Autumn Lake Healthcare At Chesapeake Woods

Based on review of Geriatric Nursing Assistant, (GNA) personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews at least every 12 months on 1 out of 2 GNA files reviewed during the recertification survey.The findings include: On 12/18/2025 at 10:13 AM Staff #8, GNA record review revealed that their 12-month performance review was last completed 5/17/2024. On 12/18/2025 at 10:30 AM the Director of Nursing (DON) was interviewed and asked if they had any more documentation related to Staff #8, GNA's 12-month performance evaluation. The DON stated they do not have Staff #8's performance evaluation for 2025. The DON verbalized understanding that GNA's performance evaluation should be done annually.

Number of residents sampled: Number of residents cited: Based on review of medical records and interview with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1of 5 residents (Residents #4) reviewed during the investigation phase of the survey for unnecessary medications. The findings include: On 12/15/2025 at 11:40 AM Resident #4's Medical Management Review (MMR) and the Medication Administration Record (MAR) were reviewed. The MMR had 2 recommendations for Resident #4. The first recommendation was addressed by Staff # 32, Physician Assistant (PA) as evidence by the written order, signature and date on the MMR. However, the second recommendation by the consulting pharmacist was not addressed. The consulting pharmacist stated that Resident #4 has an order for Midodrine 5mg three times a day for hypotension, low blood pressure (BP). Midodrine should be administered no later than 6pm (3-4 hours before bedtime) to avoid supine hypertension, high BP. Currently evening…

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.

Number of residents sampled: Number of residents cited: Based on observations, record review, and interviews, it was determined that the facility failed to ensure that resident meals were palatable, sufficiently portioned, and the foods were maintained outside of the food danger zone. This was evident for 2 (Resident #82 and Resident #5) of 2 residents interviewed and 2 of 2 foodservice operation days observed during the annual survey. The findings include: The Food Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. On 12/11/2025 at 1:15 PM, a telephone interview with Resident #82's Power of Attorney (POA) revealed that the resident was not receiving adequate food portions. On 12/11/2025 at 1:37 PM, Resident #5 voiced complaints regarding the taste and texture of the food. The resident further explained that the roast beef served for dinner on 12/10/2025 was tough, resembling rubber, and could not be cut with a butter knife. On 12/16/2025 at 9:15 AM, 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.

Number of residents sampled: Number of residents cited: Based on the QAPI process and interview it was determined that the facility staff were unable to report what individuals are legally responsible to establish and implement policies regarding the management and operations of the facility. The findings include: On 12/19/25 at 9:14 am during an interview with the Administrator the surveyor asked questions about the governing body, the Administrator verbalized not knowing what the surveyor was speaking of. The Administrator verbalized they have corporate leadership that comes to the facility, but she was uncertain who was legally responsible for the building and the leadership.

Number of residents sampled: Number of residents cited: Based on observations, record review, and interviews, it was determined that the facility failed to maintain essential equipment in proper operating condition. This was evident for 4 of 4 pieces of equipment reviewed during the annual survey.The findings include:All essential kitchen equipment, including but not limited to walk-in coolers, steam tables, dishwashers, ovens, stoves, and warming cabinets, must be maintained in safe operating conditions in accordance with the manufacturer's specifications and remain accessible throughout kitchen operations.On 12/10/2025 at 7:40 AM, the surveyor observed an inoperable steam table located in front of the cookline. The Healthcare Service Group (HCSG) District Manager confirmed the steam table was nonfunctional.At 7:55 AM, the surveyor observed that the Type 2 ventilation system above the high-temperature mechanical dishwasher was insufficiently removing steam from the unit. The steam escaped from the sides of the dishwasher and dissipated throughout the kitchen area.At 8:20 AM, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observations, record review, and interviews with facility staff, it was determined that the facility failed to ensure a call bell system was accessible to residents. This was evident for 1 (Resident #8) of 1 resident's and 1of 1 restroom call bell systems reviewed during the annual survey.The findings include:On 12/11/2025 at 10:34 AM, the surveyor conducted an interview with Resident #8, who was seated in a wheelchair at the foot of the bed. Following the interview, the surveyor asked Resident #8 to press the call bell for assistance due to reported pain and discomfort. The resident was unable to access the call bell, which was positioned behind the wheelchair. The resident confirmed this was the designated location for the call bell each morning when seated in the wheelchair.At 11:19 AM, the surveyor once again reported to the nurses' station that Resident #8 was experiencing discomfort and requested repositioning from the wheelchair. 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 and interviews, it was determined that the facility failed to provide residents with a homelike environment. This was found to be evident for 15 residents (#11, #20, #24, #35, #39, #52, #58, #60, #61, #62, #65, #68, #70, #79, #238) out of 94 resident environments observed by the surveyors during the survey. The findings include: During the initial screening on 02/12/24 at 10:04 AM, the surveyor observed that walls above the sink were damaged in rooms 73, 75, 80, 83, 84, 85, 87, and 89 on the Choptank Unit. The Corporate Maintenance Director was informed of the wall damage in the bathroom walls on the Choptank Unit on 02/15/24 at 09:38 AM. He stated he would investigate it and get back to the surveyor with his observations. On 02/15/24 at 11:03 AM, the Corporate Maintenance Director told the surveyor that he observed that the walls above the sinks were damaged from water splashing and the walls would be repaired and covered with fiberglass to protect the walls from future damage. During an interview with the Administrator and Director of Nursing on 2/23/24 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 review, and interviews, it was determined that the facility failed to accurately document wound assessments in a resident 's medical record. This was found evident for 1 (Resident #17) of 2 Residents reviewed for pressure ulcers. 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. On 2/20/24 at 10:28 AM, the surveyor reviewed Resident #17's medical record. The review revealed a wound note from Wound Nurse Practitioner Staff #31. The note revealed that on 3/30/23, Staff #31 evaluated Resident #17 and documented the resident had a stage 3 pressure ulcer (classification of wound; stage 3 is a full -thickness wound, where the wound is through the top two layers of the skin and into the fatty tissue below). Further review revealed an assessment…

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 hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This was found evident for 1 (Resident #17) of 5 residents reviewed for care planning. The finding include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team. On 2/12/24 at 10:56 AM, the surveyor interviewed Resident #17. In this interview Resident #17 stated he/she had not been to a care plan recently. On 2/16/24 at 9:27 AM, the surveyor interviewed Social Worker, Staff #8. During the interview Staff #8 described how care plan meetings are set up. She stated when a care plan is scheduled a letter is sent to either the Resident or the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident's medical records, and interviews, it was determined that the facility staff failed to provide activities of daily living (ADL) care in accordance with the resident's plan of care. This was found to be evident for 2 of 4 (Resident #188 and #17) residents reviewed for ADLs during an annual and complaint survey. The findings include: Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. 1a) On 2/28/24 at 9:25 AM, the surveyor reviewed Resident #188's medical record. The review revealed that Resident #188 was admitted to the facility in June of 2022. Further review revealed that Resident #188 had a baseline care plan initiated shortly after being admitted . The care plan indicated that Resident #188 preferred to receive showers. On 3/5/24 at approximately 10:30 AM, the surveyor asked for shower documentation for Resident #188 for the month of September of 2022. 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 interviews, record review, and facility policy, it was determined that the facility failed to provide respiratory care consistent with the professional standards for oxygen administration. This was found evident of 1 out of 3 (Resident #17) residents reviewed for respiratory care during an annual and complaint survey. The findings include: Pulse oximeter - a device that uses a light source to analyze the light that passes through a finger and can determine the percentage of oxygen saturation in the red blood cells, referred to as a pulse ox. Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels. On February /2024 at 9:55 AM, the surveyor reviewed Resident #17's medical record. The review revealed that Resident #17 had a care plan initiated on 11/6/23 related to the resident's emphysema (a lung condition that causes shortness of breath) and Chronic Obstructive Pulmonary Disease (COPD) (condition involving constriction of the airways and difficulty or discomfort in breathing). One of the interventions listed 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 record review, interviews and facility policy, it was determined that the facility failed to have a process in place that ensured a resident's medication irregularity report was reviewed by the primary care physician and that the recommendations were addressed timely. This was found evident of 1 (#17) of 5 residents reviewed for medication regimen review. Then findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the Inter-Disciplinary Team (IDT), including the resident, their family, and/or resident representative. On 2/26/24 at 12:25 PM the surveyor reviewed the Medication Regimen Review (MRR) for Resident #17. During the review it was…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary drugs. This was evident for 1 (Resident #17) or 5 residents reviewed for unnecessary medications. The findings include: On 2/26/24 at 12:25 PM the surveyor reviewed Resident #17's medical record. The review revealed a Medication Regimen Review (MRR) for Resident #17 completed on 12/11/23. The report stated Resident #17 was ordered two vitamin D3 oral medications. One dose every 7 days and the other one to be given every day. The Pharmacist recommended the provider evaluate if both agents were needed and consider discontinuing one of them. On 2/27/24 at 9:45 AM, the surveyor reviewed the Vitamin D3 orders. Both orders were written on 12/8/23. The order for the Vitamin D3 to be given every 7 days was discontinued on 2/27/24 at 8:34 AM, one day after the recommendations were requested by the surveyor. On 2/27/24 at 9:51 AM, the surveyor conducted an interview with the DON. In this interview the DON stated 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 on interview, and medical record review, it was determined that the facility failed to limit a as needed psychotropic medication from being prescribed for less than 14 days. This was found evident in 1 (Resident #17) out of 5 residents reviewed for unnecessary medications. The finding include: On 2/26/24 at 12:25 PM the surveyor reviewed Resident #17's medical record. The review revealed a Medication Regimen Review (MRR) irregularity report was completed for Resident #17 on 11/20/23 and 12/4/23, both for the same medication alprazolam (prescribed to treat anxiety). On 11/20/23 the Pharmacist recommended a 14-day stop date with the as needed alprazolam order. On 12/4/23 the Pharmacist recommended discontinuing alprazolam order and stated; if the medication cannot be discontinued then the provider should document the indication for use, intended duration and rationale for the extended time period. On 2/27/24 at 9:45 AM, the surveyor reviewed the alprazolam order written for Resident #17. The order was written on 11/1/23 and was written to be given as needed. The order was not…

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

Based on observations and interviews, it was determined that the facility failed to store medications appropriately according to standards of practice. This was evident for 1 of 30 medications observed during medication administration and 1 of 1 random floor observations. The findings include: Gout- a type of inflammatory arthritis that causes pain and swelling in the joints. On 03/01/2024 at 10:02 AM the surveyor observed a Licensed Practical Nurse (LPN), Staff #34, prepare and administer medications for Resident # 26. The Infection Preventionist/ Staff Educator, Staff #2, was present and stood opposite the surveyor and Staff # 34 for the duration of the observation. During preparation, the surveyor observed Staff #34 retrieve a blister pack with Allopurinol tablets, a medication prescribed to treat gout. Staff #34 reviewed the expiration date printed on the package and it was listed as 2/29/2024. Staff #34 pulled then retrieved another blister pack of Allopurinol from the medication cart prescribed for Resident #26 and the expiration date was 12/23/2023. Staff #34 retrieved…

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, facility policy review, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by 1) safeguarding Resident identifiable information from the public and 2) Keeping accurate documentation. This was found evident in 3 (Resident #17, #21 and #188) of 53 Residents reviewed during the survey. The findings include: 1. On 2/12/24 at 12:16 PM, the surveyor observed a medication cart with a computer on top of the cart. The computer screen was facing the B hallway on the Chesapeake wing. On further observations, the computer screen had Resident #17's medication profile displayed and the surveyor could see a list of medications. On 2/12/24 at 12:18 PM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #29. During the interview Staff #29 locks the computer screen and confirms that the computer screen should not be displaying the Resident ' s health care information. She also identifies the cart belong to the nurse that is working in the B hallway LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of policies and procedures, the facility failed to ensure that staff performed hand hygiene. This was evident for 2 (# 28 and # 29) out of 7 staff observed for hand hygiene. The findings include: On 02/20/24 at 08:18 AM, the surveyor observed Geriatric Nursing Assistant (GNA) #23 go into room [ROOM NUMBER] to serve breakfast, touch the resident environment, then proceed to the juice cart and return to room to finish helping the resident. She then went into room [ROOM NUMBER] and assisted the resident, touching the resident environment and exited the room towards the breakfast cart. When asked what the facility hand hygiene policy was GNA #23 stated we perform hand hygiene after touching a patient. She further stated I haven't touched a pt, but I can find hand sanitizer on the medication cart. The surveyor observed GNA #24 on 02/20/24 at 08:20 AM, enter room [ROOM NUMBER]. GNA #24 helped the resident set up breakfast, touching the resident environment and exited. GNA…

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 and staff interview it was determined that the facility staff failed to ensure a resident's responsible party (RP) was informed of a change in the medical regimen. This was evident for 1 (#89) out of 53 residents that were part of the survey sample. The findings include: An investigation into intake #MD00178510 revealed Resident #89's primary physician prescribed Seroquel (an antipsychotic) on 4/8/21, Haldol (an antipsychotic) on 3/4/22 and Depakote (an anticonvulsant used to treat epilepsy and bipolar disorder) on 3/4/22. The resident's RP was not informed of the medications being ordered for the resident and the medications were administered before the RP was aware of the orders per the complaint. A review of Resident #89's clinical record revealed the RP was not informed of the medications being ordered. The Director of Nursing (DON) was interviewed on 3/4/24 at 1:25 PM. She was informed of the three medications that were ordered and started without informing the RP. She said she would check the Electronic Health Record because she thought it may…

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 it was determined that the facility staff failed to ensure a resident's responsible party (RP) was informed of a fall. This was evident for 1 (#88) out of 53 residents in the survey sample. The findings include: An investigation into intake #MD00178237 revealed Resident #88 had a fall in April of 2022. The resident informed their cardiologist on 4/9/22 that they fell a couple of nights ago. The cardiologist assessed the resident for signs of an injury but did not observe any injury. The resident complained of left side pain along the ribcage. Cardiologist collaborated with primary physician regarding care and an x-ray was ordered for a chest x-ray. The x-ray was obtained the next day. Further review of the clinical record revealed that the resident's RP was not notified of the fall.

Based on interviews, and record review, it was determined that the facility failed to protect a Resident from abuse from a staff member. This was found evident of 1 of 17 (Resident #37) Residents reviewed for abuse allegations during an annual and complaint survey. The findings include: On 2/12/24 at 12:01 PM, the surveyor interviewed Resident #37. During this interview Resident #37 described an event in which Geriatric Nursing Assistant (GNA) Staff #26, responded to his/her call for assistance. After Resident #37 requested assistance with an incontinent incident, Staff #26 laughed at him/her and walked out of the room without responding to the request for assistance. Resident #37 reported this incident to the facility. On 2/22/24 at 10:19 AM, the surveyor reviewed the report of the investigation the facility conducted on the incident Resident #37 alleged about Staff #26. The report contained a copy of the Facility Reported Incident investigation that was submitted to the Office of Health Care Quality on 1/3/24. The report stated the facility suspended Staff #26 pending 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 interview, and record review, it was determined that the facility failed to immediately report an allegation of abuse to the State Office of Health Care Quality. This was found evident in 1 out of 17 (Resident #189) Residents reviewed for abuse allegations during an annual and complaint survey. The findings include: On 3/04/24 at 1:05 PM, the surveyor reviewed an investigation report the facility conducted regarding an allegation of abuse of Resident #3. The surveyor reviewed 8 questionnaires titled, 'Resident Interviews'. All 8 questionnaires were conducted on 10/2/23. Each questionnaire had the name of the resident being interviewed but did not indicate who conducted the interview. The last question on the form stated; Has anyone hurt or harmed you? One resident (Resident #189's) response to the question was, Only verbal abuse by Aids. On 3/4/24 at 1:26 PM, the surveyor interviewed the Director of Nursing (DON). During the interview the DON stated she along with the Administer In Training (AIT) conducted the investigation regarding Resident #3. She further stated she 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility staff failed to ensure a thorough investigation was conducted and maintain documentation of the investigation. This was evident for 2 (Resident # 88 and #90) out of the 53 residents that were part of the survey sample. The findings include: 1a) An investigation into intake #MD00178237 revealed Resident #88 had a fall in April of 2022. The resident informed their cardiologist on 4/9/22 that they fell a couple of nights ago. The cardiologist assessed the resident for signs of an injury but did not observe any injury. The resident complained of left side pain along the ribcage. Cardiologist collaborated with primary physician regarding care and an x-ray was ordered for a chest x-ray. The x-ray was obtained the next day. A review of the facility's investigation of the fall revealed that the nurse conducting the investigation completed a checklist of tasks that needed to be completed for a thorough investigation. One of the items…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview it was determined that the facility staff failed: 1) to ensure that a physician sent a death certificate to a funeral home and 2) failed to ensure the physician provided supervision for a resident with significant weight loss. This was evident for 1 (#337) out 3 residents reviewed for death and 1 (Resident # 96) out of 1 resident reviewed for weight loss. The findings include: The investigation into intake #MD00198914 revealed Resident #337 died on [DATE]. The funeral home handling the funeral did not receive the resident's death certificate. A review of the resident's clinical record revealed that there was no evidence that the facility sent the death certificate to the funeral home that picked up the body or to the funeral home that received the body. Staff #21 was interviewed on [DATE] at 9:09 AM. She said the second funeral home called her to ask for the death certificate. She didn't realize they didn't have it, so she called the Director of Nursing and got…

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 review of pertinent facility documentation it was determined that the facility failed to 1) maintain proper infection control and sanitation procedures and 2) promote a resident's dignity and respect while providing feeding assistance to a resident during lunch. This was found to be evident during observations on both units and individual observations for 1 (Resident #70) when a dining experience was observed during the facility's annual Medicare/Medicaid survey. The findings include: 1) Observation of meal service on 3/26/19 at 8:30 AM on the Homestead unit Staff # 14 was observed serving meals from the hot cart. H/she did not have a hairnet on or a mask. The Dietary Director was notified at 8:45 Am of the observations of Staff #14 not having a hairnet on while serving breakfast. Observation of lunch on 3/26/19 at 11:30 AM on the Homestead unit Staff #14 was observed serving lunch with a hairnet on and a mask on. She was asked by the surveyor why she had a mask on now and she stated that she had not received her flu shot. Interview on 3/28/19 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, interview and review of pertinent information it was determined that the facility failed to adequately train their Geriatric Nursing Assistants (GNA's) to serve as dietary personal during meal services. The findings include: Observation on 3/25/19 through 3/28/19 revealed GNA staff that were assigned to residents and responsible for providing care throughout the day however, were also observed assigned to the hot cart and serving breakfast and lunch during the breakfast and lunch meal services on the Homestead Unit. Staff #3, the Dietary Manager, was interviewed multiple times throughout the survey and asked for documentation to be provided to the survey team that the GNA's that are responsible for serving food from the hot cart are trained in the different meal consistencies and portion sizes. On 3/28/19 Staff #3 provided the survey team with a list of staff that were identified as in-serviced on 2/27/19 but there was no attached training. He stated that he could type something up but did not have anything at this moment in writing for the survey team. He…

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 it was determined the facility failed to enhance and promote a resident's dignity and respect while providing feeding assistance to a resident during lunch. This was found to be evident for 1 resident (Resident # 70) when a dining experience was observed during the facility's annual Medicare/Medicaid survey. The findings include: A lunch dining experience was observed on 3/25/19 at 12:30 PM. A Geriatric Nursing Assistant (GNA), Staff #4 entered the C-Wing dining room at 12:30 PM. Upon entering the room from the unit, Staff #4 did not wash or sanitize his/her hands. At 12:32 PM, Staff #4 went over and stood above Resident #70 and fed him/her their lunch. Staff #4 finished feeding the resident at 12:43 PM. The Nurse on the unit, Staff #21 was made aware of all concerns on 3/25/19 at 12:48 PM. The Director of Nursing was made aware of concerns on 3/25/19 at 1:20 PM.

Based on review of the facility reported incident MD00128582, investigative information, medical records and interview with staff it was determined that the facility failed to keep a resident free from abuse. This was evident for 1 out of 3 residents (Resident #81) reviewed for abuse. The findings include: On 3/26/19 Resident #81's medical records were reviewed. This review revealed a Brief Interview for Mental Status completed on November 2018 with a score of 8 out of 15, the scores between 8 and 12, indicate moderate cognitive impairment. Review of the facility self-reported incident on 3/26/19 revealed that on 7/3/18 when the geriatric nursing assistant (GNA) entered the resident's room the GNA noted that the resident was undressed and had thrown the sheet and adult briefs in the trash and had urinated in the bed. The GNA also revealed she noted that the resident's finger was crooked. The investigating report revealed the GNA left the room and went a got the resident's nurse. When the nurse and the GNA entered the resident's room the resident stated She punched me and broke my…

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 include the required statement of the resident's appeal rights and ombudsman contact information in the written notice of transfer. This was found to be evident for 2 out of 2 residents (Residents #90 and #73), reviewed for hospitalization during the investigative stage of the survey. The findings include: 1. On 3/28/19 review of Resident #90's medical record revealed the resident had been discharged to the hospital on 2/15/19. Further review of the medical record revealed a letter sent to the responsible family member regarding the Notice of Hospital Transfer. Review of this letter failed to reveal any documentation regarding the resident's appeal rights or the contact information for the ombudsman. On 3/28/19 at 3:37 PM surveyor discussed the concern with the Director of Nursing that the letter does not include the required information regarding appeal rights. The concern regarding the failure to include required information in the Notice of Hospital Transfer was again reviewed at time of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview 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. assess medication usage and 2. assess the resident's dental condition. This was found to be evident for 2 out of 6 residents (Resident #82 and Resident #1) reviewed during the investigative stage of the survey. The findings include: The MDS is a federally-mandated assessment tool used by nursing home staff to 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. On 3/27/19 Resident #82's medical records revealed an MDS with an assessment reference date (ARD) of 3/4/19 which documented that the resident had not received any psychotropic medication during the 7 day look back period and it was documented that the resident received…

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, observation and interview with facility staff, if was determined that the facility failed to follow a resident's care plan related to nutritional intervention needs. This was evident during the review of 1 of 25 residents (Resident #13) reviewed for care planning during the annual survey. The findings include: Resident #13 was observed from 12:25-12:55 PM attempting to eat lunch on 3/25/19. Resident #13 was noted struggling to complete the task of eating; getting his/her hand from the plate to his/her mouth. The resident was observed repeatedly picking up food with his/her fork and staring at it. S/he would repeat the motion of putting food on the fork without completing the motion of getting the fork to his/her mouth. This continued for 30 minutes as staff walked back and forth past the resident. The Director of Nursing (DON) and the Homestead Director Staff #2 were notified of the observations at 1:06 PM on 3/25/19. Review of the resident's medical record on 3/25/19 revealed…

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 facility staff, it was determined that the facility failed to have an effective system in place to ensure that the hand off communication regarding resident consultations and prescriptions were clearly and effectively communicated with staff. This was evident for 1 out of 9 residents (Resident #1) reviewed during the investigative stage of the annual survey. The findings include: On 3/28/19 Resident #1's medical records were reviewed. This review revealed that the resident was admitted to the facility in October 2018 for rehabilitation and with diagnosis that includes Multiple sclerosis (MS) (an unpredictable, often disabling disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body). Review of the physician orders failed to have Tecfidera listed as a medication ordered. Medical records review revealed that the resident had a neurology appointment in November 2018 and returned to the facility with a copy of the consultation report. Review of the neurology consultation…

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

Based on review of employee files and interview it was determined that the facility failed to have an effective system in place to ensure newly hired Geriatric Nursing Assistants (GNA's) had skills assessments completed prior to being allowed to work independently with residents. This was found to be evident for 2 out of the 4 employee files (GNA #20 and #17) reviewed for new hire competencies. The findings include: On 3/29/19 at 9:52 AM, Nurse Educator #8 reported that she assesses new hires for competency with hand hygiene. She went on to report that there is a check off list that the person orienting them will check off that the new hires have accomplished and that when this check off is completed it should go to human resources to be included in the employee file. On 3/29/19 review of GNA #20's employee file revealed a hire date in March 2018. No documentation was found that a new hire skills assessment had been completed. On 3/29/19 review of GNA #17's employee file revealed the GNA started working at the facility as a GNA in March of 2018. Review of the Inservice Record…

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

Based on review of employee files and interview it was determined that the facility failed to complete annual performance reviews for Geriatric Nursing Assistants (GNA's) for a more than a one year period of time. This was found to be evident for 2 out of the 2 GNA's (GNA #14 and #16) reviewed for annual evaluation and education. The findings include: On 3/29/19 review of GNA #16's employee file revealed a hire date in May of 2010. Further review of the file failed to reveal documentation of an annual performance evaluation since 2017. On 3/29/19 review of GNA #14's employee file revealed a hire date in December of 1994. Further review of the file failed to reveal documentation of an annual performance evaluation. On 3/29/19 at 9:31 AM the Director of Nursing (DON) reported that the previous DON had not done evaluations due to raises not being merit based but that she had started re-implementing annual evaluations starting in January 2019. She went on to state that the evaluations were being conducted based on month of hire and confirmed that GNA #14 would not be scheduled for 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 medical record review, observation and interview it was determined that the facility failed to ensure anti-anxiety medication was destroyed after a resident expired and that narcotics that remained in the facility were included in the shift to shift narcotic count. This was found to be evident during observation of 1 of the 2 medication storage rooms. The findings include: On [DATE] at 11:30 AM observation of the medication room, with Nurse #23, on the Chesapeake unit revealed a container of liquid lorazepam (also known as Ativan, an anti-anxiety medication) in the locked compartment of the medication refrigerator. The medication was labeled as belonging to Resident #139 and Nurse #23 reported that the resident had died. Review of Resident #139's medical record revealed the resident had expired in late [DATE]. Review of the unit's narcotic count book revealed the medication had been received at the facility on [DATE], one dose had been administered to the resident and that 29.75 ml of the medication…

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

Based on observation, interview and review of medical records and facility policies it was determined that the facility failed to ensure a less than 5% error rate during medication administration as evidenced by: 1) Staff crushing medications that were on the facility Do Not Crush list, including extended release and 2) staff failing to take blood pressure prior to administering blood pressure medications. These errors were identified based on observation of 3 out of 3 residents (Residents #5, #27 and #81) observed during medication pass observation with 1 nurse on 1 unit. The findings include: On 3/28/19 between 9:30 AM and 10:30 AM surveyor observed the medication preparation and administration. There were 28 opportunities for error and 3 medication errors. 1) Observation of medication preparation for Resident #27 included 12 medications. Included in the observation were: Guaifenesin ER (extended release) 600 mg give 1 tablet by mouth two times a day. All 12 of the medications were observed to be crushed by the nurse (Staff #13) and mixed with applesauce. Prior to administration…

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

Based on observation and record review and interview, the facility failed to ensure that the resident was served a therapeutic diet as prescribed by the physician. This was observed of 1 out of 14 residents (Resident #37) during the annual survey. The findings include: Therapeutic Diet means a diet ordered by a physician or delegated registered or licensed dietitian as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet. Review of the physician's order sheet on 3/25/19 at 2:25 PM revealed a diet change to dysphagia (difficulty in swallowing) puree texture diet (smooth and lump free, which requires no chewing). This order went into effect on 3/25/19. Observation of the lunch time meal on 3/26/19 at 12:16 PM revealed that Resident #37 was not given a puree diet. The resident was served macaroni and cheese and stewed tomatoes with chunks of tomatoes and a slice of bread. The resident was observed coughing several times while ingesting the meal. Interview on 3/26/19 at 12:21 PM with Geriatric Nursing Assistant (GNA) #14 who…

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 with residents and facility staff it was determined the facility failed to have a resident's physician assessment as part of the resident medical record. This was found to be evident for 1 of 25 residents, (Resident # 88) reviewed during the facility's annual Medicare/Medicaid survey. The findings include: An interview was conducted with Resident #88 on 3/25/19 at 10:06 AM and s/he stated that the physician came in to visit one time since being admitted to the facility. The resident went on to say the physician visited her/him in the hallway a month ago. Medical record review on 3/27/19 revealed Resident #88 was admitted to the facility on [DATE]. A physician progress notes for 2/20/19 and 3/17/19 was inside of the resident medical record. There was not an initial assessment in the medical record. An interview was conducted with the Unit Manager, Staff # 12 on 3/27/19 at 11:10 AM and s/he was asked when a resident is first admitted to the facility, when does 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 observation, interview and review of complaint and maintenance documentation it was determined that the facility failed to have an effective system in place to ensure batteries for electronic lifts were charged and available for use and failed to have documentation of preventative maintenance of the lifts. This was found to be evident on 1 of the 2 nursing units. The findings include: Review of complaint MD00134906 revealed a concern regarding the batteries for the electronic lifts not being charged. Electronic lifts are used to assist staff with safely transferring residents. Review of the facility documentation revealed an inventory of 3 sling lifts and 3 sit to stand devices. All six of these pieces of equipment require the use of a portable battery in order to function. On 3/27/19 at 12:43 PM surveyor observed a sling lift in a resident's room, GNA #18 reported it had been working slow so the battery needs to be changed out. GNA #18 was then observed replacing the battery with a fully charged battery from the utility room. Afterwards, observation of the charging station…

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.