The following observations were made: 1. The hand sink adjacent to the walk in refrigerator was not functional. Interview of the food service manager revealed that the sink had been disconnected to allow for repairs to the caulking around the basin. 2. The drain pipe for the sanitizer compartment of the 3 compartment sink…

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

Based on observation and interview, it was determined the facility staff failed to provide Resident #92 with the most dignified existence. This was evident for 1 of 56 residents investigated for dignity during the survey process. The findings include: On 1/4/19 at 12:30 PM, surveyor observation revealed Resident #92 was served lunch. The lunch was noted to be sitting in the room on the overbed table. The facility staff failed to feed the resident until 12:50 PM (20 minutes after the tray was placed in the room). Surveyor observation of Resident #92's breakfast on 1/5/19 at 8:34 AM revealed the resident's breakfast in the room sitting on the overbed table. Further observation revealed the facility staff failed to feed the resident until 8:40 AM. On 1/8/19, Resident #92's was served lunch at 12:50 PM; however, the facility staff failed to feed the resident until 1:02 PM. Surveyor observations of the facility staff revealed the facility failed to re-heat the resident's food prior to feeding. Interview with staff nurse #12 on 1/9/19 at 7:30 AM revealed the residents that need to be fed…

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

Based on clinical record review, staff interview, and resident interview it was determined that the facility staff failed to ensure residents' choices regarding showers and getting weighed were honored (#92 and #93). This was true for 2 out of the 28 residents reviewed during the investigative stage of the survey. The findings include: 1. I interviewed Resident #93 on 1/3/19 at 2:06 PM. Resident stated that he/she has only received one shower since admission and he/she would like at least one a week. The Director of Nursing (DON) was interviewed on 1/8/19 at 12:32 PM. She said she would investigate the shower issue. A review of the staff documentation of bathing for the resident from October thru January revealed that the resident only received bed baths. The DON was interviewed on 1/9/19 at 10:51 AM. She said she understood the findings. She said the resident often refuses and she has instructed staff to document when the resident refuses. Acknowledged that staff did not document the refusals. Stated the resident has a hip wound and does not like getting it wet. The DON said they…

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, it was determined that the facility staff failed to follow a resident's wishes as to when the resident's health care agent authority to change life-sustaining treatments became effective. This was evident for 1 (Residents #102) of 8 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 for documenting 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. Review of Resident #102's medical record on [DATE] revealed a valid set of advance directives that indicated Resident #102's durable power of attorney for health care's authority would become operative when Resident #102's attending physician and a second physician determine that 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 observation and staff interview it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior(#92). The findings include: On 1/03/2019 at 9:26 AM surveyors toured the facility including the kitchen and dining room. The following observations were made: 1. Surveyors observed dried food crumbs, loose potato chips and single serve sugar packets on the floor of the dry goods room. 2. Dining room service area observed with soiled countertops and crumbs scattered on the floor. The cabinet door under the sink was in disrepair and the inside of the cabinet was soiled with plastic trash and crumbs. Food debris was observed in 3 out of 4 steam tables. 3. The floor of the dining room was observed with crumbs and food debris around dining tables. 4. Meal carts were observed soiled with dried food stuck to the bottom ledge. On 1/09/2019 at 7:45 AM surveyors toured the facility kitchen and the dining room. The following observations were made: 1. Dining room floor observed with dried…

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

Based on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative. This was found to be evident for 2 (Resident # 37 and 62) out of 56 residents reviewed for a facility-initiated transfer during the investigative portion of the survey. The findings include: 1. A medical record review for Resident # 37 was conducted on 01/09/19. Review of the physician order written on 12/03/18 revealed that Resident # 37 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the ombudsman. 2. A review of Resident #62's clinical record revealed that the resident was sent to the hospital on 9/7/18. There was no evidence on the chart that the ombudsman was notified of the transfer. The Director of Nursing was informed of the finding at the exit conference.

Based on review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization. This was evident for 1(# 37) of 4 residents reviewed for Hospitalization during the annual recertification survey. The findings include: Review of the medical record for Resident #37 revealed the resident was transferred to an acute care facility on 12/03/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. On 01/08/19 01:28 PM, the Director of Nursining confirmed that Resident #37 and the Resident's responsible party did not receive the facility bed hold policy when Resident #37 was transferred to the hospital.

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 ensure that the Minimum Data Set (MDS) Assessments accurately reflected a resident's status (#44, 92). This was evident for 2 of 2 residents reviewed for accurate MDS assessments during the annual survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1. Review of Resident #44's 11-1-18 quarterly MDS assessment stated in answer to question J1900C that the resident had experienced 2 falls with a major injury. Interview with Unit Manager on 1-4-19 at 8:15 AM revealed Resident #44 had two falls and no injuries. Interview with the MDS Coordinator #5 on 1-9-19 at 8:41 AM stated the 11-1-18 MDS question J1900 was incorrect and Resident #44 had not had 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 medical record review, observation and interview, it was determined the facility staff failed to turn and reposition Resident #92 every 2 hours as ordered and failed to apply Prevalon boots as ordered to Resident #92. This was evident for 1 of 10 residents investigated for limited range of motion during the survey process The findings include: 1 A. The facility staff failed to turn and reposition Resident #92 every 2 hours as ordered. Medical record review for Resident #92 revealed on 12/10/18 the physician ordered: turn and reposition every 2 hours. Surveyor observation of Resident #92 on 1/10/19 at: 7:10 AM, 8:08 AM (being fed breakfast), 9:01 AM, 9:15 AM, 9:30 AM, 9:45 AM-10:00 AM (receiving care by Hospice staff), 10:15 AM, 10:30 AM, 10:45 AM, 11:00 AM, 11:15 AM, 11:30 AM, 11:45 AM, 12:00 PM, 12:15 PM, 12:30 PM, 12:45 PM, 1:00 PM and 1:45 PM revealed the resident in bed and on back. During the every 15 minute observations of Resident #92, the facility staff failed to turn and reposition the resident every 2 hours as ordered. 1 B. The facility staff failed to apply…

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 observation, review of resident clinical records and staff interview it was determined that the facility staff failed to plan and develop a care plan to address a resident's elopement status. This was evident for 1 (Resident 102) out 5 residents reviewed for accidents during an annual recertification survey. The findings are: During an observation of Resident #102 on 01/03/19 at 12:39 PM, Resident #102 was observed wandering the hall ways of the nursing unit with an alarm anklet in place. A review of Resident #102's on 01/03/18 failed to reveal an elopement risk assessment and care plan to address resident's ability to elope. The nursing unit manager was interviewed on 01/09/19 at 2:06 PM and confirmed there was not a nursing elopement risk assessment completed for Resident #102 upon admission to the facility. The nursing manager stated that an elopement care plan was initiated on 01/03/19.

Based on medical record review and interview, it was determined the facility staff failed to 1) revise Resident #102's impaired swallowing care plan to reflect current interventions identified by the interdisciplinary team, and 2) revise Resident #102's behavior care plan to reflect current recommendations from the facility psychologist and failed to revise Resident #7's care plan. This was evident for 2 (Resident #102, #7) of 2 residents reviewed for care planning. The findings include: 1) Review of Resident #102's medical record revealed an at risk for impaired swallowing related to dysphagia care plan. The nursing staff initiated the impaired swallowing care plan with interventions on 12/11/18. In an interview with the facility speech language pathologist (SLP) on 01/10/19 at 9:30 AM, the SLP stated that the nursing staff and Resident #102's family had been educated on swallowing compensatory strategies that included: Resident #102 is to take smaller bites of food, take multiple swallows, alternating solid and liquid boluses, and to sit at a 90-degree upright position during…

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

Based on medical record review and staff interviews and observation, it was determined that the facility failed to administer a medication in accordance with generally accepted standards of nursing practice. Nursing staff signed/initialed on the Medication Administration Record (MAR) that a medication was held but failed to notify the physician and receive further instructions. This was evident for 1 (Resident #63) of 5 residents reviewed for medication regimen review during the survey. The findings included: On 1-3-19 at 6:30 AM Staff #25 obtained Resident #63's blood sugar level as ordered. The level was 66 which is considered low especially in the morning. Staff #25 did not repeat the blood sugar test. Staff #25 then indicated on the medication administration record that the 6:30 AM ordered dose of insulin was held. Resident #63's medical record did not reveal that Staff #25 called the physician about the low blood sugar level or notified the physician that the ordered dose of insulin was held. On 1-9-19 at 1:00 PM the above finding was confirmed with Unit Manager #3.

Based on medical record review, observation and interview, it was determined the facility staff failed to obtain a pulmonary consultation for Resident #7, failed to apply ted stocking to Resident #30 and failed to turn and reposition Resident #92 every 2 hours as ordered, failed to apply Prevalon boots to Resident #92 as ordered and frequently used a painful stimuli to arouse a resident(#102). This was evident for 4 of 56 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to obtain a pulmonary consultation as ordered for Resident #7. Medical record review for Resident #7 revealed on 11/14/18 the physician ordered: pulmonary appointment for nonspecific right apical lung nodule (4 millimeters-mm). A pulmonary consultation with a physician who specializes in the diagnosis and treatment of lung disease. Lung nodules are described as spots in the lungs. Further record review revealed on the discharge summary it was noted: lung nodule-4 mm right lung nodule, incidental finding on head CT imaging. Recommendation for 6 months…

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, observation and interview, it was determined the facility staff failed to apply palm guards as ordered to Resident #7. This was evident for 1 of 56 residents selected for review during the annual survey process. The findings include: Record review for Resident #7 revealed on 6/4/18 the physician ordered: right and left palm guards every 4 hours. A palm guard is used as a barrier between fingers and palm skin to prevent injury to the palm from severe finger flexion contracture. A contracture is the shortening or stiffening of muscles, skin, or connective tissues that results in decreased movement and range of motion. Surveyor observation of the resident on: 1/4/19 at 9:36 AM revealed the resident noted with left hand contracture; however, no splint or palm protector was noted on the resident. On 1/9/19 at 12:40 PM and 1/10/19 at 10:00 AM revealed the resident in bed; however, the facility staff failed to apply the right- and left-hand palm protectors. Interview with the resident at that time revealed palm protectors had been in use at 1 time. The…

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

Based on medical record review and interview, it was determined the dietician failed to thoroughly assess and document assessments for Resident #92 when weight loss was noted. This was evident for 1 of 56 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #92 revealed the following documented weights: 10/31/18: weight 134 11/2/18: weight 128.8 11/9/18: weight 125.4 (a weight loss of 6.42% since admission to the facility) 11/16/18: weight 123.4 (a weight loss of 7.91% since admission to the facility) and 11/22/18: weight 124. Further record review revealed the dietician assessed and documented on Resident #92's medical record on 11/6/18 when the documented weight was 129.8 (a 3.13% weight loss) noted for Resident #92. Interview with the dietician on 1/9/19 at 7:50 AM revealed the dietician stating that she meets with the unit managers on Thursdays to discuss any triggered weight losses and the unit managers will document their interactions; however, there is no evidence of the dietician assessing Resident #92 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner(#1, #31, #102). This was evident for 3 of 56 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #1 revealed on 8/10/18 the consultant pharmacist was in the facility and documented: the resident receiving 3 antipsychotics (Seroquel, Risperidone and Zyprexa). Antipsychotic medications can reduce or relieve symptoms of psychosis, such as delusions (false beliefs) and hallucinations (seeing or hearing something that is not there). Formerly known as major tranquilizers and neuroleptics, antipsychotic medications are the main class of drugs used to treat people with schizophrenia. They are also used to treat people with psychosis that occurs in bipolar disorder, depression and Alzheimer's disease. Other uses of antipsychotics include stabilizing moods in bipolar disorder and reducing…

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

Based on medical record review and interview, it was determined the facility staff failed to ensure Resident #2 was free from psychiatric medications. This was evident for 1 of 56 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #2 revealed on 10/5/15 and 11/5/15 the attending physician and medical director assessed the resident and determined the resident lacked adequate decision-making capacity to make decisions related to his/her care related to brain injury. It was further noted at that time, the resident's sister and father were appointed to be Health Care Agent and the family agreed to make health care decisions for the resident. Further record review revealed on 12/18/18 at 8:00 PM the physician ordered: Risperdal .25 milligrams by mouth every morning for aggression. Risperdal is used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, irritability associated with autistic disorder). This medication can help the resident to think clearly and take part in everyday life.…

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 staff failed to ensure medications were kept in a locked and secured location. This was true for 1 out of the 3 nursing units. The findings include: This surveyor observed an unlocked medication cart outside of room [ROOM NUMBER]B on 1/3/19 at 1:44 PM. Nurse #23 came to the cart at 1:48 PM and locked it. She acknowledged it was unlocked when I told her of my observation. There was a resident present prior to the nurse returning but the resident was at the nursing station asking for ice. The resident's back was to the cart and the resident was 3 feet away. The conversation between the resident and the staff at the nursing station lasted 3 minutes. The Director of Nursing was interviewed on 1/9/19 at 10:54 AM. She was informed of the findings. She said she had told staff to always lock the cart and if unlocked it should always be in view.

Based on medical record review and interview, it was determined the facility staff failed to obtain laboratory blood work as ordered by the physician for Resident #57. This was evident for 1 of 56 residents selected for review during the survey process. The findings include: Medical record review for Resident #57 revealed on 11/16/18 at 9:50 AM the Certified Registered Nurse Practitioner ordered: CMP (Comprehensive Metabolic Panel) on 11/29/18. Further record review revealed the facility staff failed to obtain the laboratory blood test as ordered by the physician. The comprehensive metabolic panel (CMP) is a blood test that gives doctors information about the body's fluid balance, levels of electrolytes like sodium and potassium, and how well the kidneys and liver are working. Magnesium testing may be ordered as a follow up to chronically low blood levels of calcium and potassium. It also may be ordered when a person has symptoms that may be due to a magnesium deficiency, such as muscle weakness, twitching, cramping, confusion, cardiac arrhythmias, and seizures. Interview with the…

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

Based on medical record review and interview, it was determined the facility staff failed to maintain the medical records for Residents (#92 and #56) in the most complete and accurate form. This was evident for 2 of 56 residents selected for review during the survey process. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. A. The facility staff failed maintain the medical record for Resident in the most accurate form. Medical record review for Resident #92 revealed on 12/10/18 the physician ordered: turn and reposition every 2 hours. Surveyor observation of Resident #92 on 1/10/19 at: 7:10 AM, 8:08 AM (being fed breakfast), 9:01 AM, 9:15 AM, 9:30 AM, 9:45 AM-10:00 AM (receiving care by Hospice staff), 10:15 AM, 10:30 AM, 10:45 AM, 11:00 AM, 11:15 AM, 11:30 AM, 11:45 AM, 12:00 PM, 12:15 PM, 12:30 PM, 12:45 PM, 1:00 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 observations and interviews with staff it was determined that the facility failed to ensure residents had a means of directly contacting staff. This was evident in 1 Public bathroom and 1 Staff bathroom that was accessible to residents. The findings include: 1. On 1/10/2019 at 11:35 AM surveyors observed the call light system in the public bathroom behind the front desk. The chord for the call light system was wrapped around the toilet grab bar multiple times preventing the call light system from being activated by pulling the cord. Interview of the Maintenance Director revealed that housekeeping wraps the cord around the grab bar when they clean the bathroom floor. 2. On 1/08/2019 at 12:14 PM the Staff Bathroom adjacent to the Unit C Nurse's Station was observed to be open and accessible to residents. This surveyor observed that there was no call light system in this bathroom. This bathroom was observed to be open and accessible to residents on 1/09/2018 at 9:00 AM and 1/11/2019 at 8:45 AM. On 1/11/2019 at 8:46 AM surveyors interviewed a Certified Nursing Assistant (Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview of facility staff, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The findings include: On January 3-4th, 2019 surveyors conducting resident interviews observed the following environmental concerns: 1. On 1/3/2019 at 11:23 AM the floor in room [ROOM NUMBER]A was observed soiled and sticky. 2. On 1/4/2019 at 9:48 AM the baseboard molding below the air unit in room [ROOM NUMBER]C was observed to be in disrepair and peeling from the wall. These findings were confirmed and reviewed with the Director of Maintenance on 1/11/2019 at 6:45 AM.