Mallard Bay Nursing And Rehab

Based on observation during tour and interview with facility staff, it was determined that the facility staff failed to ensure that resident medications and supplies, including oxygen were maintained in a secure fashion. This was an observation on 2 occasions and 2 additional times after the implementation of education by the facility DON and occurred on 3 of 3 units.The findings include:On 3/23/26 at 10:50 AM an oxygen tank was observed sitting on the floor with no supporting device present. The oxygen tank was located to the left behind the bed of Resident #12 who resides on unit 1.RN #1 was notified of the observation and concern and immediately proceeded to get a tank holder and secure the oxygen tank.Tour of the facility on the 3rd unit on 3/25/26 at 7:31 AM noted a treatment cart with a Collagenase Santyl cream on top labeled for Resident #17. This surveyor observed 2 residents wheeling past in power wheelchairs and staff sitting at the nursing station. Staff RN #7 was notified of the observation and concern and upon looking at the cream stated that it was just delivered 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 the review of a complaint related to a new admission diet, staff and resident interviews, and medical record review, it was determined that the facility failed to employ sufficient staff to ensure all residents with dietary concerns were met. This was evident during the review of 3 of 3 (Resident #16, #26, #27) residents related to complaints about diet. The findings include:On 3/25/26 at 10:30 AM, review of the complaint 2962212 regarding admission assessments, revealed Resident #16 was admitted to the facility over 2 weeks ago in addition to other comorbidities for diabetic management with an A1C level of 11.5%. (A1C measures average blood sugar levels over the past 2-3 months, normal levels are below 5.7%). A review at this time of the hospital discharge orders, included a recommendation for a carbohydrate-controlled diet. Further review, however, revealed that upon admission, Resident #16 was ordered a regular diet with no acknowledgement of the need for the carbohydrate-controlled diet until…

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 staff failed to thoroughly investigate allegations related to potential abuse and injuries of unknown origin. This was evident during the review of 2 of 8 facility reported incidents (Residents #3). The findings include:1. The surveyor reviewed the facility investigation for Resident #3 on 3/23/26 at 1:54 PM. Resident #3 had 2 separate allegations of abuse, on 2/5 or 2/6 and again on 2/8. The facility provided the investigation packets which contained interviews of staff who cared for or were scheduled the days of the allegations. Although both incidents were investigated with a focus on Resident #3, the facility investigation did not contain any other resident interviews inquiring about abusive or neglectful treatment from facility staff, specifically the staff that were working on the days the allegations of abuse from Resident #3 were reported. During interview with the DON and Corporate [NAME] President of Clinical Operations on 3/24/26 as to the concern that there was no type…

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 complaint related to the oral status of residents with tracheostomies and percutaneous endoscopic gastrostomy (PEG) tubes, observations, interviews with residents and staff, it was determined that the facility failed to provide oral care to a resident that was dependent on staff for activities of daily living (ADL). This was evident during the review of a complaint for 1 of 3 (#23) residents related to quality of care. 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. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. Resident #14 was observed and interviewed on 3/24/26 at 11:09 AM. S/he was noted with a tracheostomy and a behavior of intermittently chewing on the comforter, towel or blanket nearby. This resident made good eye contact with the surveyor and so s/he was interviewed. S/he was noted with a thicker white substance in the mouth that…

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

Based on medical record review, observation and interview with facility staff, it was determined that the facility staff failed to ensure that the residents' medical records were maintained and documentation was complete. This was evident for 3 of 22 (#2, #7 and #16) medical records reviewed during a complaint survey. The findings include:1. Review of the complaint and medical record for Resident #7 on 3/23/26 at 9:50 AM revealed concerns related to wound care. However, according to the medication administration record (MAR) for the specific dates reported the wound care and subsequent treatments were signed off. During a face-to-face meeting with Resident #7 and the facility DON on 3/25/26 at 11:15 AM s/he had continued complaints about wound care and staff not changing the bandages. This surveyor reviewed that the MAR was reviewed for the dates that s/he had complained about and that staff had signed off that they completed the tasks. Resident #7 then stated that it occurred again this past weekend. This surveyor stated they would review the MAR for the identified concerns. 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 and medical record review, it was determined that the facility failed to ensure infection control orders were followed and consistent throughout the facility. This was evident during the review of a complaint related to residents on transmission-based precautions.The findings include:Contact precautions involve full-time gown/glove use and resident isolation for acute, infectious, or draining infections, usually time limited.Enhanced Barrier Precautions (EBP) use gowns/gloves only for high-contact care (e.g., dressing, transfers) for residents with known MDRO (multi-drug-resistant organism) colonization, allowing room sharing and social participation. Resident #17 at 8:24 AM was observed in the room with physical therapy. There were no signs up identifying the need for any personal protective equipment (PPE), however, a foley catheter could be seen from the doorway.At 8:25 AM, Resident #18 was observed in bed. The facility nurse practitioner (NP) was in the room on her personal phone, with no PPE and the assigned GNA, staff #13 was currently…

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 the facility staff failed to 1) ensure Minimum Data Set (MDS) assessments were accurately coded and 2) complete a discharge assessment. This was evident for 5 (#1, #6, #2, #5, #7 ) of 10 residents reviewed for complaints during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1)On 1/6/26 at 10:02 AM a review of Resident #1's medical record was conducted and revealed Resident #1 had a fall on 10/28/25, 11/1/25, and 11/2/25. Review of Resident #1's admission MDS with an assessment reference date (ARD) of 11/3/25, Section J, falls, only captured 1 fall without injury. The facility failed…

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 failed to ensure residents received treatment and care in accordance with professional standards of practice (Residents #1, #2 and #3). This was evident for 3 of 10 residents reviewed during a complaint survey.1.The facility staff failed to administer medications as ordered by the physician for Resident #3. A review of Resident #3's medical record was conducted on 1/6/26 for the Resident's complaints of not receiving medications as ordered in December 2025. Review of Resident #3's November and December 2025 Medication Administration Records (MAR) revealed: On 11/28/25 the Resident was ordered Triamcinolone Acetonide Mouth/Throat Paste, apply to left lower side of gum topically after meals and at bedtime for mouth ulcer for 7 days. The Resident was not administered Triamcinolone Acetonide until 12/1/25. On 12/9/25 the Resident was ordered Triamcinolone Acetonide twice daily for 7 days. The Resident did not receive the medication on 12/9,…

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 failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed. This was evident for 2 (#1, #6) of 10 residents reviewed during a complaint survey.The findings include:1) On 1/6/26 at 10:02 AM Resident #1's medical record was reviewed and revealed Resident #1 was admitted in October 2025 with diagnoses that included a cerebral infarction with hemiplegia and hemiparesis affecting the left non-dominant side. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.Review of Resident #1's care plan, has an ADL (activities of daily living) self-care performance deficit r/t impaired mobility, disease process, advanced age, dementia, activity intolerance, and left hemiplegia had the intervention, encourage the resident to use call bell for assistance. A second care plan stated, has had an actual fall r/t impaired mobility,…

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, it was determined that facility staff failed to ensure that resident medical records remained private and confidential. This was evident for 1 of 3 nursing units observed during a complaint survey.The findings include: On 1/8/26 at 8:43 AM observation was made of Resident #10's electronic medical record displayed on an opened computer screen that was sitting on top of an unattended medication cart on the 200-nursing unit. Resident #2's medications were on display and an opportunity to look at additional information was available. The medication cart was sitting in the hallway outside of room [ROOM NUMBER]. On 1/8/26 at 8:45 AM Staff (LPN) #21 walked up the hall to the medication cart where the surveyor was standing. The surveyor informed Staff #21 of the finding. Staff #21 stated, I didn't mean to leave the computer screen open. On 1/8/26 at 8:46 AM the Director of Nursing (DON) was informed of the finding. The DON stated she would speak to Staff #21 about the concern.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to document the details of a transfer of a resident (Resident #9). This was evident for 1 of 3 residents reviewed for transfers during a complaint survey.The findings include:Review of Resident #9's medical record on 1/7/26 revealed the Resident was admitted to the facility on [DATE] and transferred from the facility on 12/4/25 to another nursing facility.Further review of the Resident's medical record did not reveal the reason the Resident was transferred to another facility, notice given to the Resident and the Resident's representative in writing and a completed discharge summary for the Resident.Interview with the VP of Clinical Services on 1/7/26 at 1:17 PM confirmed the facility staff failed to document the details of Resident #9's transfer to another nursing facility on 12/4/25.

Based on record review and interview it was determined the facility failed to follow-up when the Nurse Practitioner documented that a resident needed glasses due to not being able to see properly. This was evident for 1 (Resident #1) of 10 residents reviewed during a complaint survey.The findings include:On 1/6/26 at 10:02 AM Resident #1's medical record was reviewed and revealed an 11/12/25 Nurse Practitioner (NP) note written by NP #8 that documented that Resident #1 told NP #8 that he/she could not see without his/her glasses, and his/her glasses were broken.A 11/13/25 health status note documented, staff continues to monitor for falls as a safety precaution. Has had several falls recently without injuries.A 11/21/25 at 12:45 PM note documented that Resident #1 was observed on the ground in the courtyard. Resident #1 was returned to his/her room and assessed where he/she complained of dizziness and blurred vision.A 11/21/25 at 21:08 (9:08 PM) note by NP #8 documented, per the nursing staff, the patient fell out of [his/her] wheelchair onto [his/her] face while in the courtyard.…

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, observation, and interview, it was determined the facility staff failed to ensure fall mats and the resident's call bell were properly in place for a resident with a history of falls. This was evident for 1 (#6) of 10 residents reviewed during a complaint survey.The findings include: On 1/6/26 at 2:45 PM a review of Resident #6's medical record revealed Resident #6 had been a resident of the facility since 2017 and had diagnoses that included a non-displaced fracture of the right humerus, primary osteoarthritis, obsessive-compulsive disorder, unspecified dementia, and repeated falls. Resident 6's medical record was reviewed and revealed Resident #6 had a fall on 9/28/25 that resulted in a hematoma on the head with laceration. Review of a 10/23/25 nursing note documented that Resident #6 fell and sustained a right humerus fracture. Review of a 11/20/25 health status note documented Resident #6 was discussed in risk management meeting related to falls and a perimeter mattress and fall mats would be implemented. A care plan is a guide that addresses the unique…

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 failed to provide respiratory services in accordance with professional standards of practice. This was evident for 1 (#5) of 10 residents reviewed during a complaint survey.The findings include: On 1/7/26 at 12:45 PM a review of Resident #5's medical record revealed the resident had been admitted to the facility in October 2025 from an acute care facility with diagnoses that included seizures, traumatic brain injury, and chronic pain with spinal cord stimulator. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.Review of Resident #5's admission MDS…

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 obtain outside services for a resident per the hospital discharge summary in a timely manner. This was evident for 1 (#2) of 10 residents reviewed during a complaint survey.The findings include: On 1/7/26 at 7:55 AM a review of Resident #2's medical record revealed Resident #2 was admitted to the facility in June 2025 and was readmitted to the facility on [DATE] following a hospitalization for a repair of a fracture of the right femur. Review of Resident #2's hospital Discharge summary dated [DATE] documented on 10/24/25 the resident had an open reduction internal fixation of the hip for a right femoral neck fracture and was to schedule an appointment as soon as possible for a visit in 1 week. Further review of the medical record revealed Resident #2 was not seen by the orthopedic doctor until 12/9/25. On 1/7/25 at 11:36 AM an interview was conducted with the VP of Clinical Services, Staff #10. Staff #10 confirmed 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 medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (#1, #2) of 10 residents reviewed during a complaint survey.The findings include: A medical record is the official documentation of 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)The facility staff failed to keep neuro checks after unwitnessed falls in Resident #1's medical record.A neuro check after a fall refers to a neurological assessment performed by a healthcare professional to evaluate potential brain injuries by checking a person's level of consciousness, orientation, pupil response, muscle strength, sensation, and coordination. On 1/6/26 at 10:02 AM Resident #1's medical record was reviewed and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that the facility failed to maintain an environment free of physical restraints. This was evident for 1 (Resident #2) of 1 resident reviewed for restraint usage during a complaint survey. The findings include:Brief Interview for Mental Status Evaluation (BIMS) - comes from a quick test that looks at how well you think, learn and remember. Scores range from 0 to 15. Lower scores can point to difficulties with memory or thinking (cognitive) skills. During a review of complaint #2639805 on 10/20/25 at 9:02 AM it was reported that Resident #2 was observed strapped to his/her wheelchair. During a medical record review 10/20/25 at 9:58 AM it was discovered that Resident #2 had a BIMS of 0 which indicated Severe Cognitive Impairment. A Nurse Practitioner Follow-Up Note from 10/14/25 reported, the patient is not able to sit still and had a diagnosis of severe dementia with agitation. During a review of the Care Plan for Resident #2 it was revealed that…

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

Based on medical record reviews and interviews, it was determined the facility failed to review and revise the interdisciplinary care plans to reveal accurate interventions to meet the needs of the residents. This was evident for 1 (Residents # 1) of 1 resident reviewed during the complaint survey.The findings include:Resident #1 was readmitted to the facility in May 2025 with diagnoses which include Systemic Lupus Erythematosus and Rheumatoid ArthritisOn 10/20/25 at 12:01 PM the surveyor reviewed Resident #1's clinical record. The review revealed that the resident received intravenous antibiotics for infections on several occasions. The most recent were Vancomycin via a peripherally inserted central catheter (PICC) line for several days from June 2025 to October 2025, Daptomycin via PICC line from August 2025 to September 2025 and Amoxicillin -Pot Clavulanate by mouth in October 2025.Further review of the clinical record failed to reveal a Care Plan with interventions for antibiotic therapy and PICC line care while the resident was receiving treatment for infections. During 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.

Based on medical record reviews and interviews, it was determined that the facility failed to ensure medical records were complete and accurate. This was evident for 2 (Resident #3 and #1) of 4 residents reviewed for accurate medical record documentation during the complaint survey.The findings include: 1) During a medical record review on 10/20/25 at 11:19 AM it was revealed that Resident #3 had several medications documented in the Medication Administration Record (MAR) as not given and reported the reason not given as 9 = Other/See Progress Notes. During a review of the Progress notes it was discovered that there was no documentation for the reasons the medications were not administered. The following medications were documented with 9 = Other/See Progress Notes and had no documentation found in the progress notes. Atorvastatin on 9/28/25 Meloxicam on 9/27/25, 9/28/25, 9/29/25, 9/30/25, 10/01/25, 10/11/25 Metoprolol on 9/30/25 Risperdal on 9/30/25 ABH Gel on 9/27/25, 9/28/25, 9/29/25, 9/30/25, 10/01/25, 10/02/25, 10/03/25. 10/04/25, 10/05/25, 10/06/25, 10/10/25, 10/12/25…

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 resident interview, the facility failed to ensure that a resident's dignity was maintained for 1 of 3 residents reviewed for privacy during observation rounds and failed to ensure that staff wore facility-issued identification badges while providing resident care. This was evident for 5 staff observed during the survey. The findings include: 1. On 9/2/25 at 10:00 AM, during observation rounds, Resident #74 was observed lying in bed near the door with his/her Foley catheter bag exposed and visible to anyone walking by in the hallway. The bag was not covered with a privacy bag. During an interview with Resident #74 on 9/2/25 at 10:10 AM, the resident stated, My bag is always like this.The facility's failure to maintain resident dignity had the potential to cause embarrassment, loss of self-respect, and decreased quality of life. 2. On 9/2/25 at 8am during a facility-wide observation, multiple staff members, including Geriatric Nursing Assistant (GNA #15), Licensed Practical Nurse (LPN #11), and Registered Nurses (#3, #27), were observed providing direct care…

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

Based on observations and interviews with facility staff it was determined the facility failed to ensure that resident's rooms were properly maintained and their environment was homelike. This was found to be evident for 2 resident rooms observed on the 100 hallway during the facility's survey.Findings include,While conducting an initial tour on 9/2/25 at 9:20AM of the 100 hallway, an observation was made of Resident # 2's bathroom. On the right side of the wall above the baseboards there was a large spackled area that was in need of paint. Further observations were made of Resident # 33's room on the same date at approximately 9:50AM and the wall area behind the bed was completely marred and in need of repairs. The Administration team was made aware of the concerns at the exit conference on 9/5/25 at 1:45 PM.

Based on record review and staff interview, the facility failed to ensure that residents were free from misappropriation of property when Registered Nurse (RN) #25 misappropriated Resident #76's prescribed oxycodone following discharge from the facility. This deficient practice was evident for 1 Resident (#76) reviewed for medications. Findings include:Oxycodone is a controlled opioid medication with a high potential for misuse, addiction, and dependence. Proper handling and destruction of controlled medications is required to ensure resident safety and prevent diversion. On 09/05/2025 at 11:27 AM, during investigation of Facility Reported Incident (FRI) 358648, it was discovered that in August 2024, RN #25 removed Resident #76's oxycodone from the medication cart following the resident's discharge from the facility. Documentation review revealed RN #25 documented the medication as wasted. Licensed Practical Nurse (LPN) #24 cosigned the narcotic destruction record, indicating the medication had been destroyed, despite not physically witnessing the destruction. During interview, the…

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

Based on record review and staff interview, the facility failed to ensure that allegations of misappropriation of resident (#76) property were reported to the Office of Health Care Quality (OHCQ) as required. This was evident for 1 resident. Findings include:On 09/05/2025 at 11:27 AM, while investigating Facility Reported Incident (FRI) 358648, it was discovered that Registered Nurse (RN) #25 misappropriated Resident #76's oxycodone from the medication cart in August 2024 following the resident's discharge from the facility. Documentation showed RN #25 recorded the medication as wasted. Licensed Practical Nurse (LPN) #24 cosigned the narcotic sheet with staff #25, although LPN #24 reported she did not physically observe the destruction of medication.During an interview with the Director of Nursing (DON), she stated that after Resident #76 was discharged , the resident contacted the facility to inquire about the missing medication. At that time, an internal investigation was initiated, and RN #25 tested positive for oxycodone use. RN #25 was subsequently terminated and reported to…

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

Based on medical record review and interviews with facility staff it was determined the facility failed to follow the resident careplan to ensure ongoing communication between the dialysis center and the facility for continuity of care for a resident receiving dialysis services. This was found to be evident for 1 (Resident # 93) of 3 residents reviewed for dialysis during the facility's survey.Findings include,An interview was conducted with the DON (# 2) on 9/3/25 at 11:35 AM and she was asked to explain how the facility communicates with the dialysis center regarding Resident # 93. The DON stated that there is a communication book that is carried with the resident when s/he goes to dialysis. The DON further stated that the resident is a health care professional and likes to keep the dialysis book on person. The survey team asked the DON how clinical information regarding the resident status is communicated from the dialysis center to the facility if the book remains with the resident. The DON stated that the staff at the dialysis center sometimes call the facility with updates.…

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

Based on record review and staff interview, the facility failed to ensure that services provided met professional standards of quality by not maintaining accountability and proper destruction of controlled substances, resulting in the misappropriation of Resident #76's prescribed oxycodone. This deficient practice involved 1 resident (#76) reviewed.Findings include:Oxycodone is a controlled opioid medication with a high potential for misuse, addiction, and dependence. Proper handling and destruction of controlled medications is required to ensure resident safety and prevent diversion.On 09/05/2025 at 11:27 AM, during investigation of Facility Reported Incident (FRI) 358648, it was discovered that in August 2024, RN #25 removed Resident #76's oxycodone from the medication cart following the resident's discharge from the facility.Documentation review revealed RN #25 recorded the medication as wasted. Licensed Practical Nurse (LPN) #24 cosigned the narcotic destruction record, indicating the medication had been destroyed, despite not physically witnessing the destruction.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 observations, record review, and staff and resident interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #59) out of 40 residents reviewed during the survey.The findings include: On 9/02/2025 at 8:52 AM, the surveyor began their initial observation of Resident #59 who was sleeping at this time. Later that day, around 1 PM, the surveyor returned and discussed in detail with Resident #59, their wound care and having maggots in their wound 2 times. The first time occurred about a week after he/she arrived at the facility. Resident #59 stated that it wasn't that many, I didn't even know they were there until the nurse was doing the dressing change. But the second time was last week, and there were more; I could feel them moving around. Resident #59 was asked if this was reported. Their reply was, Yes, there was a nurse and the unit manager. On 9/04/2025 at 10:20 AM, the surveyor spoke with the Unit Manager #3 for Unit 3, who was also the…

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

Based on observations, record review, and resident and staff interviews, it was determined that the facility failed to ensure that a resident received their assistive devices to maintain vision. This was evident for 1 (Resident #7) out of 1 resident reviewed for hearing and vision services during the survey.The findings include: On 9/02/2025 at 3:31 PM, the surveyor was able to speak with Resident #7 about his/her concerns during their stay at the facility. Resident #7 stated that s/he has been paying for vision insurance and needs their glasses. Resident #7 stated that he/she saw the eye doctor a while back this year, but still has not received their glasses. On 9/04/2025 at 12:35 PM, a record review revealed that Resident #7 had a prescription for glasses dated February 10, 2025; however, the resident stated that s/he had not received any new glasses this year. On 9/04/2025 at 12:45 PM, the ADON #3 was asked how a resident would get their glasses when they have a prescription. She stated that she was not sure and would get back with that information. On 9/05/2025 at 10:45 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.

Based on medical record review and interviews with the resident and facility staff it was determined the facility failed to ensure that a wheelchair used for transporting residents had leg lifts in place prior to transport. This was found to be evident for 1 (Resident # 19) of 40 residents reviewed during the survey.Findings include:Record review revealed Resident #19 was admitted with the following but not limited diagnosis: Pyogenic Arthritis (serious and painful infection of a joint) and Pain in Right Knee. An interview was conducted with resident # 19 on 9/2/25 at 10:30AM. The resident was lying in bed with a pillow placed underneath the uncovered knee area that appeared to be swollen. The resident told the surveyor that his/her right leg was healing, but recently, his/her leg was bent backwards while in therapy. The resident went on to say that on the same day that his/her leg was bent back while in therapy, their knee was bent backwards while being pushed in the wheelchair by therapy staff (# 18). The resident stated that the area was not injured or fractured, but remained 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 record review and staff interview, the facility failed to ensure resident records were complete and accurate when the Assistant Director of Nursing (ADON) falsified resident (#12's) weights; failed to include the indication for use of an anticoagulant medication (Xarelto) on the Medication Administration Record (MAR) and Physician Order Sheet (POS) for one resident (#80) and failed to document a change in condition for a resident (#59). This occurred for 3 of 40 residents reviewed during the survey. Findings include: 1. Review of resident #12's medical record revealed the following documented weights: 09/05/24 – 120.6 lbs. (pounds) 10/15/24 – 129.1 lbs. (8.5 weight gain) 11/11/24 – 130.6 lbs. (11 weight gain) 12/10/24 – 142.4 lbs. (21.6 weight gain) 12/17/24 – 141.6 lbs. (21 weight gain) 12/23/24 – 141.4 lbs. (21 weight gain) 12/31/24 – 140.9 lbs. (20 weight gain) 01/02/25 – 140.9 lbs. (20 weight gain) 01/03/25 – 140.9 lbs. (20 weight gain) 02/02/25 – 122.8 lbs. (18.1 weight loss) These entries indicated repeated, significant, and inconsistent fluctuations in weight. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with facility staff, it was determined that the facility failed to ensure that infection control guidelines were being followed. This was found to be evident for 1 of 3 units toured and during medication administration observations for the survey.The findings include:1. An initial tour was conducted of the 100-unit on 9/2/25 at 9:30AM and the hand sanitizer dispenser was empty for four dispensers. Two of the empty dispensers were sitting on top of the Personal Protective Equipment (PPE) Cart and the other 2 empty dispensers were located on the wall next to the nurse station, across from room [ROOM NUMBER] and on the wall across from the nurse station, near room [ROOM NUMBER]. The nurse (Staff # 11) was made aware and informed the environmental staff worker that was on the unit of the concern. The dispensers were filled by staff. The Administration team was made aware of all concerns at the exit conference on 9/5/25 at 1:45 PM. 2. On 9/3/25 at 11:30 AM, during observation…

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

Based on observations, medical record review, and interview, it was determined the facility failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed and failed to position a resident comfortably in a chair. This was evident for 6 (#9, #3, #44, #40, #45, #29) residents observed on 2 of 3 nursing units during a random tour during a complaint survey. The findings include: A tour of the facility was conducted on 4/29/25 at 10:28 AM along with the Director of Nursing (DON). 1) Observation was made of Resident #9 lying in bed. Resident #9's call bell was observed hanging down the wall and the call bell button was lying under the bed on the floor. The DON stated, that is not supposed to be hanging there like that. The DON placed the call bell on top of the resident. Review of Resident #9's care plan, has an ADL (activities of daily living) self-care performance deficit r/t (related to) muscle weakness, had the intervention, encourage the resident to use bell to call for assistance. A second care plan, 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 medical record review and interview, the facility staff failed to notify a resident's physician and/or representative for a change in condition. This was evident for 4 (#6, #5, #17, #21) of 52 residents reviewed during a complaint survey. The findings include: 1) Review of Resident #6's medical record on 4/23/25 revealed the Resident was admitted to the facility in November 2024 and was transferred to the hospital on [DATE]. Review of the Resident's vital signs on the following dates and times prior to the Resident's transfer to the hospital revealed the Resident had an elevated heart rate on: 12/13/24 at 8:19 AM heart rate of 121, 12/13/24 at 10:03 PM heart rate of 110, 12/17/24 at 7:34 AM heart rate of 114. The Resident's heart rate on 12/18/24 at 9:38 AM was 135 and the Resident was transferred to the hospital. Further review of the Resident's medical record revealed the facility staff failed to notify Resident #6's physician of the elevated heart rates on 12/13/24 at 8:19 AM, 12/13/24 at 10:03 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 reviews of facility reported incidents and interview, it was determined the facility failed to report allegations of abuse to the regulatory agency, the Office of Health Care Quality (OHCQ) within 2 hours of the allegation. This was evident for 4 (#9, #19, #18, #17) of 13 residents reviewed for facility reported incidents during a complaint survey. The findings include: 1) On 4/24/25 at 7:17 AM a review of facility reported incident MD00213274 was conducted and revealed Resident #9 reported to his/her daughter that a nurse hurt his/her arm. There was swelling to the right hand. The date of injury was unknown. Resident #9's daughter reported the incident via text message to Staff #9, the Assistant Director of Nursing (ADON) on 1/5/25 at 11:45 AM. The ADON then reported it to the Director of Nursing (DON) on 1/5/25 at 11:50 AM and the Nursing Home Administrator (NHA) was notified on 1/5/25 at noon. Review of the email confirmation of when the initial report was sent to OHCQ was dated 1/6/25 at 2:40 PM which was not within 2 hours of an injury of unknown origin of suspected…

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 facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 7 (#18, #21, #40,#19, #17, #20, #39) residents of 13 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 4/23/25 at 3:24 PM a review of complaint MD00205813 was conducted and revealed Resident #18 was sent to the emergency room on 5/19/24. While in the emergency room bruising was noted to the resident's left side of the face and it appeared to be in different stages of healing as bruising was red, yellow, and purple. Resident #18 was unable to state what happened or caused the swelling and bruising. Resident #18 was unable to recall if he/she fell or was hit. It was alleged that a nurse from the emergency room called the facility to inquire about the bruising and swelling and was informed by the on-duty nurse that it was being investigated by management. Review of a 5/15/24 at 9:15 AM nursing note documented, I noticed bruising to 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 medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 6 (#5, #3, #46, #40, #7, #21) of 52 residents reviewed for complaints during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 4/23/25 at 11:07 AM a review of Resident #5's medical record was conducted and revealed Resident #5 was prescribed Tirzepatide Subcutaneous Solution Auto-injector 2.5 MG/0.5ML (Tirzepatide) Inject 0.5 ml subcutaneously one time a day every Wednesday for type 2 Diabetes Mellitus. Review of Resident #5's admission MDS with 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 complaint, record review, and interview, it was determined the facility failed to have documentation that residents were offered and/or received a shower on the resident's assigned shower day. This was evident for 6 (#16, #27, #52, #50, #51, #41) of 52 residents reviewed for complaints during a complaint survey. The findings include: 1) On 4/23/25 at 3:55 PM a review of complaint MD00206200 alleged the facility was short staffed and residents were laying in their urine and feces and not receiving proper care. Review of Resident #16's medical record revealed the resident was admitted to the facility in February 2023 as the resident required 24 hour a day nursing care. On 4/24/25 at 10:10 AM an interview was conducted with Resident #16 who stated that there was not enough staff and that showers were not being given and that he/she has not had a shower in a year. Resident #16 stated he/she has only had bed baths. Resident #16 stated, I never refuse a shower. Review of Resident #16's care plan documented Resident #16 had a self-care deficit related to paraplegia and impaired…

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 complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health. This was evident for 8 (#6, #11, #12, #30, #37, #42, #1, #5) of 52 residents reviewed during a complaint survey. The findings include: 1) Review of Resident #6's medical record on [DATE] revealed the Resident was admitted to the facility in [DATE] with a diagnosis to include disorders of the bladder. Further review of the Resident's medical record revealed on [DATE] the physician ordered the Resident to have Macrobid 100 mg two times a day for UTI (urinary tract infection). Macrobid is a antibiotic medication that can be used to treat urinary tract infections. Review of the Resident [DATE]'s Medication Administration Record revealed the Resident only received Macrobid for 4 days (12/2, 12/3, 12/4 and [DATE]). The facility staff failed to administer Macrobid on [DATE] even though it is in the facility's…

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, the facility staff failed to do quarterly nutrition assessments for residents and failed to recognize a resident's weight loss and notify the physician and dietician. This was evident for 3 (#15, #17, #21) of 52 residents reviewed during a complaint survey. The findings include: 1) Review of Resident #15's medical record on 4/24/25 revealed the Resident was admitted to the facility in 2019 and had a diagnosis to include malnutrition. The Resident was discharged from the facility on 8/17/24. Further review of the Resident's medical record revealed the last nutritional assessment completed on the Resident was 3/2/23 and there were no notes from the Dietitian after 3/2/23. Interview with the Dietitian on 4/25/25 at 9:54 AM, the Dietitian stated she is consulted to work at the facility 12 hours a week. At that time the Dietitian also reviewed Resident #15's medical record and confirmed there is no nutritional assessment or note after 3/2/23 until discharge on [DATE]. 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 complaints, documentation review, and interview, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 16 of 42 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, multiple staff interviews, and review of staffing schedules. This deficient practice had the potential to affect all residents. The findings include: 1) Sixteen out of forty-two complaints that the Office of Health Care Quality (OHCQ) received and reviewed on this survey alleged the facility did not have sufficient nursing staff to provide essential care to the residents that resided at the facility. Complaints consisted of geriatric nursing assistants (GNAs) not having enough time to give resident showers and toilet and change residents. 2) Five of the 16 complaints were related to residents not receiving showers. a) On 4/23/25 at 3:55 PM a review of complaint MD00206200 alleged the facility was short staffed 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.

Based on facility record review and interview, it was determined the facility failed to have a full time licensed Nursing Home Administrator (NHA) authorized by the State of Maryland from 11/9/22 until 11/15/23 and 2/4/24 until 3/4/24. This is being cited as past noncompliance since the facility currently has had a licensed administrator in place that was verified by the Surveyor on 4/24/25. The findings include: On 4/24/25 the Surveyor asked the Administrator to provide a timeline of the NHAs for the facility since November 2022 to investigate an anonymous complaint the facility had been operating without a full time licensed Nursing Home Administrator. Review of the timeline list of the facility's NHAs provided by the current Administrator on 4/24/25 revealed Staff #46 was the Administrator 11/9/22-1/1/23, Staff #47 was the Administrator 12/12/22-6/30/23, Staff #48 was the Administrator 7/3/23-9/29/23, Staff #49 was the Administrator 11/15/23-2/4/24, Staff #50 was the Administrator 3/4/24-8/18/24, and Staff #1, the current Administrator, has been at the facility since 8/19/24.…

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

Based on staff interview, it was determined the facility failed to obtain a full-time social worker when the certified number of beds exceeded 120 in the facility. Currently the facility was licensed for 160 certified beds. This was evident for 1 out of 1 required personnel and had the potential to affect all residents. The findings include: On 4/23/25 at 10:06 AM Staff 4, the Social Work Assistant was interviewed and stated she had been employed at the facility for almost 3 weeks and was full-time. Staff #4 stated, we do not have a full-time social worker here. Staff #4 described her duties and stated, I have a check off list that I have to do. The assistant is here to help the Director. Staff #4 stated she had an administration degree for the medical front and back desk and was a certified medical assistant and had a certification in activities. Staff #4 stated she was previously an activities director. Staff #4 stated she was trained by the Regional Social Services Director and that the Regional Director was always on call. On 4/24/25 at 2:50 PM an interview was conducted with…

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

Based on medical record review and interview, the facility staff failed to respect a resident's privacy (Resident #8). This was evident for 1 of 52 residents reviewed during a complaint survey. The findings include: Review of Resident #8's medical record on 4/24/25 revealed the Resident was admitted to the facility in July 2024 and was assessed by the facility staff on 1/17/25 to have a BIMS (Brief Interview for Mental Status) of 15 out of 15, fully alert and oriented. During interview with Resident #8 on 4/24/25 at 8:07 AM, the Resident stated he/she recently had a visitor who is a friend of the Resident in his/her room. Resident #8 stated during the visit a housekeeper (Staff #12) approached the visitor and told the visitor that they couldn't use his/her phone. The Resident stated he/she used to work with the visitor's mother and when the visitor would come in to visit she would bring me snacks and we would facetime the visitor's mom. The Resident stated we had done this many times and that he/she didn't believe Staff #12 should have done that. Interview with Staff #12 on 4/24/25…

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 facility documentation, medical record, and staff interview, it was determined the facility failed to ensure that a resident was free from neglect when the facility failed to provide the required services to meet the needs of the resident. This was evident for 1 (#46) of 52 residents reviewed during a complaint survey. The findings include: On 4/24/25 at 2:46 PM a review of an anonymous complaint alleged the facility needed to be investigated as they were doing illegal things. A review of the grievance log for November 2024 documented a grievance filed on 11/25/24 for substandard quality of care for Resident #46. Review of the grievance investigation revealed a witness statement from Staff #9 that documented that on the morning of 11/25/24 at 8:10 AM Staff #54 went to Staff #9's office and stated that Resident #46 was visibly upset this morning when she entered the resident's room and disclosed to her that he/she was left sitting in a soiled brief from 10:30 PM until 8:00 AM when Staff #54…

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

Based on record review and staff interview it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS) assessments which should have included the resident's participation in the resident interviews and failed to complete MDS assessments timely. This was evident for 1 (#18) of 52 residents reviewed for assessment reviews during a complaint survey. The findings Include: The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate the residents' progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. The Minimum Data Set (MDS) assessments are an integral part of RAI and include completion of standardized assessment questions. There are comprehensive MDS assessments and periodic non-comprehensive MDS assessments which facilities conduct to maintain an accurate understanding of each resident's most current needs 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.

Based on observation, medical record review, and staff interview, it was determined that facility staff failed to develop a comprehensive, resident centered care plan for nutrition. This was evident for 1 (#17) of 52 residents reviewed during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 4/28/25 at 8:00 AM a review of Resident #17's medical record was conducted. Review of the weight section of the medical revealed on 2/3/25 the resident had a documented weight of 183.8 pounds (lbs.). There was no weight in March 2025. A weight was taken on 4/1/25, 4/2/25, and 4/3/25, which was documented as 166.6 lbs. which was a 17.2 lb. weight loss which was a 9.4 % weight loss. Resident #17 was currently on a No salt packet, finger food, thin liquid diet with ice cream and pudding twice per day. Review of the care plan section of Resident #17's medical record failed to produce a nutritional care plan. On 4/28/25 at 2:48 PM the dietician 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 interview, the facility staff failed to have quarterly care plan meetings for residents and failed to update a care plan after a change in condition. This was evident for 3 (#12, #3, #17) of 52 residents reviewed during a complaint survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. 1. Review of Resident #12's medical record on 4/23/25 revealed the Resident was admitted to the facility in June 2024.…

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 incident review of wound care, the facility failed to change a wound dressing. This was evident for 1 (#31) out of 7 residents. Findings include: On 4/24/25 at 2:19 PM a medical record review was conducted for Resident #31. On 9/24/23 daughter went to visit Resident # 31 who has wounds on his/her right foot. The date on the dressing stated 9/23/23 with the initials of Staff #36. Mother went to the unit manager and stated the dressing was not changed on resident right foot as the dressing change indicated it was changed on 9/23/23. It was not changed on 9/22/23. Unit manager at the time Staff #35 stated they must have put the wrong date on the dressing. Mother then stated Don't try that because the nurse stated yesterday that Nurse #39 said she did not have the time to change the dressing because she was the only nurse for 40 residents with no medication aid. Nurse advised the evening nurse to change the dressing which evening nurse failed to do. On 9/18/23 daughter went to visit Resident #31 again., and dressing on the right foot was dated 9/16/23 by 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.

Based on interview and record review, it was determined the facility failed to keep a resident with decreased cognition from exiting the building unsupervised. This was evident for 1 (#47) of 52 residents reviewed during a complaint survey. The findings include: On 4/23/25 at 1:14 PM a review of an anonymous complaint alleged the facility needed to be investigated as they were doing illegal things. On 4/24/25 at 8:39 AM the surveyor received a call from a complainant stating that a resident got out of the building, eloped, and no one knew where the resident was for several hours, that the police were called and brought the resident back to the facility. Review of Resident #47's medical record revealed a 5/25/24 at 13:40 health status note that documented, Resident was not in room during rounds. Building and grounds checked by staff. 911 called. Resident found by staff in the community across the street. 911 returned call, stated found patient (no officer responded.). The resident told the staff he/she was fine and was just out walking. According to the Centers for Medicare 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.

Based on medical record review and staff interview, it was determined that the facility failed to ensure a physician supervised the care of a resident, as evidenced by the physician failing to evaluate a resident's weight loss. This was evident for 2 (#17, #21) residents reviewed for 42 complaints reviewed during a complaint survey. The findings include: 1) On 4/28/25 at 8:00 AM a review of Resident #17's medical record was conducted. Resident #17 was admitted to the facility in November 2022 with diagnoses that included unspecified dementia, obsessive-compulsive disorder, schizophrenia, delusional disorders, and major depressive disorder. A review of the weight section of Resident #17's medical record revealed on 1/2/25 the documented weight was 183.8 pounds (lbs.). On 2/3/25 the resident weight was documented 183.8 lbs. but had the wording, no weights ordered. See last weight obtained. There was no weight documented in March 2025. A weight was taken on 4/1/25, 4/2/25, and 4/3/25, which was documented as 166.6 lbs. which was a 17.2 lb. weight loss which was a 9.4 percent weight…

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 complaints, medical record review, and interview, it was determined the facility failed to provide timely medication to meet the needs of the residents. This was evident for 1 (#1) of 42 residents reviewed for complaints during a complaint survey. The findings include: 1) On 4/23/25 at 2:37 PM a review of complaint MD00216820 alleged that Resident #1 had not received his/her medications as ordered. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Ankylosing spondylitis (AS), which is a chronic inflammatory disease that primarily affects the spine, causing inflammation and potentially leading to the fusion of vertebrae, resulting in stiffness and reduced flexibility and visual loss. Review of Resident #1's 4/16 /25 hospital discharge summary documented the medication Biolle Gel Tears Ophthalmic Gel 1%, 1 drop in both eyes was to be administered 3 times a day for dry eyes. Review of Resident #1's April 2025 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 medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to monitor the blood pressure prior to administering a blood pressure medication per physician's orders. This was evident for 2 (#7, #21) of 52 residents reviewed during a complaint survey. The findings include: 1) On 4/23/25 at 12:05 PM a review of complaint MD00214363 alleged that Resident #7 was not receiving medication as prescribed. A review of Resident #7's medical record was conducted and revealed a physician's order for Losartan Potassium 50 mg. one time a day for hypertension. The order stated to hold the medication for a SBP (systolic blood pressure) less than 110. The top number of the blood pressure refers to the amount of pressure in the arteries during the contraction of the heart muscle. This is called systolic pressure. Review of Resident #7's January 2025 Medication Administration Record (MAR) documented that the SBP was not within physician ordered parameters on 1/19/25 and 1/21/25 and the medication 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, observation, and interview, it was determined the facility staff failed to provide dental care for a resident with a missing tooth. This was evident for 1 (#17) of 42 residents reviewed for complaints during a complaint survey. The findings include: On 4/28/25 at 8:00 AM a review complaint MD00200383 was conducted and alleged that in December 2023 Resident #17 had a missing front tooth, that it could have been a crown or veneer, but it was noticeable. A review of Resident #17's medical record was conducted. A social service note dated 12/8/23, that was not entered into the medical record until 1/30/24, documented that the social worker received a call from the Ombudsman stating Resident #17's daughter had called to complain, stating that she thought there was a communication problem with the facility. The Ombudsman also stated she received a call from Resident #17's grandson stating Resident #17 had a missing front tooth and apparently the family was not notified. Further review of Resident #17's medical record failed to produce any further…

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, the facility staff failed to obtain outside services for a resident in a timely manner (Resident #12). This was evident for 1 of 52 residents reviewed during a complaint survey. The findings include: Review of Resident #12's medical record on 4/23/25 the Resident was admitted to the facility in June 2024 and was readmitted to the facility on [DATE] following a hospitalization with a diagnosis to include infection and inflammatory reaction due to internal joint prosthesis. Review of the Resident's hospital discharge summary revealed the Resident needs a follow up with Infectious Disease physician. Further review of the medical record revealed the Resident has not been seen by the Infectious Disease physician or has an appointment scheduled. Interview with the Director of Nursing on 4/30/25 at 9:40 AM confirmed the facility staff failed to schedule an appointment for Resident #12 to see the Infectious Disease physician.

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #30). This was evident for 1 of 52 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of 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. Review of Resident #30's medical record on 4/23/25 revealed the Resident was admitted to the facility 6/10/23 to following orthopedic surgery for rehabilitation and was discharged from the facility on 6/29/23. During interview with Resident #30's representative (RP) on 4/23/25 at 1:38 PM, the RP stated he/she received a call from the facility on the morning of 6/29/23 that the Resident had fallen and they were sending him/her to the hospital. The RP stated he/she would like to have more information…

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 notify a resident's physician when a treatment plan had changed (Resident #187). This was evident for 1 out of 59 residents reviewed during an annual survey. The findings include: Review of Resident #187's medical record on 8/22/22 revealed the Resident #187 was admitted to the facility in February 2022 from the hospital for surgical aftercare following surgery of digestive system. Further review of the Resident's medical record revealed the facility staff completed a SBAR (Situation-Background-Assessment-Recommendation) Communication form on 3/25/22 that stated, The change in condition, symptoms, or signs observed and evaluated is/are quarter size blood clots and the Medical Director was notified at 11:00 PM. Further review of Resident #187's medical record revealed a nurse's note on 3/26/22 at 8:01 AM that stated, new order for ultrasound pelvis with [name of body part] at diagnostic center. On 3/31/22 at 6:48 AM a nurse's note stated Resident continues with [name of body part] bleeding…

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 provide written notice for emergency transfers to the Ombudsman. This was found to be evident for 1 out of 1 (#71) resident reviewed for a facility-initiated transfer during the investigation of the survey. The findings include: A review of Resident #71's clinical record revealed that on 7/16/22, the resident was sent to the hospital for treatment and evaluation. The review also revealed that the facility staff failed to provide written notice for emergency transfer to the Ombudsman. The Administrator was informed of the regulatory concern on 08/17/22 at 2:30 PM, and the Administrator stated he/she is unaware of the regulation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #14 and #70). This is evident for 2 of 6 residents reviewed for pressure ulcers during the annual survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). 1. Review of Resident #14's medical record on 8/18/22 revealed the Resident 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 a review of the medical record and interview with staff it was determined that the facility failed to ensure that the physician addressed a resident's significant weight gain. This was evident for 1 (#51) of 7 residents reviewed for weight gain or loss during the annual survey. The findings include: On 8/14/22 at 2 PM, a review of Resident #51's medical record revealed, in a weight tracking system report, Resident #51's weight was documented as 216 lbs. (pounds) on 07/05/2022 and on 08/02/2022, Resident #51's weight was documented as 241.0 lbs., which was an 11.57% weight gain in 1 month. Further review of Resident's #51 medical record revealed no documentation from the dietitian, nurse, or physician that they were aware of Resident #51's weight gain. On 8/16/22 at 11 AM the DON provided an At Risk meeting LOG dated 8/3/22 that included Resident #51's 11.6 % weight gain with the recommendation to reweigh the Resident. The monthly Quality report dated 8/9/22 on weight variance was also provided and Resident #51 was noted with a weight gain of 11.6%. No intervention was noted…

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 record, the facility staff failed to serve meals as requested by residents (Resident #33 and #62). This was evident for 2 out of 24 residents reviewed for dining during an annual survey. The findings include: 1. Review of Resident #33's medical record on 8/17/22 revealed the Resident was admitted to the facility in December 2019 and has a diagnosis to include dementia. Dementia is the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities. Interview with Resident #33's responsible party on 8/17/22 at 12:45 PM revealed he/she was concerned when he/she visits Resident #33 as they are not receiving all the food as indicated on the Resident's meal ticket. Observation of Resident #33's lunch meal ticket on 8/17/22 revealed the Resident was supposed to receive chicken soup and there was no chicken soup on the tray. After surveyor intervention, the Resident was served chicken soup. Interview with the Director of Nursing on 8/18/22 at 9:00 AM confirmed the Surveyor's findings. 2.…

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 record in the most complete and accurate form for preventive health care immunization for Residents (#25, #51, and #73). This was evident for 3 of 5 residents selected for review of immunizations during the annual survey. The findings include: A medical record is 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. On 8/17/22, a medical record review for Resident #25, revealed it was unknown if the resident was immunized for influenza and Pneumococcal. The Director of Nursing then provided a copy from Maryland's Immunization information system documentation to show that Resident #25 received the influenza vaccine on 9/10/21 and the Pneumococcal vaccine on 11/25/13 and indicated the medical record would be updated. 2. On 8/17/22 Medical record review for…

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

Based on review of staff records and interview with facility staff, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received a performance review in 2018. This was true for all nursing aids who were eligible for a performance review in 2018. Failure to perform performance reviews prevents the facility from providing regular in-service education that is based on the outcome of these reviews. The evidence includes: The employee files of six GNAs were reviewed on 11/29/2018 at 10:40 AM. During the review, no performance evaluations could be found that had been performed in the calendar year 2018. The facility Administrator was interviewed concurrently regarding performance evaluations for all of the GNA staff members and confirmed that no reviews had been performed or were planned to be performed in 2018.

Based on observations and interviews with facility staff it was determined the facility failed to 1) properly date label food that was stored in the main kitchen and 2) store clean dishes in an area that was free from dust and dirt particles landing on top of them and ensure that staff does not place visibly soiled gloves on the same cart with clean dishes. This was found to be evident during an initial tour of the facility during the facility's annual Medicare/Medicaid survey. Findings include: An initial tour was conducted on 11/26/18 at 9:05 AM with the Director of Dining Services (DDS) present. The following concerns were identified: 1) Inside of the walk-in refrigerator was a large jug of diced peaches, a gallon container of Italian dressing, a gallon of California French dressing with a third remaining in each container. There was no date label on any of the containers. 2) There was a cart that contained clean dishes that was sitting underneath a large wall fan that had dust particles on the blades that was turned on. On the second shelf of the cart there was a pair of visible…

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 1) ensure the physician re-evaluated the use of an as needed antianxiety medication every 14 days, and 2) & 3) failed to monitor behaviors for residents prescribed antipsychotic medication. This was found to be evident for 3 (Residents #50, #80, and #84) out of 9 residents reviewed for unnecessary medication during the survey. The findings include: 1) On 11/29/18 review of Resident #50's medical record revealed an order, in effect since June 2018, for an antianxiety medication to be given at bedtime as needed for anxiety. Review of the November 2018 Medication Administration Record (MAR) revealed the as needed antianxiety medication had been administered on seven occasions in November 2018. Further review of the medical record failed to reveal any documentation regarding the physician's rationale for the continuation of the as needed antianxiety order for more than four months. On 11/29/18 at 2:00 PM the surveyor reviewed the concern with the Director of Nursing (DON) regarding no…

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

Based on medical record review and interview with facility staff, it was determined that the facility failed to accurately 1) document the location of a wound, and 2) maintain a medical record in the most accurate form for a resident. This was evident in the review of 2 of 34 residents (Residents #43 and #46) reviewed during the investigation phase of the survey. 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) Review of the medical record on 11/28/18 at 11:07 AM for Resident #43 revealed the diagnosis and presence of cellulitis (bacterial skin infection) and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes) of the right leg. This was documented on the non-pressure skin condition record on 10/12/18 and documented as first observed on 8/23/18. Further 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 record review and staff and resident interview it was determined that the facility failed to inform a resident of a change in his/her medication dosage. This was evident for 1 of 9 residents (Resident #84) investigated for unnecessary medications. Findings include: An interview with Resident #84 was conducted on 11/26/18 at 8:00 AM. When asked if s/he had any concerns about his/her current medications, Resident #84 stated that s/he hadn't been informed about what medications s/he was prescribed. A record review conducted on 11/26/18 at 10:00 AM revealed that Resident #84 had a BIMS score (Brief Interview for Mental Status) of 15/15, which indicates that the resident was cognitively intact, and was responsible for making decisions regarding his/her own care. A record review on 11/27/18 at 9:30 AM revealed a physician order for Resident #84 dated 11/6/18 for an antipsychotic medication 25 mg by mouth once daily. Further record review conducted on 11/28/18 at 10:30 AM revealed a physician order dated 11/23/18 that increased Resident #84's antipsychotic medication dose from 25…

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 facility staff and residents' families, it was determined that the facility failed to accommodate the preferences of a nonverbal resident as expressed through his/her family regarding the storage of tube feeding equipment. This was true for 1 of 2 residents (Resident #27) reviewed for tube feeding. The evidence includes: During an observation of Resident #27 that took place on 11/26/2018 at 2:08 PM, Resident #27 was found to be non verbal and not able to respond meaningfully to surveyor questions. The resident's medical record was reviewed concurrently and indicated that the resident was unable to make decisions for him/herself. It was also found that the resident had a feeding tube and received all nutrition and oral medication through the feeding tube. During a phone conversation with Resident #27's responsible party (RP) that took place on 11/27/18 at 2:45 PM, Resident #27's RP stated that the facility stored the syringe used to administer medication and water flushes to Resident #27 in a Styrofoam cup with the resident's name on it.…

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: 1) notify the physician of a resident's ongoing change in condition, and 2) notify the physician when a resident's blood sugar values were above 400. This was evident during the review of 1 of 2 deaths (Resident #93) and 1 out of 9 residents (Resident #35) reviewed for unnecessary medications during the survey. The findings include: 1) Review of the medical record for Resident #93 on 11/29/18 at 12:05 PM revealed admitting diagnosis including pneumonia and treatment plan to include rehab with plan to return home. Care plans occurring on 11/4/18 and 11/14/18 that included the resident, documented that the resident was short-term rehab to home and that the resident was his/her own representative. Further review of the resident's medical record revealed an admission order for Oxygen 2-4 Liters (L) to maintain oxygen saturations over 92%. The next day on 11/3/18 a new order was written on the interim physician order sheet for Oxygen 2L to maintain saturations over 92%.…

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 review of pertinent documentation it was determined that the facility failed to follow-up on grievances. This was found to be evident for 2 out of the 4 resident's (Resident #50 and # 94) reviewed for personal property during the survey. The findings include: 1) On 11/27/18 Resident #50 reported a concern regarding missing clothes and that the staff had been informed of the missing items. On 11/29/18 at 9:19 AM surveyor requested any reports of missing items for the resident from the Administrator. Review of the Complaint/Grievance Report, provided by the Administrator, revealed the concern was reported in March 2018 regarding several missing shirts. The concern was assigned to the Laundry Department/Housekeeping on 3/22/18. The remainder of the Complaint/Grievance Report, including the section for Findings of investigation and Resolution were noted to be blank. On 11/29/18 at 10:14 AM the Administrator reported the social worker had the resolution information. At 10:16 AM the Social Worker #17 reported that she filtered the concern out to the laundry…

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 a facility reported abuse allegation and interview it was determined that the facility failed to ensure accused staff member was removed from patient care immediately following an allegation of abuse. This was found to be evident for 1 out of 5 residents (Resident #4) reviewed for abuse during the survey. The findings include: Review of a facility report revealed that on 2/2/18 at 3:30 AM Resident #4 accused GNA #19 of hitting the resident. Review of the statement written by GNA #19 revealed that when trying to wake the resident up the resident started to swing at the GNA and said that I hit [him/her], the GNA left the room and reported the incident to the charge nurse. Review of the Charge Nurse #36's statement revealed the GNA reported the resident had hit the GNA and the nurse went to speak with the resident, and the nurse informed the GNA not to go back in the resident's room. No documentation was found that the GNA #19 was immediately removed from resident care after the allegation of abuse was initially made by the resident. On 11/30/18 at 2:01 PM surveyor…

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, resident and staff interview it was determined that the facility failed to accurately report intake information in the Minimum Data Set (MDS) for resident #84. This was evident for 1 of 28 residents (Resident #84) reviewed during the investigation phase of the survey. 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. An interview with Resident #84 was conducted on 11/26/18 at 8:30 AM. During the interview, the resident stated that he/she entered the facility in November 2018 from home. During a review of Resident #84's medical record that took place on 11/27/18, it was noted that Section A of the resident's Minimum Data Set (MDS) assessment with an Assessment Review Date (ARD) of 11/27/18 indicated that the resident entered the facility from a subacute hospital. During a staff interview on 11/28/18 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 staff interview, it was determined that the facility staff failed to ensure that a Minimum Data Set (MDS) Assessment inaccurately reflected a residents' status. This was evident for 1 of 9 residents (Resident #46) reviewed for pressure ulcers 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. A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are described according to their severity from Stage I (area of persistent redness); Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater); Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater); or Stage IV (full thickness skin…

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

Based on record review and interview with facility staff, it was determined that the facility failed to follow the interventions identified in a minimally-responsive resident's activity care plan. This was true for 1 of 1 resident (Resident #26) reviewed for activities. The evidence includes: Resident #26 is minimally responsive with an untestable Brief Interview of Mental Status (BIMS). The resident is entirely reliant on staff for quality of life and cannot expressly refuse a provided activity. The Activity Director was interviewed on 11/28/2018 at 10:39 AM. During the interview, the Activity Director stated that Resident #26 is up for activities several days a week and goes to group activities several days per month. The resident's activity log was requested for the previous two months, which indicated that the resident had been taken to group activities 3 times in the previous 9 weeks. Resident #26's care plan for activities was reviewed on 11/28/2018 at 1:40 PM. The review identified the goal of Resident will attend group activity of interest once weekly as desired through next…

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

Based on record review and staff interviews it was determined that the staff failed to follow the physician treatment order for Resident #13 to keep the patient's right foot elevated to reduce the risk of acquiring a pressure ulcer. This was evident for 1 of 9 residents investigated for skin conditions. Findings include: Review of Resident #13's medical record on 11/30/18 revealed a physician order dated 5/16/2016 to elevate the resident's right foot and float the heel (i.e., have it not in contact with the bed) while in bed. Upon observation on 11/30/18 at 08:30 AM, Resident #13 was in bed and his/her right leg did not appear to be elevated. During an interview with Geriatric Nursing Assistant (GNA) #25 at 8:32 AM, the staff member stated that he/she was unaware of the order. The surveyor requested to see resident's right foot and heel which were noted to be in contact with the bed and not elevated at that time. During an interview and observation on 11/30/18 at 11:00 AM, the surveyor asked Registered Nurse (RN) #30 to observe Resident #13's right foot and heel with the surveyor.…

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

Based on observation, record review, and interview with facility staff, it was determined that the facility failed to ensure that a resident only received oxygen with a physician's order. This was true for 1 of 4 residents (Resident #27) reviewed for Respiratory Care. The findings include: During an observation that took place on 11/27/2018 at 11:00 AM, it was noted that Resident #27 was receiving oxygen through a nasal cannula at a rate of 2 liters (L)/hour (hr). A concurrent record review did not reveal any active oxygen order. On 11/27/2018 at 11:48 AM, the Corporate Registered Nurse (RN # 33) stated that an oxygen order of 3 L/hr had originally been written but had since not been carried over to new monthly physician order sheets. The Corporate RN indicated that this was most likely a nursing mistake. Later on 11/27/18 at 2:00 PM, the Corporate RN stated that Resident #27's physician had been contacted and that there was now an active order for 2 L/hr of oxygen via nasal cannula. This was confirmed by the survey team at 2:30 PM. These concerns were reviewed 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 that the facility 1) failed to ensure monthly medication regimen reviews were completed by the pharmacist; and 2) failed to ensure the pharmacist identified the continuation an order for the use of an as needed antianxiety medication, in the absence of documentation of its continued need, as an irregularity. This was found to be evident for 2 out of the 9 residents (Resident #35 and #50) reviewed for unnecessary medication during the survey. The finding include: 1) On 11/28/18 review of Resident #35's medical record revealed the resident had resided at the facility for more than 6 months. Review of the Medication Regimen Review form failed to reveal any documentation that a review had been conducted during the month of October 2018. On 11/28/18 at 1:40 PM surveyor reviewed the concern with Director of Nursing that no documentation was found in the medical record that a pharmacy review occurred in October 2018 for Resident #35 resident. Review of the Consultant Pharmacist Services Provider Requirements policy revealed the…

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

Based on general observation, wound care observation, and staff interview, it was determined that the facility failed to 1) maintain standard precautions while providing wound care, and 2) & 3) failed to maintain resident care equipment in a manner to prevent the spread of infection and cross contamination. This was evident during the observation of 1 of 2 wound care procedures (Resident #43) and 2 of 2 residents (Residents #79 and #82) reviewed for urinary catheter use. The findings include: 1) During the observation of wound care for Resident #43 on 11/29/18 at 9:39 AM, completed by Staff #8 in the presence of the DON with assistance by Staff #13 a bedside commode was noted next to the bed. The bedside commode was noted to have a brown substance smeared on the lid. In addition, the bed side commode was within arms reach of Staff #8 while completing wound care and in close proximity to Resident #43's leg the location where the wound care was being completed. The DON and Staff #8 were interviewed at 11:20 am on 11/29/18 after the wound care was completed. They were asked if 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.