Autumn Lake Healthcare At Catonsville

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with the facility staff, it was determined that the facility failed to: 1) provide alcohol-based sanitizer and cold running water necessary for hand hygiene procedures, and 2) maintain infection control precautions with residents use of a urinal. This was evident for 2 (Residents #33 and #42) out of 2 residents' rooms and 1 of 1 observation of urinal storage in a resident's room during the recertification survey.The findings include: 1) On 08/07/25 at 8:10 AM, the surveyors observed a two-handle faucet in room [ROOM NUMBER] and turned on the water to assess the temperatures. The hot water was operational, but the cold water did not dispense any running water. The surveyors then turned to the alcohol-based sanitizer dispenser to sanitize their hands before leaving the room. However, the dispenser was empty. At 8:15 AM, an interview with the unit manager indicated that the staff utilized the hand sanitizer bottle located on the medication cart after exiting each resident'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 Number of residents sampled: Number of residents cited: Based on observations interviews it was determined that the facility staff failed to maintain equipment in safe operating condition. This deficient practice was discovered during the recertification survey. The findings include:On 08/07/25 at 8:25 AM the surveyor observed a black wire hanging from a hole in the wall next to Resident #50 bed. At 8:28 AM the surveyor observed the charging cord to the standing scale in the hallway next to room [ROOM NUMBER] hanging from the wall in two pieces. To the left above the electrical outlet was a hole in the wall with electrical wires exposed. At 8:33 AM while in room [ROOM NUMBER] the surveyor attempted to turn the light on the in the shared bathroom, but the light did not turn on. Resident #14 verbalized I needed to go to the room next door to turn on the light. The surveyor went to room [ROOM NUMBER] to turn on the bathroom light; the light came on. At 8:48 AM the surveyor attempted to turn the light on in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled:Number of residents cited:Based on observations, and interviews with the residents and facility staff, it was determined the facility failed to ensure: 1) there was an accessible call bell within reach for Resident #52, 2) call bell lights were operable and visible above the residents' doors for room [ROOM NUMBER] and #106, and 3) a functioning call bell system was installed in the Physical Therapy bathroom for resident use. This was evident for 4 of 4 resident call bells observed during the annual survey.The findings include:On 08/07/25 at 10:45 AM, an interview with the Resident #52 indicated that he/she was unable to reach the call bell to request assistance in getting back to bed. The surveyors noted that the resident was seated in a wheelchair, with the call bell positioned on the opposite side of the bed.At 11:15 AM, the surveyors activated the call bell. Around 11:19 AM, GNA #11 rushed into the room to deactivate the call bell and explained that she was attending to another…

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

Based on observation and interviews and review of contractor records, it was determined that the facility failed to keep a sanitary environment. This was found evident in the conference room, ice machine room, kitchen, laundry room and rehabilitation room during the survey. The findings include: On 8/13/25 at 5:43 AM, the surveyor observed vermin dropping located in the first floor conference room. On 8/14/25 at 6:10 AM, the surveyor reviewed the pest management company treatment documents. The surveyor noted that several recommendations were repeated throughout the treatment reports. The pest management company wrote they observed voids (holes) in the kitchen on 2/24/25, 7/16/25 and 7/25/25. On 7/25/25 the comment stated, one of the voids in the kitchen still needs to be sealed. It also stated broken tiles were found that were holding dirty water in breakage under the floor. The company also commented that this attracts roaches to the area. Additionally the company recommended improving sanitation procedures. This was recommended on 5/29/25, 7/16/25 and 7/24/25. On 7/24/25 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 observations, pest control management record reviews, facility staff interviews, and an investigation into a complaint, it was determined that the facility failed to have an effective pest control program. This was found evident in 3 out of 3 recurrent recommendations given to the facility by the pest management company, and also evident for Complaint #292313. The findings include: 1) On [DATE] at 5:43 AM, the surveyor observed vermin dropping located in the first floor conference room. On [DATE] at 8:41 AM, the surveyor made the Regional Director of Nursing (RDON) aware of the observations and requested any pest management documentation. The RDON stated she would pass the request on to the Nursing Home Administrator. On [DATE] at 10:36 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the surveyor asked how the facility handles pest control. The NHA stated that a pest management company comes and treats the facility weekly. He further stated 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.

Number of residents sampled: Number of residents cited: Based on observations and interviews it was determined that the facility staff failed to provide accommodation for a married couple who resided in the facility to live together. This deficient practice was evidenced in 2 (#56, #57) of 2 residents who are married who were residing separately in the facility. This deficient practice was discovered during the recertification survey. The findings include:On 08/07/25 at 1:17 pm while interviewing Resident #56 they verbalized their wife resides in the facility, but they sleep in separate rooms. Resident #56 verbalized they would like to share a room. On 08/13/25 at 8:41 am during an interview with Social Services Director #1 the surveyor asked were they aware Resident #56 & Resident #57 are married and want to share a room. They verbalized when Resident #57 was admitted they talked about sharing a room. Resident #56 was admitted in January 2024, and Resident #57 was admitted in August 2024. She had to check what the specifics are. At 8:44 am the surveyor spoke with the Administrator…

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

Number of residents sampled: Number of residents cited: Based on observations, staff interviews and record review, it was determined that the facility failed to provide documentation for the use of a physical restraint. This was evident for (Resident #39) reviewed during the annual recertification survey. The findings include: On 8/7/2025 at 8:00 AM and 12:00 PM, Resident #39's bed was observed positioned against the wall with a floor mat on the left side of the bed. Resident #39 was in bed during both observations. In contrast, B bed was in the middle of the room and C bed was by the window, both B and C beds were facing forward and not against a wall. On 8/11/2025 at 10:30 AM, the bed was again observed against the wall, though the resident was not in bed at this time. On 8 /12/ 2025, at 9:24 AM, Resident #39 was observed in bed with the bed against the wall, and a fall mat was in place on the left side of the bed. When interviewed, Staff #8 Geriatric Nursing Assistant, (GNA) and Staff #10 Licensed Practical Nurse, (LPN) stated that Resident #39 rolls from side to side and out of…

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

Based on record review, and interviews, it was determined that the facility failed to accurately document a discharge Minimum Data Set (MDS) assessment in a Resident's medical record. This was found evident of 1 (Resident #135) of 60 residents reviewed in the survey. The findings include: On 8/11/25 at 1:47 PM, the surveyor reviewed Resident #135's medical record. The review revealed that Resident #135 was admitted to the facility in late September 2023 as a hospice respite patient.Further review revealed that on both 9/29/23 and 10/2/23 a progress note was written that described Resident # 135 being found in the sitting position on the floor next his/her bed. In both notes Resident #135 was assessed for injury. On 8/12/25 at 11:23 AM, the surveyor reviewed Resident #135's September and October 2023's Medication Administration Record (MAR). The review revealed that Resident #135 had two pain medications ordered and both were ordered as needed. The review also revealed no documentation to indicate either the Tylenol or Morphine were given. The orders were written for Tylenol 650mg to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review, it was determined that the facility failed to implementing the comprehensive person-centered care plans' interventions that includes timelines to meet residents on-going needs i.e. toileting/ oxygen supply needs. This was evident for 1 (Resident #59) of 2 residents reviewed for care plans during the annual survey. The findings include: During a floor rounding, on 08/07/2025 at 08:33 AM, Resident #59 reported that a night shift staff after 11:30pm last night refused to empty a full urinal. The staff replied- it will get emptied in the morning then just left. The resident was up-set being out of breath it happened repeatedly, that his/her couldn't hold bladder until morning or taking a fall risk to walk to the bathroom to empty it, additionally the urinal smells was bothersome; not being cleaned after emptying each time. Observation, on 08/08/2025 at 01:21 PM and on 08//11/2025 at 8:10 AM, found that Resident #59's urinal was full at bedside. Interview, on…

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

Based on observations and interview it was determined that the facility staff failed to consistently provide Activities of Daily Living (ADL) care to a dependent resident as evidenced by mucous on a resident's face/neck and the staff failed to provide incontinence care to a resident who had a strong scent of urine. This deficient practice was evidenced in 1 (#50) of 1 resident observed with unmet ADL needs during the recertification survey. The findings include:On 08/07/25 at 8:28 AM during observation rounds the surveyor observed Resident #50 in bed with copious oral secretion on the right side of their face and neck. On 08/15/25 at 8:41 AM while Licensed Practical Nurse (LPN) #33 provided Resident #50 their medications, the surveyor verbalized to LPN #33 the resident had a strong odor of urine. LPN #33 verbalized they don't have any Geriatric Nursing Assistants at this time, and they are looking for someone to work on Unit C. After LPN #33 finished giving Resident #50 their medications, LPN #33 went back to the medication cart and prepared medications for another resident. LPN #33…

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, facility policy and interviews, it was determined that the facility failed to adequately document wounds and responses to treatment of skin conditions. This was found evident of 1 (Resident #138) of 2 residents reviewed for wounds. The findings include: On 8/14/25 at 11:58 AM, the surveyor reviewed Resident #138's medical record. The review revealed that Resident #138 had a past medical history of peripheral vascular disease and foot pain. On further review it was noted that the facility identified a change of condition on 12/5/23. The change in condition was related to a new open wound on Resident #138's Left Lower Extremity (LLE). A skin assessment was done and noted Resident #138 had a vascular wound to his/her LLE. Nowhere in the change of condition or the skin assessment was the wound's size or characteristics documented. An order for wound care was written to on 12/5/23 for wound care that included, cleaning the wound, and applying a xeroform and kerlix wrap daily to the LLE. The next skin assessment was completed on 12/13/23 and again there was no…

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

Based on observations, record review, and staff interview, it was determined that the facility failed to ensure that: 1) tube feeding bag was appropriately labeled and 2) the cap on the tube feeding bag was securely closed to prevent potential cross-contamination and the attraction of pests/insects. This was evident for 1 (Resident #116) out of 1 resident reviewed for tube feeding. The findings include:On 08/07/25 at 8:40 AM, the surveyors observed that tube feeding, and normal saline bags were hanging on an IV pole without proper labeling. In addition, the inadequately closed tube feeding bag also drew fruit flies to the resident's surroundings.At 9:30 AM, the surveyors accompanied the Director of Nursing (DON) to the Resident #116's room to show that the tube feeding and normal saline bags were missing labels.On 08/08/25 at 9:30 AM, the surveyors returned to check on the resident's condition and reevaluated the labeling of the tube feeding and normal saline bags. The surveyor observed that both bags had been dated 08/07/25 with a black marker.At 10:45 AM, an examination of the…

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

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 utilize an appropriate pain assessment based on a Resident's cognitive status. This was evident for 1 (Resident # 135) of 4 residents reviewed for pain. The findings include: On 8/11/25 at 1:47 PM, the surveyor reviewed Resident #135's medical record. The review revealed that Resident #135 had a past medical history that includes, but not limited to, abnormal weight loss and senile degeneration of the brain. He/she was admitted to the facility in late September 2023 as a hospice respite patient. A progress note dated 9/29/23 at 8:44 AM, documented that Resident #135 was very confused while awake and not easily redirected. On 8/12/25 at 11:23 AM, the surveyor reviewed Resident #135's September and October 2023's Medication Administration Record (MAR). The review revealed that Resident #135 had two pain medications ordered and both were ordered as needed. The review also revealed no documentation to indicate either 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 record review, review of consult services, and interviews it was determined that the facility failed to administer medication according to procedures that assure accurate dispensing of medications. This was found evident in 2 (Resident #135 ‰) out of 7 residents reviewed for medication regimen review. The findings include:1a) On 8/11/25 at 1:47 PM, the surveyor reviewed Resident #135's medical record. The review revealed that Resident #135 was admitted to the facility in late September 2023 as a hospice respite patient.On 8/12/25 at 11:23 AM, the surveyor reviewed Resident #135's September and October 2023's Medication Administration Record (MAR). The review revealed that Resident #135 did not have any as needed pain medications documented as administered or any as needed anxiety medications documented as administered. Resident #135 had orders for Tylenol 650mg every 6 hours as needed for pain, Morphine 5mg every 4 hours as needed for pain and Lorazepam 0.5mg every 4 hours as needed for anxiety. On…

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

Based on observation and staff interview, it was determined that the facility failed to properly store and label medications and biologics as evidenced by: 1) failing to ensure that multi-dose medications were properly labeled and dated, also 2) that wasted pills were properly disposed of and 3) resident medication was secured in a locked cart. This was evident in 2 of 4 medication carts observed during the survey. The findings include:While conducting the medication storage and labeling facility task on D-wing on 08/07/2025 at 11:08 AM, it was noted that the ear and eye drops of residents #91, #66 and #2 were not appropriately dated with the month, day and year that the medications were opened. LPN #8 was informed.On 08/07/2025 at 1:07 PM during the medication storage and labeling task, this surveyor observed that RN #3 left medication cart #2 on the A-wing unlocked . This was brought to the attention of the nurse.While reviewing cart 1 on the B-wing on 08/08/2025 at 1:30 PM, a large number of loose pills were found in the back of the cart under the medication bubble packs. LPN #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 record reviews, and interviews, it was determined that the facility failed to: 1) maintain medical records in accordance with acceptable professional standards and practices by keeping complete documentation and 2) file documents in the correct resident's medical record. This was found evident for 2 (Resident #132 and #135) of 60 sampled residents, and for 1 (Resident #6) of 1 resident chart reviewed for change in condition documentation during the recertification survey.The findings include: 1) On 8/11/25 at 12:32 PM, the surveyor reviewed Resident #132’s medical record. The review revealed that Resident #132 had a past medical history that included, but not limited to, acute respiratory failure with hypoxia, sleep apnea, and thrombotic pulmonary embolism. On further review an order was written on 3/27/23 that stated, oxygen at 2 liters per minute via nasal cannula continuously. Next, the surveyor reviewed Resident #132’s vital signs. On 3/26/23, 3/27/23, 3/28/23, 3/29/23, 3/30/23, 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/4/23, 4/5/23, 4/7/23, 4/11/23, 4/12/23, 4/13/23,4/14//23,…

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 interview, it was determined that the facility failed to provide residents with a copy of their baseline care plan and their admission medications. This was evident for 2 (#97, #107) of 3 residents reviewed for baseline care plans during the annual survey. This has the potential to affect all residents that are newly admitted to the facility. The findings include: The baseline care plan is to be developed within 48 hours of a resident's admission with a variety of detailed components of the care that the facility intends to provide to that resident. The facility is required to provide the resident and the representative with a written summary of the baseline line care plan including a list of current medications, dietary instructions, and services to be administered by the facility and personnel acting on behalf of the facility. 1) Resident #107 was interviewed on 3/2/23 at 11:28 AM. Upon questioning the resident indicated that he/she was not involved in a care plan meeting and did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) Resident #63's medical record reviewed on 3/16/23 at 12:06 PM revealed the resident was admitted to the facility on [DATE] with diagnoses that included diabetes, depression, and dementia without behavioral disturbance. Review of a care plan focus/problem initiated on 8/19/21 related to depression did not reveal a resident-specific goal with measurable objectives in order to evaluate the resident's progress toward his/her goal. The goal for this care area was simply written as the resident will show decreased signs and symptoms of depression through the 90-day review date. There is not any indication of the signs and symptoms the staff should assess or the baseline for each evaluation and review. The care plan interventions and goals have remained without revisions since 8/1/21. On 7/8/22 a focus area related to Dementia with behavior disturbances was initiated due to resident #63 having the potential to demonstrate verbal aggressiveness did not reveal a resident-specific goal with measurable objectives to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews and interviews with staff and a resident, it was determined that the facility failed to ensure an interdisciplinary team, which included the resident and or the resident's representatives, contributed to the resident's comprehensive care plan as evidenced by the failure to conduct a quarterly care plan meeting. Additionally, facility staff failed to document an evaluation of each care plan for effectiveness and revise the care plan following each required assessment. This is exemplified for 10 residents (#23, #12, #63, #15, #11, #41, #58, #25, #29, #72) out of 35 residents investigated during the annual 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. 1) Resident #23's medical record was reviewed on 03/9/23 at 02:30 PM. Review of the MDS assessments revealed that quarterly assessments were dated 12/13/22, and 9/12/22, and the annual 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 observation and staff interviews, it was determined that the facility staff failed to properly store medications, covid test supplies, and resident care equipment in 2 of 2 medication rooms and 3 of 4 medication carts observed. The findings include: Observation was made on B wing on 3/6/23 at 8:31 AM in the medication storage room. 2 nonrebreather masks with tubing were observed under the medication room sink. On top of the medication refrigerator was: 1 box labeled [NAME] Binax Covid-19 Ag cards. The box contained 4 expired Covid 19 test cards with expiration dates of 12/2/22. 1 box with 4 expired Covid AG cards also contained 12 packs of nasal swabs with expiration dates of 2/21/23. In a separate box were 21 Covid AG cards with expiration dates of 12/2/22 and 10 nasal swab sticks with expiration date of 2/21/23. Each box contained 1 Covid-19 Ag positive control swab with expiration date of 12/23/22. Staff #11 a Registered Nurse (RN) was made aware of these findings on 3/6/23 at 9:18 AM, she stated…

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

Based on complaint, resident interviews, and observations of the kitchen services with the testing of a food tray, it was determined that the facility failed to serve food at a preferable/palatable temperature. Food complaints and concerns were identified for 4 (#320, #116, #326, #322) of 29 residents selected in the final sample and a failed test tray was identified D-wing. This had the potential to affect all residents. The findings included: In an interview with Resident #320 on 3/1/2023 at 10:10 AM, the Resident stated that the food was horrible, always cold, no taste, and no seasoning. Resident #320 added that s/he was a diabetic, but they served her/him a lot of starches, same desert for lunch and dinner (always pineapple). No option to choose / No preference list. Always getting chicken or pork (I don't eat pork). I don't eat half the time because the food is not nice. In an interview with Resident #116 on 3/1/2023 at 10:37 AM, Resident #116 stated that the food was awful, you get what you get, 99% of the time the food is cold when you get it. They don't offer condiments.…

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 facility's room and bed breakdown, observations, and interview it was determined that the residents have limited access to space to accommodate dining. This is identified for the residents residing in the A, C, and D wings of the facility. The findings include. Review of the facility's room and bed breakdown reveals the A-wing has a total of 25 beds. C-wing has a total of 31 beds. D-wing has a total of 44 beds. The total number of resident beds for the A, C, and D wings = 100. On 3/10/23 at 1:00 PM, an interview was conducted with 6 representatives from the resident council members. The residents were asked if there was space to eat in the dining room. The The group indicated that dining occurs is in the upstairs (2nd floor) multipurpose room and space is limited. They did not know of any other dining space beside their rooms. The residents were asked how or who determines the residents that eat in the dining room. The response indicated that residents are asked, and staff makes a list. Environmental observations of the facility during the survey revealed…

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

Based on observation and staff interview, it was determined that the facility staff failed to treat each resident in a dignified manner by 1) leaving a urinal that contained urine on the bedside table next to the resident's lunch, 2) standing over a resident while feeding the resident, This was evident for 3 (Resident #322, #11) of 35 residents investigated during the annual survey. The findings include: 1) During an observation of Resident #322 on 3/2/2023 at 1:05 PM, the surveyor observed the resident sitting at the edge of his/her bed eating lunch; Noted was a half full urinal with clear yellow liquid (urine) on the bedside table next to the resident's lunch. Resident #322 confirmed it was his/her urine in the urinal that has been sitting on the table since this morning. When asked if the urinal was on the table when lunch was served, the resident stated yes and added that it happens every day. The Resident's nurse, Licensed Practical Nurse (LPN # 16) was notified of the surveyor's observation on 3/2/2023 at 1:10 PM. LPN #16 immediately went into Resident #322's room and emptied…

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 surveyor observation and staff interview it was determined the facility staff failed to have a process to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive, and in good repair. This was evident throughout the survey and in 3 of 4 nursing units. The findings include: On 3/17/23 at 10:27 an interview was conducted with the maintenance director (Staff #7). He was asked to describe the process of how he is to be notified of maintenance concerns. He indicated that the staff are to document environmental concerns in logbooks at each nursing station and he frequently reviews/checks the logbooks for identified concerns. He indicated that the staff is not always documenting concerns in the books, and staff will wait and tell him about concerns when they see him. There was a brief discussion about the facility's preventive maintenance program. He revealed that the preventive maintenance program is not computerized, but he has listed monthly inspections that are…

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, review of facility reported incident investigations and review of policies, it was determined the facility failed to thoroughly investigate allegations of abuse, neglect, misappropriation of resident property, and injuries of an unknown source. This was evident for 5 (Resident #327, #328, #329, #331, #27) of 9 residents reviewed for abuse, neglect, misappropriation of resident property, and injuries of an unknown source during this complaint survey. The findings include: On 3/13/2023 at 1:41 PM, the surveyor requested from the Director of Nursing (DON) a copy of all investigations for facility reported incidents (FRIs). On 3/14/2023 at 11:50 AM, in a follow up interview with the DON regarding the status of the requested FRI records, she stated that the Nursing Home Administrator (NHA) looked through the first batch of boxes sent from Genesis (previous owner of the facility) but could not find any of the FRIs requested by the survey team. She added that they were in the process of creating new files as they could not wait indefinitely for Genesis to send 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, interviews, and medical record review, it was determined that the facility staff failed to provide thorough grooming and personal hygiene services. This was evident for 3 (#41 and #58) out of 4 residents reviewed for activities of daily living (ADL) care during the annual and complaint survey. The findings include: Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents (regardless of payer) of long-term care facilities certified to participate in Medicare or Medicaid. 1) On 3/01/23 at 8:43 AM, Resident #41 observed that he/she had long nails. The resident stated that he/she needed help clipping nails. However, no one offered personal hygiene services. On 3/14/23 at 9:50 AM a second observation of Resident #41 noted he/she still had long nails. A review of Resident #41's medical record on 3/09/23 at 1:04 PM revealed that he/she was admitted to the facility in December 2021 with diagnoses that include but are not limited to cerebral infarction,…

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 a complaint, medical record review, and staff interview, it was determined that the facility failed to 1) ensure resident's weekly weights were obtained and documented, 2) follow physician's orders for dressing changes, 3) ensure residents received medications as ordered by the physician, 4) ensure residents received surgical wound care continuously and document wound status in weekly skin assessments, 5) monitor a resident's blood sugar levels as per physician's orders, 6) receive appropriate incontinent care, and 7) residents are taken to specialist appointments this is identified for 7 residents (#333, #320, #97, #375, #33, #29, and #25) of 35 residents investigated during the annual survey. The findings include: The Aspira Peritoneal Drainage Catheter is a tunneled, long-term catheter used to drain accumulated fluid from the peritoneal cavity (space within the abdomen that contains the intestines, the stomach, and the liver) to relieve symptoms associated with malignant ascites (excess abdominal…

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 staff it was determined that the facility staff failed to ensure that the facility was free of medication error rates of 5% or greater. This was evident for 2 errors out of 26 opportunities for error observed during Medication Administration review, resulting in a medication error rate of 7.69%. The findings include: Staff #22 was observed on 3/13/23 at 9:05 AM on the D-Wing nursing unit preparing the following medications in 8 separate medication cups for Resident #30: Amlodipine (for blood pressure) 10 mg - 1 tablet Bisacodyl (laxative) 5 mg - 2 tablets Cranberry (supplement) 450 mg - 2 tablets Folic acid (supplement) 1 mg - 1 tablet Furosemide (fluid pill) 40 mg - 1 tablet Loratadine (for allergies) 10 mg - 1 tablet Famotidine (antacid) 20 mg - 1 tablet Tylenol extra strength (for pain) 500 mg - 2 tablets Staff #30 confirmed prior to entering the resident's room that she had a total of 11 pills prepared. Upon entering the room, Staff #22 checked Resident #30's blood pressure using a wrist cuff on the resident's right wrist.…

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, resident, and staff interviews, it was determined that the facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This was evident for 4 (#320, #116, #326, #322) of 29 residents in the facility reviewed during a recertification and complaint survey. The findings include: In an interview with Resident #320 on 3/1/2023 at 10:10 AM, the Resident stated that the food was horrible, always cold, no taste, and no seasoning. Resident #320 added that s/he was a diabetic, but they served her/him a lot of starches, same desert for lunch and dinner (always pineapple). No option to choose / No preference list. Always getting chicken or pork (I don't eat pork). I don't eat half the time because the food is not nice. In an interview with Resident #116 on 3/1/2023 at 10:37 AM, Resident #116 stated that the food was awful, you get what you get, 99% of the time the food is cold when you get it. They don't offer condiments. When asked if they were offered substitutes if they did not like what was served, Resident #116 stated that I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to provide a resident with the right to participate in the development and implementation of his or her person-centered plan of care. This was evident for 1 (#107) of 1 resident reviewed that was cognitively intact and deemed capable to make own decisions but was locked in a memory care unit. The findings include: Resident #107 was interviewed on 3/2/23 at 11:28 AM. Upon questioning, the resident indicated that he/she was not invited to a care plan meeting and therefore did not participate in developing and implementing his or her person-centered plan of care. A review of the medical record on 3/3/2023 at 11:30 AM revealed resident #107 was admitted to the facility on [DATE] from the hospital after a fall with injury to his/her knee. A brief interview for mental status (BIMS) conducted by the social services director on 1/11/23 was reviewed and revealed resident #107 was cognitively intact. On 1/12/23 the resident's attending…

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

Based on resident and staff interviews and review of the medical record, it was determined that the facility staff failed to support resident choices. This was evident for 1(#19) of 2 residents reviewed for choices. The findings include: An interview was conducted on 3/13/23 at 11:53 AM with Resident #19. The resident indicated that he/she preferred to get up early and would like to be assisted out of bed at 6:00 AM but they refused to do it. He/she indicated that he/she had informed staff of his/her preference on numerous occasions over the past 3 months. The Resident indicated that he/she was frustrated and had told Staff #15 the Unit Manager, but nothing was done. When asked what time he/she had gotten up that day, the resident indicated that the staff had gotten him/her out of bed at 8 am and stated, because Staff #50 was here. Otherwise, staff normally assisted him/her out of bed at 11 am. Staff #6 a Social Worker (SW) was present with the resident ' s permission. Staff #6 indicated that she told Staff #15 the Unit Manager about the resident ' s request a month and a half ago…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to provide a notice of rights and services to a resident upon admission to the facility. This was evident for 1 (#107) of 1 resident reviewed that was cognitively intact and deemed capable to make own decisions but was locked in a memory care unit. The findings include. Resident #107's medical record was reviewed on 3/3/2023 at 11:30 AM. Resident #107 was admitted to the facility on [DATE] from the hospital after a fall with an injury to his/her knee. A brief interview for mental status (BIMS) conducted by the social services director on 1/11/23 was reviewed and revealed resident #107 was cognitively intact. On 1/12/23 the resident's attending physician (staff #27) documented that resident #107 has adequate decision-making capacity. A social services assessment dated [DATE] revealed the resident was oriented to time, person, place, and situation. Resident #107 was interviewed on 3/6/23 at 3:27 PM. The resident was asked if…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (Resident #118) of 3 residents reviewed for hospitalization during the annual survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. On 03/10/23 at 10:03 AM a review of Resident #118's medical records was conducted. It appeared that Resident #118 was sent to the hospital on 1/04/23 for a scheduled procedure and readmitted to the facility on [DATE]. A nursing staff wrote a progress note on 1/04/23 at 10:59 PM: writer got a call from XX [name of hospital] around 5 PM stating that resident's surgery went well and he/she was being discharged and will be on clear liquid diet for 24 hours. After waiting a couple of…

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

Based on observation, medical record review, and staff interviews, it was determined that the facility failed to conduct an accurate Minimum data set (MDS) assessment by failing to include a resident ' s vision problems. This was evident for 1 (#72) of 7 residents reviewed for communication and sensory. 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 & #39'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. During an interview on 3/2/23 at 12:15 PM, Resident #72 stated that he/she was not sure if he/she saw an eye doctor after requesting to see one. Review of Resident #72 ' s medical record on 3/15/23 at 8:58 AM revealed an Ophthalmologist consultation note dated 1/3/23 which indicated that the resident came for evaluation…

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 the facility failed to 1) provide a physician-ordered safety device for 1 (resident #12) 5 residents reviewed for accidents and 2) promote an environment free from potential accidents by failing to ensure the central supply room and dirty utility room remain locked in the memory care unit. This was evident for 6 days as observed during the survey. The findings include: 1) Resident #12's medical record was reviewed on 3/3/23 at 9:43 AM. Review of the medical record revealed resident #12 had a history of falling due to poor safety awareness and a gait imbalance. A care plan intervention was always written as Hipsters to bilateral hips. May remove during ADL care showers and skin checks. Review of the physicians' orders revealed an order that was initiated on 11/23/22 as Hipsters to bilateral hips at all times: May remove during ADL care showers and skin checks. [Hipsters are hip protectors, a specialized form of pants or underwear containing pads (either hard or soft) along the outside of each…

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 a resident who admitted to the facility with a urinary catheter was continuedly received care for a foley catheter, and 2) develop a care plan which included the use of the catheter and associated interventions. This was evident for 1 (#66) of 2 residents reviewed for bowel and bladder incontinence during the annual survey. The findings include: A foley catheter is a flexible tube placed in the body which is used to empty the bladder and collect urine in a drainage bag. 1) On 3/07/23 at 12:01 PM, the surveyor reviewed Resident #66's medical record. Resident #66 was admitted to the facility in January 2023 from an acute care facility following diagnoses that included but were not limited to dementia, chronic kidney disease, dehydration, pulmonary embolism, and anorexia. Further review of medical records revealed that the facility failed to place an order for Resident #66's Foley catheter continuously. The resident had an order on 1/22/23 as change foley catheter when occluded or…

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

Based on a review of medical records, observations, and interviews, it was determined that the facility failed to ensure residents' colostomy care was provided by appropriate competent skilled nursing staff. This was evident for 1 (Resident #58) of 2 residents reviewed for colostomy care during the annual survey. The findings include: An ostomy is a surgery that makes a temporary or permanent opening in the skin called a stoma. A stoma is a pathway from an internal organ to the outside of your abdomen. A colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the skin of the abdomen. A colostomy bag, also called a stoma bag or ostomy bag, is a small, waterproof pouch used to collect waste from the body. A review of Resident #58's medical records on 3/07/23 at 08:20 AM revealed that the resident had a colostomy related to a history of bowel obstruction since 12/23/2022. The surveyor interviewed several nursing staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to ensure documented Resident ' s new psychotic diagnosis. This was evident for 1 (Resident #83) of 6 residents' unnecessary medication reviewed during the annual survey. The findings include: On 3/06/23 at 9:43 AM, a review of Resident #83's medical records revealed that the Resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to aphasia, cerebral infarction, and hemiplegia. Also, Resident #83 had a new diagnosis, major depressive disorder in August 2022, abnormal weight loss in September 2022, and schizoaffective disorder in January 2023. Further review of the Physician Assistant's (PA, Staff #25) written progress note dated 01/04/23 showed, Patient recently diagnosed with Schizoaffective disorder and started on Abilify (Antipsychotic medication). Patient also on medications for depression. During an interview with Staff #25 on 3/09/23 at 9:21 AM, the surveyor asked about…

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

Based on observation, documentation review, and staff interview, it was determined that the facility failed to maintain an accurate account of all controlled substances. This was evident for 1 of 4 medication carts observed during medication storage review. The findings include: A medication cart on B-Wing (Memory Care Unit) was observed on 3/14/23 at 10:03 AM. Registered Nurse (RN) #11 was present. Review of the resident specific narcotic sign out sheets and observation of the narcotic medications in the locked narcotic drawer revealed the following: A) The sign out sheet for Resident #68 ' s Methylphenidate 54 mg (milligrams) extended release, indicated that 13 pills remained. However, 12 pills were observed in the punch card. B) The narcotic sign out sheet for Resident #46's Ativan 0.5 mg indicated that there were 28 tablets. However, the punch card contained 27 tablets. C) Resident #104's Ativan 0.5 mg sign out sheet reflected 3 remaining tablets; 2 tablets were observed in the punch card. D) The sign out sheet for Resident #103's Lacosamide 50 mg indicated 28 tablets remained,…

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, record review, and staff interview it was determined that the facility staff failed 1) to ensure that behavior monitoring including interventions and effectiveness of the interventions was accurately documented in the resident ' s record for 1 (#44) of 2 residents reviewed for Behavioral-Emotional, and 2) it was determined that the facility failed to maintain complete and accurate medical records as evident for 1 (#372) of 35 residents investigated during an annual and complaint survey. The findings include: On 3/2/23 Resident #44 was observed alone in his/her room, yelling, cursing, and talking to unseen others from approximately 9:15 AM - 10:40 AM. Resident #44 ' s medical record was reviewed on 3/17/23 at 9:13 AM. The residents' diagnoses included but were not limited to delusional disorder, major depressive disorder, and neurocognitive disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function. Its features may…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility 1) failed to develop policies and procedures to ensure residents' education, documentation, and procedure related to the Influenza vaccine for residents, and 2) failed to document/restore residents' Influenza and Pneumococcal vaccination consents in their medical records. This was evident for 1 (Resident #58) out of 5 residents reviewed who were eligible for Influenza and Pneumococcal vaccines during the annual survey. The findings include: Pneumococcal vaccine helps prevent pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. [Centers for Disease Control and Prevention- vaccines and preventable disease] Flu is a contagious disease that spreads around the United States every year, usually…

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 it was determined that the facility failed to ensure that building parts were kept clean and/or in good repair. This was identified in the ventilation ducts in the kitchen. The findings include. During a brief tour of the facility's kitchen on 3/1/23, a ventilation grate in the side of the metal duct along the kitchen ceiling appeared unsightly with accumulations of rust-like grime on the entire grate. A kitchen follow-up was conducted with the food service director (staff #5) on 3/21/22 at 10 AM. He confirmed the observed condition of the rust-like appearance of the ventilation grill/grate on the side of the box like duct work along the ceiling.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 9 (#16, #35, #255, #43, #20, #79, #100, #77 and #106) of 34 investigations conducted during the survey 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. The findings include: 1) Review of resident #16's medical record, beginning on 12/13/2018, revealed that the resident had a chronic lower leg wound that was noted in July 2018. The wound was followed by a consultant wound specialist. Review of the MDS assessment, 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 interview of facility staff and review of dietary supervisor credentials, it was determined the facility staff failed to ensure a full time qualified dietetic service supervisor for oversight of food preparation. This was evident during the facility's annual survey. The findings include: An initial tour of the kitchen on 12/12/18 at 11:50 AM, revealed that the full time Food Service Director (Staff #10) was not clinically qualified, as per Federal and state regulations. Staff #10 stated that he/she was charge of the kitchen full time and that he/she did not possess certification as a Certified Dietary Manager (CDM). Staff #10 stated he/she was a contracted employee and was not currently enrolled in a class to obtain his/her certification as a CDM.

Based on review of the facility's scheduled meal service times and interview with staff, it was determined that the facility staff failed to ensure that there was no more than 14 hours between dinner and breakfast the following day. This was evident on all units of the facility. The findings include: The facility's meal schedule was reviewed on 12/18/18 at 9:26 AM. The schedule revealed that dinner was scheduled to be delivered on A, C and D units between 4:45 PM and 5:00 PM; breakfast was scheduled to be delivered to the same units between 7:30 AM and 7:45 AM. The Homestead unit was scheduled to receive their meal trays 20 minutes later. The schedule reflected a lapse greater than 14 hours between the dinner meal and breakfast the following morning. On 12/18/18 at 9:42 AM, Staff #18 indicated when asked that snacks are only provided to the residents upon request or if prescribed and that a substantial evening snack was not provided to all residents daily.

Based on surveyor observation and interview with staff, it was determined that the facility staff failed to 1) properly label and date food items and remove expired food items, 2) failed to maintain food service equipment in a manner that ensured sanitary food service operations, 3) failed to ensure that dietary staff were in compliance with wearing hair/beard restraints, 4) failed to distribute and store food under sanitary conditions and 5) failed to monitor dishwasher temperatures and the walk-in freezer temperatures. This was evident during the initial tour of the kitchen and on a subsequent visit. The findings include: 1) On 12/12/18 at 11:50 AM, an initial tour of the kitchen was conducted with the Food Service Director (Staff #10). In the dry storage room, there were 10 32-ounce cartons of Imperial Thickened Dairy Drink, that had an expiration date of 12/10/18. In the walk-in refrigerator, there were 26 clear plastic bowls containing vanilla pudding, not labeled with the date they were prepared. The Food Service Director confirmed the findings at that time. 2) On 12/12/18…

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

Based on surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement plans of action to correct quality deficiencies identified during the prior annual quality indicator survey. The findings include: On 12/21/18 at 8:05 AM the surveyor reviewed the results of the facility's last quality indicator survey, dated 8/16/17. The corrective actions implemented by the facility after the last annual survey (dated 9/8/17) failed to effectively correct deficiencies related to failing to maintain a safe, clean, comfortable homelike environment, failing to ensure the accuracy of assessments, failed to appropriately and timely revise care plans, failed to maintain residents free of unnecessary medications, failed to maintain residents free of significant medication errors, failing to store, prepare, store food sanitarily, and failing to maintain accurate medical records. These failures resulted in a continuation of the deficient practices as…

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 2) Observation was made of Resident #97 lying in bed on 12/17/18 at 2:35 PM. Resident #97 was wearing a nasal cannula with oxygen flowing at 2L/min (Liters per minute). The water bottle on the oxygen concentrator was dated 10/31/18, and the nasal canula tubing was dated 10/31/18. On 12/17/18 at 2:40 PM, Staff #1 was interviewed and asked how often the water on the oxygen concentrator was changed and how often the tubing was changed. The response was every Wednesday. The surveyor showed Staff #1 the date on the water bottle and the response was, well he/she is prn. The surveyor asked if the opened bottle of water attached to the oxygen concentrator should have sat there opened for 47 days and Staff #1 stated, it should not have. I will change it right now. Based on surveyor observation, review of facility documentation and interview with facility staff, it was determined that the facility staff failed to implement and maintain an ongoing infection prevention and control program by failing to 1) ensure resident…

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

Based on observation and staff interview, it was determined that the facility staff failed to keep the walk-in freezer in the kitchen in safe operating condition. This was evident during the initial tour and subsequent visits to the kitchen. The findings include: On 12/12/18 at 11:50 AM, during the initial tour of the kitchen with the Food Service Director (Staff #10), observation of the kitchen's walk-in freezer revealed that there were droplets of condensation with small ice mounds on the back ceiling of the freezer. At that time, Staff #10 attributed the condensation to the defrost cycle of the freezer. On 12/20/18 at 11:51 AM, observation of the kitchen's walk-in freezer by 2 surveyors revealed dripping liquid condensation and ice mounds on the back ceiling of the kitchen's walk-in freezer. The liquid condensation had dripped on the of card board box containing food product and there was a layer of ice on top of the box which was located on the top shelf of a wire rack. On the freezer floor, near the wire rack, pieces of ice were observed. Cross Reference F 812

Based on observation and staff interview, it was determined that the facility failed to ensure that the facility maintained an adequate amount of potable emergency water available. This was evident during the facilities annual survey. The findings include: Potable water on hand is calculated at 1 gallon per resident (total bed capacity) x 3 days. The total bed capacity was 136 at 3 gallons which would be a total of 408 gallons needed on hand. On 12/12/18 at 11:50 AM during the initial tour of the kitchen, Staff #10 revealed the facility had 120 gallons of potable water on hand which was 288 gallons less than required, and he/she indicated that the facility did not have the room to store more potable water.

Based on record review and interview with facility staff, it was determined that the facility staff failed to provide the resident and their representative with a summary of the baseline care plan including the resident's medications and dietary instructions. This was evident for 1 (#205) of 5 residents reviewed for accidents and 1(#92) of 5 residents reviewed for position/mobility. The findings include: 1) Review of Resident #205's medical record on 12/20/18 at 12:51 PM revealed a Post admission Patient-Family Conference form, electronically signed and dated by Staff #6, on 12/9/18. The form indicated that a care plan meeting was held on 12/9/18 and that the resident attended the meeting. The entry Copy of medication list and dietary instruction given was not checked off to indicate that they had been provided to the resident/representative. The attendance section indicated that the resident was in attendance but was not checked to indicate that his/her representative was present. No documentation was found in the record to indicate that the resident and the representative had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to develop and implement comprehensive, accurate resident-centered care plans with measurable goals. This was evident for 6 (#77, #106, #77, #92, #102 and #255) of 34 residents investigated during the 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. 1) Review of the medical record for Resident #77 revealed a care plan Resident exhibits or is at risk for alterations in or is at risk for alterations in comfort related to acute pain with the goal resident will achieve acceptable level of pain control x 90 days with interventions Utilize pain scale, medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated, complete pain assessment per protocol. The goal was not measurable, as it did not state what an acceptable level of…

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

Based on review of the medical record and interviews with a resident and resident representative, it was determined that the facility staff failed to revise a residents plans of care and failed to ensure that a resident's representative was offered an opportunity to participate in development of the care plan. This was evident for 7 (# 64, #79, #205, #51, #100, #38 and #106) of 34 residents reviewed during the investigative phase of the survey. 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. The findings include: 1) Resident #64's medical record was reviewed throughout the survey, beginning on 12/13/18. Review of resident #64's care plans revealed a plan of care with an indicated focus of Resident is at risk for complications related to the use of psychotropic drugs. The care plan was initiated on 9/29/15 with a stated goal of resident will have the smallest most effective dose without side effects. Review of the residents prescribed medications on 12/13/18 did not reveal 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 surveyor observation, it was determined that the facility failed to provide care and services that promote the highest practicable well-being by failing to ensure proper positioning of a dependent resident for dining. This was evident for 1 (#79) of 6 residents reviewed for activities of daily living. The findings include: Resident #79 was observed, on 12/14/18 at 12:31 PM, lying in bed. The head of the bed was elevated approximately 45 degrees. The resident had slid down in the bed causing his/her feet to rest against the footboard. His/Her head was barely elevated. An overbed table was positioned in front of the resident, but was elevated approximately 1 foot above the residents' head. A lunch plate was on the table, however, Resident #79 was unable to see the food due to the table height. He/She was reaching up and over the table, feeling for and grabbing food with his/her hands to eat it. Staff #25 was made aware at 12:34 PM and returned a few minutes later with Staff #24. The resident allowed the staff to pull him/her up in the bed. The MDS (Minimum Data Set) is 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 surveyor observation, review of the medical record and interviews with the resident and staff, it was determined that the facility failed to ensure that a resident with limited range of motion receive appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This was evident for 3 (#64, #102 and #92) of 5 residents reviewed for mobility.The findings include: 1) Observation and interview of resident #64, on 12/13/18 at 10:07 AM, revealed that the resident had a left arm/hand contracture and the resident said that he/she does not get range of motion (ROM) therapy. Resident #64 had indicated that he/she was to get restorative care, however, he/she heard that restorative care was not available. Review of resident #64's medical record, beginning on 12/13/18, revealed an order, dated 8/30/18, for discontinuation of skilled occupational therapy services recommend restorative continue with ROM exercises to all extremities. Interview of the Director of nursing (DON) on 12/17/18 at 2:39 PM related to the facilities restorative…

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 Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews and review with the GNAs at least every 12 months this was evident for 3 out of 6 personnel files reviewed. The findings include: On 12/18/2018, a list of Geriatric Nursing Assistants was requested with their hire date. From that list, a random pick of 6 employee personal files were requested. On 12/19/18, GNA personnel files were reviewed for yearly performance reviews. 1. Staff #11's Date of Hire (DOH) was 9/18/13. The last performance review found in the personnel file was dated 9/2017. 2. Staff #12's DOH was 8/25/11. There were no yearly performance reviews found in the personnel file. 3. Staff #13's DOH was 5/7/12. The last performance review was dated 6/2017 Interview of the nurse practice educator on 12/20/18 at 11:12 AM confirmed the delinquent performance evaluations, with indication by the nurse practice educator, that the facility was behind in conducting yearly performance evaluations.

Based on review of the medical record and interview with facility staff, it was determined that the facility failed to ensure that residents were free of any significant medication errors. This was evident for 1 (#42) of 1 resident reviewed for Behavioral-Emotional services. The findings include: Resident #42's medical record was reviewed on 12/19/18 at 1:15 PM. The resident's record contained documentation of numerous episodes of the resident displaying behavior problems. A physician's order was written on 12/5/18 to discontinue Valproic Acid (an anti-seizure medication also used for mood stabilization) 125 mg (milligrams) twice a day (8 AM and 8 PM) and to start Valproic Acid 125 mg three times a day (6AM, 2PM and 10 PM) for mood disorder. Review of the medication administration record revealed that, on 10 out of 14 days in December, Resident #42's 6 AM doses of Valproic Acid was not documented as administered. The missed doses occurred on December 6, 7, 8, 11, 12, 13, 14, 15, 18 and 19. Additionally, the 10 PM dose was not documented as administered on December 7. Staff #3 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 review of the medical record and interview with staff, it was determined that the facility staff failed to maintain complete and accurate medical records. This was evident for 3 (#79, #106 and #16) of 34 residents reviewed during the investigative phase of the survey. The findings include: 1) Resident #79's medical record was reviewed on 12/18/18 at 2:34 PM. A skin check (an assessment form used to identify new and previously noted skin injury/wounds) dated 12/15/18 17:17 indicated that the resident had a wound on his/her right heel and dorsal right foot. Another check sheet, dated 12/9/18 17:17, indicated the resident had a left heel pressure ulcer and included measurement, type of tissue and that it was healthy. Both skin check forms included Refer Skin-Other Wound UDA/Skin Integrity Report (SIR) Further review of the record revealed several more skin check sheets, but failed to reveal Skin Integrity Reports or other documentation of comprehensive wound assessments. Staff #26 was present in the nurse's station and when asked where full wound assessments could be found,…

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

Based on observation and staff interview, it was determined that facility staff, Geriatric Nursing Assistant (GNA) #2 failed to treat residents with dignity and respect. This was evident for 3 Residents (#28, #40, and #205) out of 49 residents reviewed during the survey. The findings include: On 12/18/18 at 12:32 PM, surveyor observed GNA #2 standing beside the bed of Resident #28 while feeding him/her. During an interview, GNA #2 stated that although she was aware that it is expected of her to sit while assisting residents to eat, she did not because there were no seats available and acknowledged surveyor's concerns. However, at 12:38 PM surveyor observed GNA #2 standing beside the bed of Resident #40 while feeding the resident. In addition, surveyor observed Resident #205 going into the resident's room where GNA #2 was feeding a resident. The GNA yelled from across the room at Resident # 205 and stated; No, this is not your room. The GNA approached Resident #250, pushed his wheelchair backwards out of the door, and down the hall to the nurses' station. Further observation revealed…

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

Based on surveyor observation and interview with staff, it was determined that the facility staff failed to accommodate the residents individual dining needs by failing to provide assistance with positioning for dining. This was evident for 1 (#79) of 6 residents reviewed for Activities of Daily Living. The findings include: Resident #79 was observed on 12/14/18 at 12:31 PM lying in bed. The head of the bed was elevated approximately 45 degrees. The resident had slid down in the bed causing his/her feet to rest against the footboard. His/Her head was barely elevated. An overbed table was positioned in front of the resident but was elevated approximately 1 foot above the residents' head. A lunch plate was on the table, however, Resident #79 was unable to see the food due to the table height. He/She was reaching up and over the table, feeling for and grabbing food with his/her hands to eat it. Staff #25 was made aware at 12:34 PM, and returned a few minutes later with Staff #24. The resident allowed the staff to pull him/her up in the bed. The MDS (Minimum Data Set) is a complete…

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 staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on both floors of the facility on 4 of 4 nursing units. The findings include: The following observations were made by multiple surveyors during initial observations of residents and the environment on 12/12/18 and 12/13/18. On 12/19/18 at 3:44 PM, an environmental tour was conducted for the second floor of the floor of the facility with a representative from maintenance (staff #7) and eventually the environmental services supervisor (staff #9) joined the tour and began taking notes of the surveyor's previous observations. Environmental concerns include: RM (Room) 203 dirt and grime was noted on the heating/AC unit around the grates. RM 205: The tv for the a-bed was extremely dusty on the screen and on top of the TV. Staff #7 was shown that the…

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

Based on resident and staff interview, it was determined the facility failed to timely report an allegation of abuse. This was evident for 1 (#255) of 5 residents reviewed for unnecessary medications. The findings include: On 12/17/18, Resident #255's medical record was reviewed. On 10/29/18, in a behavioral health progress note, the CRNP (certified nurse practitioner) documented that Resident #255 had placed his/her hands on another resident and indicated that Resident #255 had rubbed the resident's chest and arm without that resident's consent. The facility's investigative documentation was reviewed and failed to reflect that the State Agency had been notified of the allegation of abuse incident. On 12/7/18 at 12:10 PM, during an interview, the DON confirmed that the facility had not reported the allegation of abuse to the State Agency as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to document a resident's discharge in the medical record. This was evident for 1 (#107) of 3 residents reviewed for discharge. The findings include: Review of Resident #107's medical record on 12/19/18 documented the resident was admitted to the facility on [DATE]. There was no further documentation about the resident. There was a physician's discharge summary that was signed by the physician on 11/15/18 which documented that the resident left the facility AMA (against medical advice) on 9/14/18. There was no other documentation found in the medical record about the resident. The nurses did not document that the resident left the building and did not document any information that led up to the resident's departure. Reviewed with the Director of Nursing (DON) on 12/19/18 at 2:08 PM. The DON confirmed that there was no documentation in the medical record about the discharge.

Based on medical record review and staff interview, it was determined that the facility staff failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This was evident for 1 (#255) of 3 residents reviewed for hospitalization. The findings include: On 12/17/18, review of Resident #255's medical record revealed documentation that, in mid-November 2018, Resident #255 was transferred to the hospital emergency room for evaluation and treatment following a fall that resulted in a right hip fracture. Continued review of the medical record failed to reveal documentation that the resident had received an explanation of why he/she was going to the emergency room and the potential response of the resident. Staff #6 was made aware of the findings on 12/17/18 at 12:32 PM.

Based on surveyor observation and interviews with a residents family member and facility staff, it was determined that the facility staff failed to provide necessary service to maintain good grooming and personal hygiene for a resident who is dependent on others. This was evident for 1 (#205) of 6 residents reviewed for Activities of Daily Living. The findings include: Resident #205 was observed on 12/12/18 at 12:43 PM to be unshaven with short razor stubble. He/she was observed again on 12/14/18 at 9:22 AM with longer stubble. Resident #205's family member was interviewed on 12/14/18 at 2:40 PM. When asked if staff are providing services to maintain proper hygiene for the resident, the family member indicated that he/she noticed the resident having an odor and filthy fingernails at times, that he/she wasn't sure if the resident was getting showers and that he/she had washed the resident up himself/herself. The family member also indicated that proper hygiene had always been important for Resident #205 in the past and added that someone was going to come that evening to shave 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 surveyor observation and interview with staff, it was determined that the facility staff failed to ensure that the resident's environment remained as free of accident hazards as is possible by failing to ensure that the bed of a resident at risk for falls was kept in a low position, and that the resident was assisted in positioning for meals to minimize choking risk. This was evident for 1 (#79) of 5 residents reviewed for accidents. The findings include: Resident #79 was observed on 12/14/18 at 12:31 PM, lying in bed. The head of the bed was elevated approximately 45 degrees. The resident had slid down in the bed causing his/her feet to rest against the footboard. His/Her head was barely elevated. An overbed table was positioned in front of the resident, but was elevated approximately 1 foot above the residents' head. Resident #79 was unable to see the food due to the table height. The resident's bed was in a high position. Staff #25 was made aware at 12:34 PM and returned a few minutes later with Staff #24. The resident allowed the staff to pull him/her up in the bed. 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 staff interview, it was determined the facility failed to provide the necessary care and services for a resident with a Foley catheter. This was evident for 1 (#106) of 3 residents reviewed for hospitalization. The findings include: Review of Resident #106's medical record on 12/19/18 revealed a physician's order written on 10/20/18 to insert Foley and obtain mls (milliliters) amount. The resident was sent out to the hospital on [DATE] and returned on 11/19/18. The nursing admission assessment, dated 11/19/18 at 17:15, documented resident has a Foley catheter 16 French 10 cc bag. There was no physician's order for the Foley catheter when the resident was re-admitted to the facility on [DATE]. There was also no care plan found in the medical record for the Foley catheter prior to discharge and after re-admission. Staff #22 was interviewed on 12/19/18 at 12:43 PM and stated, I took care of Resident #106, but I don't think he/she had a Foley. Staff #22 went to the computer and saw…

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

Based on resident interview and review of the medical record, it was determined that the facility staff failed to have an effective system in place for pain management as evidenced by failure to have complete pain assessments when the resident experienced pain and failure to implement the resident's plan of care for pain. This was evident for 1 (#77) resident reviewed for pain management. The findings include: Resident #77 was interviewed on 12/13/18 at 10:15 AM and stated, I have pain in my spine from the top of my head and down my back. I am taking Ibuprofen, but it is not strong enough and they won't give me anything stronger. Review of the medical for Resident #77 on 12/19/18 documented a physician's noted, dated 12/13/18, which stated, continues to complain of chronic lower back pain. Denies it has gotten worse, was not aware he/she could ask for ibuprofen and reminded to ask if needed. There was no further documentation in the medical record about pain that day. A 12/6/18 history and physical note that was written by the physician stated, reports he/she still has some back…

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

Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to adequately monitor a resident for behavior, side effects, or adverse consequences related to psychotropic medication. This was evident for 1(#255) of 5 resident's reviewed for unnecessary medications. The findings include: On 12/17/18, review of Resident #255's December 2018 MAR (medication administration record) documented that Resident #255 received the psychotropic medications: Divalproex Sodium (Depakote) by mouth 3 times a day for mood stabilization, Sertraline (Zoloft) (antidepressant) by mouth every day for depression/anxiety and Seroquel (Quetiapine Fumarate) (antipsychotic) by mouth every day for dementia with psychosis. Continued review of the resident's medical record failed to reveal evidence that the facility staff monitored Resident #255 for changes in behaviors that necessitated the use of the psychotropic medications, or for side effects related to the use of…

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

Based on surveyor observation and interview with staff, it was determined the facility staff failed to properly label and store all drugs and biologicals by storing medicated creams and lotions on a dresser in the resident's room. This was evident for 1 (#77) of 31 resident bedroom areas observed. The findings include: Resident #77's room was observed on 12/13/18 at 9:55 AM. A dresser was located against the wall just inside the doorway. Behind a small television on top of the dresser were 1 large plastic jar of Greers [NAME] ointment (a barrier cream), 1 bottle of Lotrimin (athletes' foot) powder, 2 60 ml (milliliter) bottles of Triamcinolone Acetonide lotion 0.1% (corticosteroid) in boxes, these items were labeled for Resident #77. A 3rd 60 ml bottle of Triamcinolone Acetonide lotion was observed with the others. This bottle had no box, was unlabeled as to whom it belonged, and the cover was missing. On 12/20/18 during an interview, Staff #18 indicated that medications are only permitted to be stored at the bedside after a physician's order had been written and a plan of care had…

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.