Autumn Lake Healthcare At Summit Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observations, record reviews and interviews, it was determined that the facility failed to ensure that residents received treatment and care to promote the highest practicable wellbeing as evidenced by 1) failure to follow physician orders and 2) failure to provide toileting hygiene for residents who were incontinent of bowel and bladder. This was evident for 3 (Resident #88, #126, and #137) out of 5 residents reviewed for quality of care during the recertification survey. The findings include:1) On 8/12/2025 at 11:24 AM Resident #88 was observed with redness around the left eye. When asked what happened to his/her eye, the resident answered that they fell last week. On 8/12/2025 at 11:30 AM An observation of Resident #88's room was conducted. An opened pack of regular briefs was observed in the bathroom and on top of the resident's dresser. Additionally, the resident showed the surveyor that they wore regular briefs at that time. On 8/12/2025 at…

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

Number of residents sampled: Number of residents cited: Based on record review and staff interview, it was determined that the facility failed provide the necessary treatment and services to promote healing. This was evident for 1 (Resident #131) out of 5 residents reviewed for pressure injuries. The findings include: On 8/18/2025 at 10:20 AM, Complaint #330046 was reviewed. The Complainant alleged the facility failed to clean and turn Resident #131 when appropriate. On 8/18/2025 at 11:02 AM, weekly wound assessments for Resident #131 were reviewed. A Stage 4 sacral wound with an onset date of 7/16/24 was documented to have worsened in the 8/14/24, 8/22/24, and 8/30/24 wound assessments. On 8/18/2025 at 12:25 PM, a review of Resident #131's Documentation Survey report for the month of August in 2024 was conducted. On the following shifts the GNAs documented that the resident was not turned or repositioned every two hours: 8/1/24 Day, 8/8/24 Night, 8/10/24 Day, 8/14/24 Day, 8/19/24 Day, 8/21/24 Evening, 8/23/24 Day, 8/29/24 Night, and 8/30/24 Day/Evening. On the following shifts 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 record review and interviews, it was determined that the facility failed to ensure the resident had an identification wrist band on which led to the wrong resident having their blood drawn. This was evident for 1 (Resident #44) of 28 complaints that were reviewed during the annual survey. The Findings Include: On 8/13/25 at 11:39 AM, complaint #330059 was reviewed and it mentioned that the resident had their blood drawn by mistake due to the resident not having an identification wrist band on. On 8/13/25 at 12:15 PM, the complainant was interviewed. They stated that on 12/9/2024, during a visit with the resident, they noticed that there was gauze and tape on the resident's hand. The complainant then asked the resident's roommate what had happened, they informed the complainant that the lab tech had come into their room and drew Resident #44's blood by mistake. The complainant stated that he asked the facility staff what had happened and they were…

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

Based on record review and staff interview, it was determined that the facility failed to provide the necessary treatment and services to promote healing. This was evident for 1 (Resident #131) out of 5 residents reviewed for pressure injuries. The findings include:On 8/26/2025 at 1:30 PM, a review of Resident #12's orders was conducted. An order for Oxygen to be given at 2 liters per minute via Nasal Cannula every 24 hours as needed at bedtime. On 8/26/2025 at 1:43 PM, an observation was made of Resident #12's room. The resident was not in the room, but oxygen was set to 10 liters per minute. Staff #21 confirmed this observation and confirmed Resident #12's current order in the resident's chart as 2 liters per minute as needed at bedtime. On 8/26/2025 at 1:46 PM, an interview was conducted with Resident #12. When asked when they use Oxygen, they stated that they use oxygen to sleep and when they are sick. When asked how much oxygen they are using at night, they stated that they use 7 liters per minute at night to sleep comfortably. On 8/26/2025 at 1:57 PM, an interview with the…

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

Based on interviews, observations and record reviews, it was determined that the facility failed to provide residents with individualized care based on assessments and physician orders. This was evident for 1 (Resident #88) out of 4 residents reviewed for nursing skills and competency during the recertification survey.The findings include:On 8/12/2025 at 11:24 AM an interview with Resident #88 was conducted. The resident reported that they had a fall last week. Resident was observed with redness around the left eye. On 8/12/2025 at 11:30 AM an observation of Resident #88's room was conducted. An opened pack of regular briefs was observed in the bathroom and on top of the resident's dresser. Additionally, the resident showed the surveyor that they wore regular briefs at that time.On 8/12/2025 at 12:44 PM a review of Resident #88's medical record was conducted. The review revealed orders that stated Resident #88 should 1) wear Hipster Padded Brief q shift while awake for fall interventions and 2) float heels when the resident is in bed and 3) place sling on Right arm. Further review…

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

Based on resident interview, record review, and staff interview, it was determined that the facility failed to prevent a significant medication error. This was evident for 2 (Resident #105 and #52) out of 6 resident's review for unnecessary medications. The findings include:1.) On 8/12/2025 at 11:45 AM, a review of Complaint #330061 was completed. The complaint alleged Resident #105 received the incorrect dose of medication.On 8/12/2025 at 12:02 PM, an interview with Resident #105's representative was conducted. The Resident's representative stated in November of 2024, there was a med error.On 8/15/2025 at 10:04 AM, a review of Resident #105's progress notes was conducted. The change of condition note on 11/10/2024 stated that the resident received 2 mg of Clonazepam instead of the ordered 1 mg of Clonazepam. Order was placed to hold the next dose of Clonazepam, vital signs every shift, and to complete neuro checks every 24 hours. On 11/10/2024 at 00:15, the note stated, during med count writer found out that the clonazepam came in 1mg, so one tablet should've been given. Nurse…

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 record review and interview, it was determined that the facility failed to obtain laboratory tests as ordered by the physician. This was evident for 1 (Resident #120) of 27 residents reviewed during the investigation portion of the survey. The Findings Include: On 08/18/2025 at 7:27 AM, Resident #120's record review revealed a change in condition stating the resident had a change in mental status with paranoid delusions on 6/17/2025. The physician placed an order to obtain a urine analysis (UA) to rule out a possible urinary tract infection on 6/18/2025. On 08/18/2025 at 7:40 AM, a review of the resident's documented lab results revealed that there were no results for the ordered urine analysis. Further review revealed that there was no documentation of refusal. On 08/18/2025 at 1:52 PM, during an interview with the Director of Nursing (DON), he explained that the reason the UA was not obtained was due to the resident refusing. When asked to provide documentation proof of refusal he stated that there was no…

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

Number of residents sampled: Number of residents cited: Based on record review, observation and interview, it was determined that the facility failed to use appropriate infection control practice of hand hygiene when performing wound care. This was evident during a wound care and dressing change observation conducted for 1 (Resident #7) of 2 residents who had pressure ulcers. The findings include:A pressure ulcer, also known as a bed sore or decubitus ulcer, is a skin injury that develops when prolonged pressure is applied to the same area of the bodyA stage 4 pressure ulcer is a severe skin injury that involves complete loss of the skin, underlying tissue (subcutaneous tissue), muscle, and sometimes bone.On 8/18/2025 at 9:00 AM, review of Resident #7's record indicated that they had multiple pressure ulcers. The resident had a facility acquired stage 4 pressure ulcer of the sacrum and unstageable ulcer of the right foot.On 8/19/2025 at 9:28 AM, an observation of wound dressing change on Resident #7 was conducted. The wound care and dressing change was performed by Staff #12. 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.

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 keep the building clean, neat, attractive and in good repair. This was evident in the four nursing units on both floors of the facility. The findings include: On 12/13/23 observations were made in the resident shared room B-14 and the findings were corroborated with the unit manager (staff #24) at 11:10 AM. Both wheeled IV feeding poles (utilized for enteral liquid feeding) bases appeared to have splashes of built up dried enteral liquid feeding. The unit manager suspected that both IV feeding pole bases were dirty with dried enteral liquid feeding, and she attempted to remove the substance with a paper towel. She validated the noticeable cobwebs inside the room attached to the upper and lower window sashes. Additionally, she had confirmed cracks and peeling paint chips on both sides of the window casings. An environmental tour was conducted with the maintenance director (staff #43) on 12/19/23 at 10 AM. The…

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

Based on interviews of facility staff, it was determined that the facility failed to ensure a full-time clinically qualified nutrition professional for the oversight of food preparation and the daily kitchen operation. All the residents in the facility have the potential to be affected by not having a qualified nutritional professional with the appropriate competencies and skill sets to carry out food and nutrition services. The findings include: An interview was conducted with the Food Service director (staff #4) 12/03/23 at 9:25 AM. She indicated that she has overseen the kitchen for the past 3 months. She was asked if she was a certified dietary manager (CDM) and she replied that she was not. On 12/5/23 at 2:30 PM the Food service director was provided a Nutritional Department Information Request List that included a request for the Food service director's credentials and copies of the certified dietary manager's credentials. She was asked again if she had any credentials as requested and she indicated she did not. On 12/06/23 at 09:56 AM the Food Vender Operational Manager 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, interview, and documentation review it was determined that the person in charge of the kitchen failed to 1) ensure kitchen staff utilized effective hair restraints, 2) ensure the required sanitation levels of the facility's dishwashing machine, 3) keep vents and pipes and conduits clean and in good repair, and 4) ensure sanitary conditions for storage/transfers of ice to reduce the risk of foodborne illness. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen. The findings include: 1. Initial inspection of the kitchen was initiated on 12/3/23 at 8:26 AM. The window air conditioner over a hand sink was noted with dust, grim, and small blackened spots/area across the front plastic grate panel. A male dietary aide (staff #9) with an exposed facial beard was observed working in the dish washing room at 8:54 AM. At 9:01 AM observations of the wash and rinse temperature gauges revealed the rinse gauge was not moving and stuck at lowest position. The wash gauge was observed at 144 degrees Fahrenheit (F.) The…

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

Based on record review and interviews with residents, families, and staff, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 8 of 21 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, 11 (#2, #27, #49, #50, #58, #78, #84, #96, #113, #222, #224) interviewable residents, 2 of 3 family interviews conducted, 2 of 10 (#32, #42) staff interviewed, and a review of staffing schedules. This deficient practice had the potential to affect all residents. The findings include: Certification and Survey Provider Enhanced Reporting (CASPER) is a system developed by the Centers for Medicare and Medicaid Services (CMS) which, in part, requires long term care facilities to submit Payroll Journal Based (PBJ) payroll data for nursing staff. The report also includes the facility's daily census. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll 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.

3. On 12/3/23 at 10:15 AM resident #96 was asked about the food and s/he responded, the food is awful, not much variety it is like low quality food, the meals are cold. 4. On 12/04/23 at 12:57 PM resident #224 indicated that the food is very bland, and the food was cold. On 12/15/23 at 10:38 AM an interview was conducted with the Food Vender Operational Manager of HealthCare Service Group (staff # 27). Upon questioning she indicated that food temperatures are recorded prior to food service and the food is maintained on the serving line. The plates are warmed and placed on a metal plate to keep food warm for an additional 20 minutes. She was asked about the breakdown of why the residents would say they get cold food, and she responded that it would depend on how long it takes to get food passed out. It should take about 20 minutes to get the food passed out. Tray line lunch time food service was observed on 12/19/23. Interview of the district manager of Healthcare Services Group (staff #36) at approximately 11:30 AM revealed that the tray line usually starts at 11:45 AM. The tray…

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 staff failed to honor Resident #42's right for self-determination regarding smoking opportunities. This was evident for 1 out of 2 residents reviewed for resident preferences during the survey. The findings include: On 12/05/23 at 03:03 PM, observation found that Resident #42 looked anxious. The resident began complaining, I only can smoke once per day in the afternoon, and I told the staff that I want to smoke in the morning too. On 12/07/23 at 11:53 AM, record review of Resident #42's record, from September 1, 2023 to December 7, 2023, revealed that he/she was admitted to the facility on [DATE]. There was no evidence that the resident had refused care or had demonstrated other behavioral problems. Further review of the resident's care plan dated 9/19/23, found that the resident was a smoker, but the care plan did not address the resident's request for more frequent smoking opportunities. During the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure a resident had a health care agent prior to obtaining an order to withhold CPR (cardiopulmonary resuscitation and 2) ensure the resident offered the opportunity to develop an advance directive for 2 (#67 and #113) of 9 sampled residents for advance directives. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The MOLST form…

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 of facility staff it was determined the facility failed to provide written notification to a resident when the facility determined that a resident no longer qualified for Medicare part A skilled services. This was identified for 1(#46) of 1 resident reviewed that remained in the facility after the termination of Medicare part A skilled services. The findings include: The SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. On 12/21/23 at 9:20AM, the surveyor requested to the Director of Nursing (DON) for the facility to complete the skilled nursing facility beneficiary protection notification review form for Resident #46. The DON reported to the surveyor that Staff #48, who they identified as a social worker, was responsible for the SNF ABN forms and the review form would go to them for completion. Review…

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

Based on medical record review and interview, the facility staff failed to thoroughly investigate complaints involving resident care. This was evident for 2 (#521 and #368) out of 44 residents reviewed during the survey. Findings include: 1). Review of Resident #521's facility reported incident (MD00174507) on 12/15/23 at 1:30pm revealed the resident's wanderguard did not alarm when he/she was being escorted out of the facility by facility nursing staff on 11/14/21. The facility's investigation revealed resident #521's wanderguard did not alarm because it was under the resident's clothing. The facility had the wanderguard alarms adjusted to a higher sensitivity. All wanderguards, worn by residents, were tested with no issues. All wanderguard alarms were tested with no issues after the adjustment. Resident #521's wanderguard was replaced. The surveyor requested the facility's investigation report for the facility reported incident at 12/15/23 at 1:45pm. The DON stated that the facility did not have the facility investigations for any facility reported incidents before 6/2022. The…

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

Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (#60) of 6 residents reviewed for hospitalization during the recertification survey. The findings include. 1) Review of Resident #60's electronic and paper medical record on 12/5/23 at 9:18 AM revealed a change in condition note dated 7/9/23 for 4:37 PM that was written as Change in Condition Note Text: Brief Synopsis of Change: Patient mental status declining slowly, slower arousal, now not eating or drinking. Summary of Change in Condition: Patient mental status declining slowly, slower arousal, now not eating or drinking. Being sent to hospital for acute change evaluation and hydration. A second late entry note was written by the unit manager (Staff 24) on 7/10/23 with the same information. Both notes did not document what interventions were put into place before the transfer, what the resident was told and if the resident understood where he/she was going and why. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility failed to provide a notice of the bed hold policy when a resident was transferred to the hospital. This was evident for 1 (Resident #116) of 6 residents reviewed for hospitalization. The findings include: On 12/12/23 at 1:55 PM a review of Resident #116's medical record was conducted and revealed that the resident was transferred from the facility to a hospital on [DATE]. There was no notice of bed hold policy found in the paper or electronic record. On 12/12/23 at 2:39 PM in an interview with the Director of Nursing (DON), she stated that she was not sure if a bed hold notice was given to the resident and would look for a copy, and that it may be kept in another place other than the medical record. On 12/12/23 at 2:59 PM in interview with DON, she stated that she was unable to find any evidence that a bed hold notice was ever given to the resident related to the resident's transfer to the hospital. On 12/13/23 at 12:06 PM the DON confirmed…

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, medical record review, and interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#58, #11) of 58 residents reviewed during the recertification survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 12/3/2023 at 9:00 AM, Resident #58 was initially observed in the hallway in a wheelchair. The resident stated s/he was heading to an appointment outside the building. On 12/5/2023 at 8:45 AM, Resident #58 stated that s/he goes out of the facility for therapy. The resident stated that s/he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4). During an interview with Resident #82 on 12/05/23 at 09:05 AM, the resident stated that he/she did not participate in any activity outside the room. Also, the resident reported that no one visited him/her in the room to offer any activities. On 12/21/23 at 8:12 AM, a review of Resident #82's medical record revealed that there was no care plan for Resident #82's activities. During an interview with Staff #11(Director of Activities) on 12/21/23 at 09:38 AM, the surveyor reviewed Resident #82's care plan with her. Staff #11 confirmed that no care plan was developed regarding the resident's activities. During an interview with the Director of Nursing on 12/21/23 at 2:10 PM, the DON was informed of the above concerns and validated the surveyor's concerns. 3). The facility reported incident MD00187009 was reviewed on 12/13/23 at 9:06 AM. The facility reported that at approximately 04:00 PM on 12/23/22, Resident #54 claimed that his/her lock box and some rings were missing. Further review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined that the facility staff failed to revise and update a comprehensive care plan for residents and failed to have care plan meetings with a residents and/or resident representatives. This was evident for 3 (Resident #38, #27, #89) of 7 residents reviewed during the recertification 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. 1a) On [DATE] at 10:08 AM, in an interview with Resident #38, the resident stated that s/he has not seen the Social Worker and has not attended any care plan meeting. S/he added I want to go home to my house; I can take care of myself. I can cook, I dress myself and I go to the bathroom by myself. On [DATE] at 9:35 AM, an interview was completed with the Social Worker (SW #48), in the presence of the Director of Nursing (DON): SW #48 stated that care plan meetings were held every three…

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

Based on a review of the medical record, policy and procedures, and interview with staff, it was determined that the facility failed to meet professional standards of practice by failing to ensure physician orders for administration of narcotics as evidenced by nursing staff documented on the Medication Administration Record (MAR) and Controlled Drug Administration Record (known as control sheet). This was evident for 4 (#13, #84, #99, and #105) of 5 residents who were reviewed Controlled drug administration records and unnecessary drugs during the survey. The findings include: Oxycodone hydrochloride is part of a group of drugs known as opioids. Opioids include any drug that acts on opioid receptors in the brain and any natural or synthetic drugs that are derived from or related to the opium poppy. Tramadol is a strong pain medication used to treat moderate to severe pain that is not being relieved by other types of pain medicines. Tramadol is a synthetic opioid and acts in the brain and spine (central nervous system) to reduce the amount of pain. Opioid (also known as narcotics)…

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, medical record review and interview, it was determined that the facility staff failed to maintain Resident #42's hygiene and appearance. This was evident for 1 out of 6 residents reviewed Activities of Daily Living (ADLs) during the survey. The findings include: Activities of Daily Living (ADLs) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. On 12/03/23 at 09:48 AM, Resident #42 was observed wearing a food-stained, malodorous, torn jacket. The resident's face was greasy and hair was dirty with dust. On 12/05/23 03:09 PM, Resident #42 was observed wearing the same food-stained jacket and overgrown hair was still dirty with dust. On 12/07/23 at 11:53 AM Resident #42's record revealed that the resident was admitted to the facility on [DATE]. There was no evidence that the resident had refused care or had demonstrated other behavioral problems. Further review of the 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.

Based on observation, medical record review and interview it was determined the facility failed to ensure effective oversight for the assessment and care of a resident's wound. This was evident for 1 out of 1 (Resident #19) resident reviewed for non-pressure skin conditions. The findings include: During surveyor's review of the medical record for Resident #19 on 12/6/23 at 10:18AM, documentation of an open skin area located on their back beginning on 11/8/2023 was present with the following active wound care order in place beginning 11/8/2023: Clean wound on mid back with NS/Wound cleanser, apply xeroform (protective non adherent dressing,) cover with dry dressing daily every shift for wound treatment. Review of the medical record for Resident #19 on 12/20/23 at 9:16AM revealed that on 11/27/23 at 1:03PM Staff #21, Unit Manager (A unit), documented the following in a care plan note: No issues or problems noted this quarter; skin integrity remains intact. Continue plan of care. On 12/20/23 at 9:47AM the surveyor conducted an interview with Staff #21 who reported Resident #19…

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, medical record review, and interview, it was determined the facility failed to: 1) properly date label oxygen tubing when changed, 2) have physician's orders for the administration of oxygen, and 3) develop and implement a person-centered comprehensive care plan with resident centered goals for respiratory care to include oxygen therapy. This was evident for 3 (#84, #59, #78) out of 5 residents reviewed for respiratory care during the recertification survey. The findings include: Oxygen therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider. 1). On 12/4/23 at 9:30 AM, an observation of Resident #59 revealed the resident was wearing an oxygen nasal cannula (NC) tubing connected to a water bottle which was connected to an oxygen concentrator set at 2.0 LPM (liters per minute). On 12/13/23 at 11:03 AM observations with the unit manager (staff #24) revealed the…

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

2. On 12/14/23 at 12:34 PM during an interview with the Director of Nursing (DoN), the Surveyor requested copies of Physician #25's visit notes on Resident #13 in the last 6 months for review and the DoN found only 2 visit notes. The DoN stated the resident was seen twice during the past 6 months: on 8/24/23 and 11/14/23. Additionally, the DoN confirmed that both visit notes were still not uploaded to the electronic medical record system. On 12/19/23 at 11:00 AM during an additional medical record audit using Resident #13's physical floor paper chart, only one Physician #25 visit note dated 8/24/23 was located. Based on medical record review and staff interview it was determined facility failed to provide timely visit notes in the electronic record or physical chart after each visit. This was evident for 2 (#13, #14) of 58 residents reviewed during the survey. The findings include. 1. Resident #14's medical record was reviewed on 12/14/23 at 9:20AM. Review of resident #14's attending physician (Staff #60) notes revealed late entry physician notes that were not documented 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.

Based on a review of the medical record, policy and procedures, and interview with staff, it was determined that the facility staff failed to ensure narcotics removed from the resident's supply were administered to the resident, as evidenced by staff documenting the removal of narcotics without documentation of the need for the narcotic or documentation that the narcotic was administered to the resident. This was evident for 4 (#13, #84, #99, and #105) of 4 residents reviewed of 4 Controlled drug administration records and medication administration records reviewed during the survey. The findings include: Oxycodone hydrochloride is part of a group of drugs known as opioids. Opioids include any drug that acts on opioid receptors in the brain and any natural or synthetic drugs that are derived from or related to the opium poppy. Tramadol is a strong pain medication used to treat moderate to severe pain that is not being relieved by other types of pain medicines. Tramadol is a synthetic opioid and acts in the brain and spine (central nervous system) to reduce the amount of pain. Opioid…

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

Based on medical record review and staff interview it was determined that the facility failed ensure that accepted physician's responses to the consultant pharmacist recommendations were implemented. This was identified for 1 (resident #14) of 5 residents reviewed for unnecessary medications. The findings include. Resident #14's medical record was reviewed on 12/11/23. Resident #14 was noted to be administered multiple psychotropic medications. Review of the monthly consultant pharmacist medication regimen reviews revealed that a recommendation was made on 3/13/23. The consultation report was not included in the resident's medical record, and it was requested from the director of nursing. Review of the 3/13/23 pharmacist consultation report acknowledged that Resident #14 was administered the psychiatric medication lithium and to monitor for potential adverse effects the medication the pharmacist recommended laboratory blood work monitoring plan. The suggested plan indicated that blood lithium levels should be drawn and monitored every 2 months, blood testing for the thyroid…

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

Based on medical record review and interview, it was determined the facility staff failed to follow physician orders by administering as needed (PRN) pain medication outside the prescribed parameters. By failing to follow the prescribed parameters for the medication administration, the resident was given an unnecessary medication. This was identified for 2 (#84, #105) of 5 residents reviewed during a recertification survey. The findings include: 1) On 12/7/2023 at 1:43 PM, review of Resident #84's medical record revealed the resident was admitted to the facility in July 2023 with medical diagnoses that include but not limited to: Obstructive and reflux uropathy, Chronic Obstructive Pulmonary disease, Acute Respiratory failure with Hypoxia, Viral Hepatitis C, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side. On 12/7/2023 at 2:33 PM, review of physician orders revealed an active order with a start date of 12/1/2023, for Oxycodone tablet 5 mg: give 5 mg via G-Tube every 8 hours as needed for pain level 6-10. Further review of the orders revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility failed to ensure that all expired drugs and biologicals used in the facility were removed from storage. This was evident on 2 of 3 medication carts and 2 of 4 medication storage rooms. Also, the facility failed to store drugs and biologicals in locked compartments. This was evident in 1 of 2 medication carts on unit A during an the survey. The findings include: 1) On 12/15/23 at 04:48 PM, the surveyor observed a medication cart on B wing with a Registered Nurse (RN #30) and the Assistant Director of Nursing (ADON). The surveyor noted one unlabeled white tablet in the medication administration cup placed in the first drawer of the cart. Also, a Chocolate shake was found on the medication cart without a label with an expiration date. RN #30 and ADON #45 verified this unlabeled medication and chocolate shake. 2) On 12/15/23 at 05:05 PM, the surveyor found five expired e-swabs (dated 2023-5-31) in the medication storage room on B wing. The…

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

Based on observation, medical record review, and interview it was determined the facility failed to ensure a resident timely received a dental provider consult for acute dental issues. This was evident for 1 out of 4 (Resident #11) residents reviewed for dental during the facility's recertification survey. The findings include: On 12/5/23 at 10:23AM the surveyor conducted an interview with Resident #11, whose main concern was their dental pain. Resident #11 reported to the surveyor they had reported the pain approximately two weeks ago to Staff #24, Unit Manager (B and C units.) The resident further reported their pain had increased during the past week, they wanted to be seen by the dentist, and facility staff had not followed back up with them. On 12/5/23, at 10:25AM the resident reported during the surveyor's interview, that they were having 10/10 (highest level) dental pain, on the pain scale to the surveyor and asked for pain medication. The interview was stopped at this time, and the surveyor communicated to Staff #40, LPN (B unit) that the resident was asking for assistance.…

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 interview, it was determined that the facility staff failed to ensure resident's religious preferences were honored and to provide a consistent Kosher diet. This was evident for 1 (Resident #91) out of 7 residents reviewed for food preferences. The findings include: On 12/04/23 at 9:05 AM, Resident #91 was calling out look what they gave me this morning Bacon! I am Jewish and I can't have any pork products and it's in my food preference too. Observation of his/her breakfast tray's meal ticket listed as following: French Toast with Margarine, however, the tray contained 2 slices of bacon. On 12/15/23 at 10:11 AM, a review of Resident #91's medical record revealed their food preference for a kosher diet was generated during admission. During an interview on 12/15/23 at 10:54 AM with Food Operational Manager Staff #27, she stated that all resident food preferences were obtained within 48 hours of their admission per procedure. Kitchen staff then entered the information into the meal track system and it generates the daily meal tray lists…

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

Based on observation, interview, and record review, it was determined that the facility staff failed to provide appealing options to residents who choose not to eat the menu scheduled food items. This was evident for 1 (Resident # 91) out of 7 residents reviewed for substitute food during the survey. The findings include: On 12/15/23 08:28 AM observation of Resident #91's breakfast tray was on the table, but the resident did not touch it. He/She explained it was the same old same old stuff, there is no variety here. He/she stated no staff was assisting her to get an alternative tray. During an interview on 12/15/23 at 10:54 AM with Food Operational Manager #27, she explained the admission package had an alternative food choice list besides the main entrée. On 12/15/23 at 11:20 PM Staff #27 provided a copy of an alternative menu as part of the admission package. On 12/16/23 at 09:02 AM interview with the Unit Manager #21 in regard Surveyor witnessed a resident's breakfast tray was not touched and staff took back the tray to the meal cart without offering a substitute tray. She…

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

Based on record review and interview it was determined that the facility failed to provide accurate and comprehensive clinical information to the survey team during the initial phase of the recertification survey. This was evidenced by the inaccurate resident matrix provided by the Director of Nursing (DON). This impeded the survey team's ability to determine all care areas that should be investigated. The findings include: A resident matrix, form CMS-802, is a document that is required to be produced by the facility's clinical administration at the beginning of a survey. The matrix is a list of all residents with details for each resident's areas of special concern such as infection, oxygen use, or the presence of a pressure ulcer. Per the Long Term Care Survey Process manual, October 2023 version, surveyors will decide which onsite-selected residents to include in the initial pool based on your screening and review of MDS indicators . and matrix information . The manual also states that each surveyor will review the matrix for residents in their assigned area to identify any…

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 of facility staff it was determined the facility failed to retain resident records for the required time period (Resident #528), ensure accuracy of medical order documentation and identify duplicate orders for the care of a resident's feeding tube (Resident #55) and document care that was provided (Resident #111 and #116). This was evident for 4 of out of 58 residents reviewed during the survey. one out of five residents reviewed for tube feedings during the facility's recertification survey. The findings include: 1. On 12/20/23 at 9:00am, the surveyor attempted to locate resident #528's medical records on the electronic database. On 12/20/23 at 12:00pm, the surveyor interviewed the Director of Nursing (DON) regarding retention of resident medical records. The DON stated that the current facility owners obtained ownership of the facility in July 2022. Any records for residents receiving care prior to July 2022 are in the ownership of the previous owners. The surveyor requested the DON to obtain resident #528's records. On 12/21/23 at…

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

Based on record review and interviews, it was determined that the facility failed to communicate with hospice representatives regarding the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. This was evident for 1 (Resident #23) of 1 residents reviewed for hospice services during the survey. The findings include: On 12/14/23 at 2:40 PM a review of Resident #23's electronic record revealed an order admitted to Hospice on 2/25/2023. On 12/18/23 at 8:57 AM a review of Resident #23's paper chart was conducted. In the Hospice section of the chart there was a handwritten physician order form dated 3/20/23 which included an order for Full bed bath every shift. The order form had 2 signatures, Registered Nurse (RN#49), and Physician (MD#50). The order also contained changes to the resident's medications. A review of the resident's electronic record revealed that the orders for medication changes were made to the resident's electronic record. However, there was no documentation found for the order full…

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

Based on observation and interview it was determined that the facility failed to ensure standard infection control precautions were maintained for residents. This was evident during several observations made throughout the facility. The findings include: On 12/4/23 at 10:43AM the surveyor interviewed Staff #46, an outside vendor contracted by the facility, who reported to the surveyor that they were testing the medical equipment throughout the facility. On 12/5/23 at approximately 12:45PM, the surveyor observed Staff #15, Regional Corporate Nurse in the hallway observing Staff #46 entering the facility with blue disposable gloves on and proceeding to open the locked hallway doors, at which time, Staff #15 acknowledged to the surveyor that they were aware Staff #46 was wearing disposable gloves in the hallway and reported that Staff #46 is not facility staff. On 12/5/23 at 12:48PM the surveyor observed Staff #46 on Unit A of the facility in the hallway with disposable personal protective equipment (ppe) on including disposable gloves and gown, while typing on their laptop situated 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 review of resident medical records and interview with facility staff, it was determined that the facility failed to provide notice to a resident and a resident's representative when the facility made the determination to involuntarily discharge the resident during an acute hospitalization. This was evident for 1 (Resident #1) of 1 resident reviewed for involuntary discharge. The findings include: The surveyor began reviewing complaint MD00199349 on 11/13/23 at 8:15 AM. The complaint indicated that Resident #1 had been hospitalized for acute aggression towards nursing staff at this facility on 10/28/23. It stated that the resident had been medically and psychiatrically cleared for discharge from the hospital but that this facility was not allowing the resident to return. On 11/13/23 at 8:56 AM, the surveyor interviewed Resident #1's case manager at the hospital that the resident had been transferred to on 10/28/23. The case manager confirmed that the facility was still not allowing the resident to return. When asked if the resident was interested in returning to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to comply with discharge requirements prior to denying readmission to a resident with documented aggression after the resident was cleared for discharge from an acute hospitalization. This was evident for 1 (Resident #1) of 1 resident reviewed for involuntary discharge. The findings include: Emergency Petitions for Psychiatric Evaluation (EPs) are completed for individuals with acute psychiatric symptoms that place themselves or others in danger. EP forms are usually completed by mental health professionals or by police officers. Individuals who receive an EP are transported to an emergency department and evaluated for acute psychiatric conditions. Completing EP forms on an individual represent an attempt to keep the individual and others safe from the abnormal and dangerous behavior being exhibited by the individual. The surveyor began reviewing complaint MD00199349 on 11/13/23 at 8:15 AM.…

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

Based on observation and interview with residents and staff it was determined that facility staff failed to treat residents with respect and dignity by failing to knock prior to entering residents' rooms, asking permission before providing services or care and failed to keep private information about activity of daily living (ADL) information in an area that was not viewable by the public as evidenced by posting information on the staffing board. This was found to be evident for 3 rooms on multiple days. This has the potential to affect all the residents. Residents #50 and #20 had personal information posted on the staffing board in the hallway. The findings include: On 3/14/19 at 2:09 PM and 3/15/19 at 12:45 Staff #11 was observed entering 3 rooms on the C unit for 2 days of the survey without knocking. During an interview with Resident #20 he/she revealed that staff seldom knock on the door before entering they just walk in. The resident further revealed that sometimes he/she may call them in but most times they do not bother to knock. During an interview with the Director 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 medical record review and interview it was determined that the facility failed to ensure the a resident and family were fully informed of the risks versus the benefits of the use of an antipsychotic medication. This was found to be evident for 1 out of 6 residents (Resident #62) reviewed for unnecessary medications. The findings include: On 3/18/19 review of Resident #62's medical record revealed the resident had been admitted to the facility in December 2018 and was not receiving any antipsychotic medication at the time of admission. Review of the psychiatric nurse practitioner notes revealed that on 1/24/19 the resident was diagnosed with Dementia associated with other underlying disease with behavioral disturbance and a recommendation was made to start [an antipsychotic medication] 25 mg by mouth two times a day for agitation/aggression related to dementia. A corresponding physician order was found. Review of the Medication Administration Record revealed the the antispychotic medication was administered twice a day as ordered since 1/25/19. Review of the Psychotropic…

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 the facility failed to accommodate the residents need to have his/her bed positioned properly as desired thus prohibiting his/her view of the television. This was observed for 1 of 1 residents (Resident #7) selected for accommodation of needs. The findings include: On 3/15/2019 at 9:35 AM and 3/18/2019 at 9:55 AM Resident #7 was observed in his bed facing the wall that is diagonal with the hallway. The resident was not able to view his television or socialize with his roommate due to facing the wall. The resident was able to communicate with the surveyor by shaking his head yes that he was interested in watching his television when he was in bed. Review of the Residents #7's Brief Interview for Mental Status (BIMS) revealed a score of 3, which indicated sever cognitive impairment. The BIMS is a structured evaluation aimed at evaluating aspects of cognition in elderly patient. Interview with geriatric nursing assistant (GNA) #11 on 3/20/19 at 10:17 AM revealed the GNA was not sure why the resident's bed was facing the wall and resident was not able…

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 with residents during a resident council meeting and observation, it was determined that the facility failed to have the facility survey results in a location accessible and frequented by the majority of said residents. The findings include: During a resident council meeting held on 3/14/19 at 11:37 AM, the residents were asked if they were aware of the location of the survey results from previous surveys. Of the multitude of alert and oriented residents in attendance, no resident, including the resident council president was able to verbalized the location of the survey results. During a tour of the facility at 12:00 PM, Surveyor located the survey results binder at the receptionist desk in lobby of the facility. However, the location of the binder was not easily accessible to all residents as it was only located on the main floor by the entrance of the facility. Residents only had access to the binder in the lobby if they were to go outside or out to an appointment. The Administrator was made aware of the findings on 3/14/19 at 1:01 PM.

Based on Beneficiary Protection Notification Review and interview with the facility staff, it was determined that the facility failed to provide an Advance Beneficiary Notice (ABN) and failed to ensure that the beneficiary(resident) or representative signed and dated the Notice of Medicare Non-Coverage (NOMNC). This was evident for 1 out of 3 residents(Resident #304) reviewed regarding liability notices. The findings include: Advance Beneficiary Notice (ABN) is a written notice from Medicare given to residents informing them that they may be responsible for paying for certain items or treatments if Medicare denies paying. The ABN gives you information to make an informed choice about whether to get items or services. A Notice of Medicare Non-Coverage (NOMNC) is a notice that must be given to people with Medicare, before the ending of all skilled services provided by skilled nursing facilities. The notice is to let you know that you have the right to appeal the ending of your skilled services if you feel you need more care. The NOMNC explains your Medicare rights and gives…

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, review of Maintenance Request Log and interview it was determined that the facility failed to ensure a clean, comfortable and homelike environment as evidenced by ceiling tiles in multiple resident rooms with stains and black splotches. This was found to be evident on 1 of the 4 units in the facility. The findings include: On 3/15/19 at 10:31 AM blackish gray splotches were observed on the ceiling tile above Resident #58's bed. Review of Resident #58's medical record revealed the resident had been admitted several months prior and was cognitively intact as evidenced by a BIMS [Brief Interview of Mental Status] of 15 out of 15. On 3/19/19 at 12:57 PM the following additional observations were made: room [ROOM NUMBER] the ceiling tile located between the foot of the bed and the bathroom had a gray splotch approximately 4 inches by 1 inch; room [ROOM NUMBER] the ceiling tile above Bed A had an approximately 10 inch in diameter brown stain; room [ROOM NUMBER] the ceiling tile above Bed B 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.

Based on review of the facility reported incident MD00123567, investigative information, medical records and interview with staff it was determined that the facility failed to keep a resident free from abuse. This was evident for 1 out of 6 residents (Resident #255) reviewed for abuse The findings include: On 3/20/19 Resident #255 closed records were reviewed. This review revealed a Brief Interview for Mental Status completed in August 2018 with a score of 15 out of 15 indicating the resident was cognitively intact. A review of the facility reported incident investigation regarding Resident #255 revealed that on 2/26/18 the resident alleged that he/she asked the nurse (Staff # 26) for pain medications. The resident revealed that the nurse would not give him/her medication, Staff # 26 stated that he needed to check the time to see if the resident could have it. The resident stated he/she told the nurse the last time the medication was administered, the resident reported that the nurse continued to refuse to give him/her medications. The resident stated that he/she informed the nurse…

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

Based on medical record review and interview with facility staff, it was determined that the facility administered a chemical restraint to a resident (Resident #10) on 2 occasions. The findings include: Review of the medical record for Resident #10 on 3/15/19 at 10:14 AM revealed diagnoses including Alzheimer's disease and major depressive disorder. 1. Review of the medical record revealed that on 3/18/19 at 8:38 AM revealed that Resident #10 was documented as aggressive and fighting on 8/10/18 at 7:15 PM. Staff contacted the resident's attending physician and a one-time dose of Haldol, an antipsychotic was ordered to be given intramuscularly (IM) for aggressive behavior. There was no documentation that any alternative intervention was attempted prior to staff administering a chemical injection. In addition, there was an order for a psychiatric evaluation. The evaluation was not found on the chart and a request for the evaluation was made to the Director of Nursing (DON) by the survey team on 3/20/19. No paperwork was provided to the survey team at the time of exit on 3/21/2019. 2.…

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

Based on review of facility policy and interview with residents and facility staff, it was determined that the facility failed to initiate an investigation into a potential allegation of abuse. This was evident during a resident council meeting. This has the potential to affect all residents. The findings include: During a resident council meeting held with residents on 3/14/19 at 11:00 AM Resident #16 verbalized that on 3/12/19, Staff #17 was verbally inappropriate towards him/her during medication pass. This exchange was heard by Resident #4 who confirmed that Staff # 17 had stated she didn't care about Resident #16. Resident #4 further verbalized that Resident #16 was visibly upset after the exchange between him/her and Staff #17. Resident #86 and #24 who were present during the facility's resident council meeting held on 3/13/19 and the resident council meeting held with the surveyor on 3/14/19 also confirmed that Staff #17 was at times verbally inappropriate towards residents and would refuse to provide care and distribute medication. Resident #16 was asked how the exchange…

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

Based on medical record review and interview with staff it was determined that the facility failed to have an effective system in place to ensure residents and responsible parties were provided written notice of hospital transfers. This was found to be evident for 2 of 5 residents (Resident #82 and #103) reviewed for hospital transfers during the investigative stage of the survey. The findings include: 1. Review of Resident #82's medical record on 3/20/19 revealed that the resident was admitted to the facility for long term care and with diagnoses that includes dysphagia (difficulty swallowing) and a gastrostomy tube (also called a G-tube) which is a tube inserted through the abdomen that delivers nutrition directly to the stomach. Medical records review revealed that the resident was transferred from the facility in February 2019 and admitted to the hospital for pneumonia. Further review of the medical record failed to reveal any documentation to indicate that the resident, or responsible party, had been provided written notification regarding the reason for the transfer, the…

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

Based on medical record review and interviews with staff it was determined that the facility failed to ensure the resident, or the resident's representative, was notified in writing of the bed-hold policy at the time of a hospital transfer. This was found to be evident for 1 out of 5 residents (Resident #82) reviewed for hospitalization during the survey. The findings include: On 3/20/19 review of Resident #82's medical record revealed the resident was admitted to the facility for long term care and with diagnosis which includes hypoxemia (abnormally low oxygen content in any tissue or organ, or the body as a whole). Further review revealed that the resident had a hospital transfer in February 2019. During an interview with the Resident #82's representative on 3/20/19, she acknowledged that the resident went out to the hospital but denied getting any documentation about the bed-hold policy. Review of the resident's chart failed to reveal any documentation that the resident or the representative received a copy of the bed-hold policy. During an interview with the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1. assess the use of antipsychotic medication (Resident #62), 2. assess that a resident was receiving restorative nursing services (Resident #61), 3. code a resident use of a diuretic correctly (Resident #24), 4. assess the resident's Activities of Daily Living (ADL) (Resident #20) and 5. code medication usage accurately (Resident #82). This was found to be evident for 5 out of 13 residents (Resident #62, #61, #24, #20, #82) reviewed during the investigative stage of the survey. The findings include: The MDS is a tool that is a federally mandated process for clinical assessment required by nursing homes to complete on each resident. The MDS provides a comprehensive assessment of the resident's functional capabilities and helps nursing home staff identify health problems. The facility staff develops plans 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 medical record review and interviews of facility staff it was determined that the facility failed to 1. develop a care plan to address the initiation and continued use of an antipsychotic medication for the treatment of agitation and aggression related to dementia and 2. failed to develop a care plan for a resident who was diagnosed with Vitamin D Deficiency (low levels can result in soft brittle bones). This was found to be evident for 1 out of 6 residents (Resident #62) reviewed for medications and 1 of 5 self reports (Resident # 96) reviewed during the facility's annual Medicare/Medicaid survey. The findings include: 1. On 3/18/19 review of Resident #62's medical record revealed the resident had been admitted to the facility in December 2018 and was not receiving any antipsychotic medication at the time of admission. Review of the psychiatric nurse practitioner notes revealed that on 1/24/19 the resident received a diagnosis of Dementia associated with other underlying disease with behavioral disturbance and a recommendation was made to start [an antipsychotic…

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 interview with staff it was determined that the facility failed to: 1. update and revise care plans that accurately reflect the resident's current assessment regarding Activities of Daily Living (ADL) and 2. update a resident care plan to include two residents being in a romantic relationship. This was evident for 3 out of 8 residents (Resident #42, Resident #19 and Resident #78) reviewed during the investigation stage of the long-term care 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. During initial tour of the unit on 3/14/19 Resident #42 was observed independently rolling around the facility in an electric wheelchair. On 3/15/19, during an interview with the resident, he/she reported that he/she can do everything independently. The resident reported that with restorative services she/he can walk a very short distance. During an interview with the Director of Nursing (DON) on 3/15/19 she 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, interview and review of medical record it was determined that the facility failed to provide activity services as indicated in the resident's care plan. This was found to be evident for 3 out of 5 residents (Resident #47, Resident #97 and Resident #7) reviewed for activities during the survey. The findings include: 1. Review of Resident #47's medical record revealed the resident was admitted in January 2019 with diagnosis that included but not limited to dementia and muscle weakness. Review of the 1/25/19 Minimum Data Set assessment revealed the resident required extensive assistance of two persons for bed mobility and total dependence for transfers. On 3/14/19 at 10:55 AM; 1:17 PM; and 3:03 PM and 3/15/19 at 10:21 AM the resident was observed laying in bed, no activity staff were observed with the resident during any of these observations. Review of the resident's care plan revealed the following: [resident] is dependent on staff for meeting emotional, intellectual, physical and social needs r/t immobility and physical limitations. The stated goal: [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, medical record review and interview it was determined that the facility failed to ensure interventions included in a resident's care plan were implemented as evidenced by failure to ensure a roam guard was in place as ordered. This was found to be evident for 1 out of 3 residents (Resident #91) reviewed for elopement risk. The findings include: On 7/2/19 review of Resident #91's medical record revealed a care plan addressing the resident's risk for elopement initiated in 2018. Interventions included in this care plan included a roam alert device to left wrist and for staff to check placement of the roam alert device every shift. Current physician orders, originally written in June 2019, to check the roam alert device function every night shift and to check it's placement every shift were found in the medical record. On 7/3/19 at 8:45 AM the resident was observed in his/her room, it was noted that the resident did not have a roam alert device on at this time. On 7/3/19 at approximately 9:10 AM the Director of Nursing denied knowledge of any missing roam alert…

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 have an effective system in place to ensure ophthalmology consults were obtained as ordered. This was found to be evident for the 1 out of 1 resident (Resident #63) reviewed for vision services during the survey. The findings include: On 3/14/19 at 10:31 AM Resident #63 was observed wearing glasses. On 3/19/19 review of the medical record revealed a physician order, dated 10/29/18 for ophthalmology consult for routine eye care. The same order was written again on 11/26/18. Further review of the medical record failed to reveal documentation that the resident had been seen by the ophthalmologist since the original order had been written in October 2018. On 3/19/19 at 3:43 PM the Unit Nurse Manager #20 reported that an ophthalmologist comes to the facility once a month and that the social worker keeps the list. Surveyor then reviewed the concern that the resident had orders in October and November 2018 for ophthalmology consult for routine eye care but no documentation could be found 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to provide necessary care to prevent the development of new pressure ulcers and to prevent infections of pre-existing pressure ulcers. This was found to be evident for 2 out of 8 residents (Resident #82 and #47) reviewed for pressure ulcers during the survey. The findings include: A pressure ulcer also known as bed sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the skin and underlying tissue. Pressure ulcers are staged according to the severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon). Pressure is one of the main causes of a decubitus ulcer. Lying on a certain part of your body for long periods…

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 of employee files and other pertinent documentation and interview with facility staff, it was determined that the facility failed to ensure staff was trained in tracheostomy care. This was evident in the review of 1 of 1 residents (Resident #55) reviewed for having a tracheostomy. The findings include: Review of the medical record for Resident #55 on 3/14/19 at 10:13 AM revealed an order from 2/5/19 to change his/her inner cannula every shift. At 10:31 AM Staff #32 from a contracted respiratory company was observed providing treatment to Resident #55 including changing the inner cannula and the trach ties. He was asked if he or a representative from the company is at the facility 7 days a week and he responded that he is only at the facility Monday through Friday. He further stated that it is up to the nursing staff to provide care to the residents in the facility on the weekends. The nursing schedule was reviewed for the previous weekend and what nursing staff was scheduled. The employee files of the nurses on duty were reviewed on 3/20/19. During the…

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

Based on review of the facility assessment, employee files and interviews, it was determined that the facility failed to ensure that geriatric nursing assistants (GNA) demonstrated skills competency prior to being allowed to work independently with residents and annually after hire. This was found to be evident for 1 of 6 recently hired GNAs (#11) The findings include: On 3/19/19 at 2:01 PM the education specialist nurse (Staff #27) reported that newly hired GNAs meet with a preceptor and keep a skills checklist with them for however long they are with the preceptor. Usually they are with another GNA or nurse for 3 days. Review of the Initial Skills Competency Checklist revealed it to be two pages long and included more than 39 specific skills that a GNA would need to perform. These skills included, but were not limited to: range of motion (ROM), mouth care, transfers from bed to chair, incontinence care, bathing, feeding, toileting and grooming. Each skill had a section for Skill Demonstration. Each section included areas for the date and initials of the individual who validated…

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 facility staff it was determined that the physician failed to address an irregularity identified by the clinical pharmacist and the clinical pharmacist failed to identify discrepancies in the residents' drug regimens. This was evident for 2 of 3 residents (Resident #70 and #16) reviewed for chemical restraints. The findings include: 1) Resident #70's medical record was reviewed on 7/3/19 at 11:45 AM. The record included a current physician's telephone order originally written 2/9/19 for Alprazolam (a psychotropic anti-anxiety drug also known as Xanax) tablet 0.25 mg(milligrams) give 1 mg by mouth every 8 hours as needed (PRN) for anxiety. The physician's order was not limited to 14 days. Monthly clinical pharmacist reviews dated 3/12/19, 4/16/19, 5/15/19 and 6/18/19 requested that the physician consider discontinuing Resident #70's Xanax due to non-use. The record revealed that the physician failed to address all 4 of the pharmacists' recommendations. Additionally, the pharmacist failed to identify that the PRN Xanax order 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 facility staff it was determined that the facility staff failed to ensure PRN (as needed) psychotropic drugs were limited to 14 days. This was evident for 2 of 3 residents (Resident #70 and #16) reviewed for chemical restraints. The findings include: 1) Resident #70's medical record was reviewed on 7/3/19 at 11:45 AM. The record included a current physicians telephone order originally written 2/9/19 for Alprazolam (a psychotropic anti-anxiety drug) tablet 0.25 mg (milligrams) give 1 mg by mouth every 8 hours as needed (PRN) for anxiety. The physicians order was not limited to 14 days. The DON (Director of Nursing) was made aware and confirmed these findings on 7/3/19 at 2:45 PM. 2) Resident #16's medical record was reviewed on 7/3/19 at 2:55 PM. The record revealed a current physicians order written 4/18/19 for Ambien (a psychotropic medication used for insomnia) 10 mg PO (by mouth) HS (hour of sleep) PRN (as needed) for sleep. Hold for drowsiness. The medication order was not limited to 14 days. The DON was made aware and…

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

Based on observation, interview and medical record review it was determined that the facility failed to ensure the medication error rate was less than 5% as evidenced by 5 observed errors out of 31 opportunities for error. The errors observed included failure to measure the dose of a pain relief gel on two separate occasions, failure to administer a pain relief gel, failure to administer the correct dosage of a medication to treat high blood pressure, and failure to assess the resident's blood pressure prior to the administration of a medication with orders to hold the medication if the blood pressure was below a certain level. This practice was found to be evident for 3 out of the 4 residents (Resident #92, #86, and #17) observed during medication administration observation. The findings include : 1. On 3/18/19 at 9:13 AM surveyor observed Nurse #5 administer medications to Resident #92. During the administration of diclofenac sodium 1% gel, the nurse was observed to squirt some of the gel out onto her gloved fingers and apply to the resident's right knee. After administration 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 observations and interviews it was determined the facility failed to: 1. store medications appropriately by removing expired medications from medication carts and 2. failed to ensure that medications were kept secure as evidenced by the observation of a container of vitamin D drops being left unattended on top of a medication cart located in a hallway while the nurse responsible for the cart was in the resident's room administering medication. This was found to be evident for 2 of 4 medication carts observed and 1 of 4 medication observations (Resident #7) completed during the facility's annual Medicare/Medicaid survey. Findings include: 1. An observation was made of medication cart # 1 on 3/21/19 at 11:25 AM and inside the cart was a bottle of Levemir 100 units/ml for Resident #89 that was opened on 2/13/19. Staff #25 acknowledged that the medication expires 30 days after opened and removed the bottle. An observation was made of medication cart # 2 on 3/21/19 at 11:35 AM and inside of the cart was a bottle of Levemir 100 units/ml for Resident # 27 that was opened 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 medical records review and interview with staff it was determined that the facility failed to obtain a radiology test in a timely manner causing a potential delay in treatment. This was evident for 1 out of 8 residents (Resident #42) reviewed during the investigative stage of the survey. The findings include: Resident #42's medical records were reviewed on 3/19/19. This review revealed that the resident had an appointment in February 2018 with a general surgeon regarding a breast ultrasound and biopsy that was completed in October 2017. Further review of the consultation revealed the following recommendation: follow up breast ultrasound in 1 year and follow up to see surgeon afterwards in 1 year (February 2019), (appointment not scheduled). Review of the medical records failed to reveal documentation that the ultrasound was completed, and that the resident had the follow-up appointment. During an interview with the Director of Nursing (DON) on 3/19/19, the surveyor requested documentation showing that the resident had the follow-up test and appointment. After researching…

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

Based on medical record review and interview with staff it was determined that the facility failed to ensure physician progress notes were written in a manner that they were readily accessible to staff as evidenced by two staff being unable to easily read a physician's progress notes. This was found to be evident for 1 out of the 9 residents reviewed during the survey but had the potential to affect any of the residents seen by this physician (Staff #31). The findings include: On 3/21/19 review of Resident #42's medical record revealed documentation of monthly hand written physician progress notes. Surveyor was unable to read the content of the notes. At 1:10 PM Nurse #30 was unable to read these physician notes out loud, stating that she would have to take her time in order to read the notes. On 3/21/19 at 2:25 PM the Director of Nursing was unable to read the hand written progress notes in their entirety. Surveyor then reviewed the concern with the Director of Nursing regarding staff also being unable to read the physician's handwriting.

Based on pertinent record review and interview with facility staff, it was determined that the facility failed to have an effective quality assurance plan (QAPI) in place to prevent the repetition of deficiencies and identified concerns that have effects on residents. This was evident in the review of the facility QAPI plan and CASPER (Certification and Survey Provider Enhanced) report. The findings include: Review on 3/21/19 at 12:40 PM of the facility monthly sign in sheets for the quality assurance and performance improvement program revealed that the facility Social Worker (SW) at the time missed 5 monthly meetings from February to September 2018. This goes along with the identified concerns related to identified issues with care plans, revisions of care plans and discharge planning which include the the social worker that were also cited and identified in previous Medicare/Medicaid surveys completed for this facility. In addition, during the review of the facility's previous surveys it was noted that abuse, Minimum Data Set accuracy, care plans and accident and hazards related…

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

Based on medical record review, observation and interview it was determined that the facility failed to ensure staff completed hand sanitation after handling soiled dressings. The findings include: Review of Resident #47's medical record revealed the resident was admitted in January 2019 with diagnoseqas that included but not limited to dementia and muscle weakness. On 3/18/19 review of the 3/14/19 wound physician's note revealed the presence of a stage 3 sacral wound, a shear wound to the right lateral leg, and an unstageable (due to necrosis) wound of the left heel. The sacrum is located on the lower center of the back. Review of the 3/14/19 nurse practitioner note revealed that the resident had a pressure ulcer to the sacral region which was being followed by the wound physician who was recommending the start of antibiotics for a wound infection. A corresponding order, dated 3/14/19, for an antibiotic 300 mg to be given every 6 hours for 7 days for a wound infection was also found in the medical record. On 3/18/19 at 10:19 AM surveyor observed the wound nurse #23 complete 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.