Forest Haven Nursing And Rehabilitation Ctr

Based on record review, observation, and interviews, it was determined that the facility failed to ensure resident personal and medical information was not publicly disclosed without consent. This deficient practice was evident for 3 of 3 residents reviewed (Residents #20, #45, and #65).The findings include:On 09/12/25 at 9:14 AM, review of the facility's website foresthavennursingcenter.com revealed testimonials posted with full resident names, photos of the residents, and information related to medical diagnoses for Residents #20, #45, and #65. At 9:30 AM, the surveyor brought the website up for the Director of Nursing (DON) to see and requested to review the consents from the residents to use their information on a publicly accessible website.At 10:05 AM, review of the electronic medical record showed all three residents had a Brief Interview for Mental Status (BIMS) score of 15, indicating they were cognitively intact.At 10:45 AM, the DON was unable to produce consents for Residents #45 and #65. A consent for Resident #20 was provided but was incomplete and verbally consented to…

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

Based on review of the facility's Facility Reported Incidents and interviews, it was determined that the facility failed to timely report an allegation of abuse (Resident #54). This was evident for 1 out of 7 residents reviewed for abuse during the survey. The findings include: Surveyor's review of the medical record of Resident #54 on 9/8/2025 at 1:45PM revealed the following allegation of abuse made by Resident #54 was documented by Physician #39 on 6/18/25 at 12:45PM: Patient seen today for monthly evaluation, reports two females verbally abused him/her stating shut the f* up, reports s/he wants to go home, states s/he feels safe here but wants to go home. On 9/8/2025 at 2:07PM the surveyor conducted an interview of the facility's Administrator regarding the allegation documented in the 6/18/25 progress note, and inquired to them as to if the facility had a self-report for the documented verbal abuse allegation, to which the Administrator replied: Let me check on this. On 9/8/25 at 2:19PM the surveyor conducted an interview with Social Services Assistant Director (SSAD) #2 who…

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

Based on record review and interview with staff, it was determined that the facility failed to provide the written notification of transfer to the resident representative, provide written notification of the facility's bed hold policy upon transfer to the hospital to the resident representative, and ensure the local ombudsman was notified of a facility-initiated transfer to the hospital. This was evident for 1 (Resident #15) out of 4 residents reviewed for hospitalization during the annual survey.The findings include:Bed Hold is holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization.On 9/5/2025 at 9:24AM, during a review of Resident #15's electronic medical record, the Surveyor discovered that the resident was transferred to the hospital on 6/23/2025 and 7/28/2025. On 9/8/2025 at 10:45AM, a review of Resident #15's electronic and paper medical record failed to reveal documentation to verify Resident #15's resident representative had been provided with written notification of the transfer to the hospital and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and including the right to refuse treatment. This was evident for 1 (#1) resident out of 3 residents investigated for complaints during the facility's annual survey.The findings include:On 09/12/2025 11:00 AM during record review of Resident #1, it revealed the face and beard were being shaved against the family/POA preferences for resident; this occurred on more than one occasion. Resident #1 was admitted on [DATE]. Resident record review of Care Plan dated 05/28/25 revealed interventions for ADLs Functional Status/Rehabilitation Potential, started 11/20/2023, which (Resident #1) requires assistance with ADL's R/T cognitive deficit; and Cognitive Loss / Dementia, started 12/06/2023, which stated (Resident #1) is unable to make daily decisions without cues/supervision R/T diagnosis of dementia.A progress note,…

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

Based on record review and interview with staff, it was determined that the facility failed to facilitate timely care plan meetings after a resident's quarterly assessment. This was evident for 1 (Resident #14) out of 4 residents reviewed for care planning during the annual survey.The findings include:A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs.Interdisciplinary team (IDT) is a team of medical professionals that provide specific patient centered care to the residents within a facility. On 9/8/2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff, it was determined that the facility failed to complete residents Pre-admission Screening and Resident Review (PASRR) forms according to professional standards of practice. This was evident for 1 (Resident #2) out of 6 resident PASRR's reviewed during the annual survey.The findings include:The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders(MD) or intellectual disabilities(ID) and related conditions. This initial pre-screening is referred to as PASARR Level I, and is completed prior to admission to a nursing facility. A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility.PASARR Level II is a comprehensive evaluation by the appropriate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed: 1) to ensure Resident (#117) was provided assistance necessary for an activity of daily living necessary to maintain proper nutrition. This was evident during a random observation; and 2) ensure that a resident who was unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene. This was evident for 1 (#114) resident out of 8 residents investigated during the survey. The findings include: 1. On 9/15/25 at 1:05PM the surveyor observed Resident #117 in the hallway sitting in their wheelchair at an overbed tray table with their lunch situated on it, with their face down to their plate licking carrots with their tongue off of their plate to get them into their mouth to eat them. Resident #117 was subsequently observed with their face down to their pudding container licking the pudding out of the container to eat it. No staff were observed to be assisting or providing supervision for the resident during this time. The surveyor went to find staff…

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

Based on observations and staff interviews, the facility failed to maintain an environment that is free from risks of accident hazards. This was evident for 1 (Resident #110) out of 6 residents reviewed during the survey. On 9/04/25 at 8:34 AM, during observation rounds, the surveyor observed Resident #110's toilet leaking water from the base. There was a large puddle of water on the bathroom floor surrounding the toilet. Also, the bathroom floor was slippery when walking on it. On 9/04/25 at 10:10 AM, the Director of Nursing staff #13 was interviewed. During the interview, the surveyor made staff #13 aware that Resident #110's toilet was leaking water from the base, and that there was a large puddle of water on the floor surrounding the toilet. Staff #13 mentioned that she would have maintenance repair Resident #110's toilet, and the puddle of water mopped from the floor.

Based on observations, record review, and interview with staff, it was determined that the facility failed to ensure that residents were properly assessed for the safe use of bedrails, failed to obtain consent from the resident or resident representative prior to use of bedrails, and failed to complete a device assessment for the use of bedrails. This was evident for 2 (Resident #15 and # 65) out of 8 residents reviewed for accidents during the survey.The findings include: Bedrails, also known as side rails, are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks. A Resident or Resident's Representative should be provided with the risks and benefits along with a signed consent obtained before the use of bedrails. 1. On 9/4/2025 at 8:15AM, during a tour of Station 4, the Surveyor…

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

Based on observation, interview, and record review, it was determined that the facility failed to ensure medications were administered in accordance with physician orders for 2 of 26 opportunities reviewed. This deficient practice resulted in residents receiving medications contrary to physician orders and a medication error rate of 7.69%.The findings include:On 09/09/25 at 8:53AM, during the morning medication pass, Resident #21 was administered Topamax in a crushed form by Staff #14. During review of the resident's electronic medical record at 9:40AM it was revealed that the physician's order read for headache no crush, indicating the medication was to be given whole and was not to be crushed.On 09/10/25 at 8:22AM, during the morning medication pass, Resident #128 was administered Ferrous Sulfate 325 mg without food. Review of the physician's order indicated the medication was to be given with meals. Staff #15 was asked about the resident being given the medication without food and they stated the food trays were on their way. The surveyor observed that the resident was not served…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medications and resident information were secured to prevent unauthorized access. This deficient practice was evident for 1 of 6 medication carts observed during the facility's recertification survey.The findings include:On September 4, 2025, at 7:42 AM, during the initial tour of the facility, surveyors observed an unlocked medication cart unattended in the hallway. The drawers of the cart were able to be opened by the surveyors and revealed medications as well as resident information with protected health information (PHI). No staff were present in the area at the time of the observation. At 7:46 AM, after two surveyors had walked the length of the unit in an attempt to locate a staff member, Staff #25 was located and alerted to the situation. The nurse for the unit was sent over to ensure the cart was secured. The Nursing Home Administrator was made aware of the findings at 12:17pm.

Based on observation, record review, and interview with staff, it was determined that the facility failed to ensure a resident who requires dental services on a routine basis received necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #15) reviewed for dental services during the survey.The findings include:On 9/4/2025 at 11:20AM, the Surveyor observed Resident #15 in bed, with the head of the bed raised about 30 degrees. As the resident spoke to the Surveyor, the Surveyor observed a brownish yellow discoloration of their own natural teeth. The resident was unable to state the last time they were seen by a dentist.On 9/8/2025 at 1:33PM, during a review of Resident #15's electronic medical record, the Surveyor discovered an active physician's order dated 7/11/2025 for a Consult: Podiatry, Ophthalmology, Dental as needed. Further review failed to reveal the last time the resident was seen by the dentist.On 9/10/2025 at 8:14AM, the Surveyor conducted an interview with Social Service Director #1. During the interview the Surveyor was informed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the residents' right to make personal dietary choices. This was evident for 1 (#112) resident out of 8 residents investigated during the survey.The findings include:On 09/04/2025 11:08 AM during observations and interviews Resident #112 discussed with surveyor of never knowing what was coming up on the food tray at any meal. Surveyor asked resident if they have the monthly menu or alternative options; Resident #112 stated No. Of note, Resident #112 has history of Multiple Sclerosis, non-ambulatory and mostly dependent. No menu or alternative choices were observed available at resident bedside or posted on their poster board. Surveyor asked Resident #112, if meal alternatives were requested and provided when the resident requested and Resident #112 stated I used to, but I don't ask often anymore, I just accept what they give me.On 09/05/2025 11:00 AM during follow-up observation and interviews at Resident #112 bedside with LPN Staff #27 present at bedside. Surveyor notified staff of resident…

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

Based on observation, interview, and record review it was determined the facility failed to ensure the accuracy of medical records for a resident. This was evident for 1 (#71) out of 14 residents reviewed for advanced directives during the facility's recertification survey. The findings include:On 9/4/25 at 12:50PM the surveyor reviewed the medical record of Resident #71 which revealed the following information: 1.) 2 certifications of incapacity, 2.) a guardianship order, 3.) 2 Maryland orders for life sustaining treatment (MOLST) in which neither was voided, with one MOLST form documented as being certified by the resident on 6/7/2025, and the other MOLST form documented as being certified by the resident's guardian on 3/16/2023. The second page of one of the MOLST forms dated 6/7/2025 was observed to be incomplete without selections having been made for sections 2 through 9 of the form. Both MOLST forms were observed existing with the medical record simultaneously in the same sleeve of the hard chart. On 9/4/25 at 1:01PM the surveyor conducted an interview with Licensed Practical…

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

Based on observation, record review, and interview with staff, it was determined that facility failed to ensure regular inspections of all bedrails being used by residents. This was evident for 2 (Resident #15 and #65) out of 8 residents reviewed for accidents during the survey.The findings include: Bedrails, also known as side rails, are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them, such as suffocation, entrapment, and psychological risks. Assuring the correct use of an installed bed rail and maintenance of bed rails is an essential component in reducing the risk of injury. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail. 1. On 9/4/2025 at 8:15AM, during a tour of Station 4, the Surveyor observed Resident #15 in his/her room sleeping. The head of the bed was raised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to have multiple-resident bedrooms that measure 80 square feet per resident. This was evident for 4 resident rooms (Room # 1, #5, #6 and #9) observed during the survey.The findings include: On 9/4/25 at 8:19 AM, the Nursing Home Administrator staff #3 and Director of Nursing staff #13 were interviewed. During the interview, staff #3 and #13 were asked if the facility had a waiver related to room sizes. Staff #3 stated that the facility did not have a waiver related to room sizes. On 9/11/25 at 10:03 AM, the surveyor reviewed the facility's CMS-2567 from the last recertification survey that was conducted on 8/2/2022. Review of the CMS-2567 revealed that facility was cited for having -multiple-resident bedrooms that measure less than 80 square feet per resident. On 9/4/25 at 2:37 AM, staff #3 was interviewed. During the interview, the surveyor asked staff #3 if room [ROOM NUMBER], 5, 6 and 9 were modified to ensure that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to ensure that resident rooms are equipped to provide visual privacy for each resident. This was evident for 2 resident rooms (Room # 1 and 8) observed during the survey.On 9/15/25 at 9:43 AM, during observation rounds with the Nursing Home Administrator staff #3 and the Maintenance Director staff # 18, the surveyor observed a missing privacy curtain for bed A in room [ROOM NUMBER]. On 9/15/25 at 9:44 AM, staff #3 and staff # 18 were interviewed. During the interview, staff #3 agreed that there was not a privacy curtain for bed A in room [ROOM NUMBER]. On 9/15/25 at 3:05 PM, during observation rounds with staff # 18, the surveyor observed a privacy curtain that did not pull across completely for bed A in room [ROOM NUMBER]. On 9/15/25 at 3:06 PM, staff #18 was interviewed. During the interview, staff #18 agreed that the privacy curtain for bed A in room [ROOM NUMBER] did not pull across completely, and that the track for 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 employee files and interviews with staff it was determined the facility staff failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs. This was evident during review of 1 (#12) of 7 residents reviewed for abuse. The findings include: During review of an allegation of staff to resident abuse, the employee file for Staff #16, a GNA (Geriatric Nursing Assistant) was reviewed on 4/23/25 at 1:25 PM. The file revealed Staff #16 was hired on 5/30/18. A General Orientation Checklist was dated 5/30/18. The record failed to contain evidence that the facility conducted initial and periodic ongoing assessments of Staff #16's ability to competently perform the skills necessary to meet the needs of the resident population of the facility. On 4/23/25 at 8:00 AM the Administrator and Staff #10 the Clinical Services Director were informed that the surveyor was unable to find Staff #16's skills assessments. The Administrator returned on 4/23/25 at 1:55 PM and confirmed there were no skills assessments for…

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

Based on review of employee files and interviews with staff it was determined the facility Administration failed to complete performance review of every nurse aide at least once every 12 months and provide regular in-service education that was based on the outcome of the reviews. This was evident during review of 1 (#12) of 7 residents reviewed for abuse. The findings include: During review of an allegation of staff to resident abuse, the employee file for Staff #16, a GNA (Geriatric Nursing Assistant) was reviewed on 4/23/25 at 1:25 PM. The file revealed Staff #16 was hired on 5/30/18. A General Orientation Checklist was dated 5/30/18. Only one annual performance evaluation was found in the file. On 4/23/25 at 8:00 AM the Administrator and Staff #10 the Clinical Services Director were informed that the surveyor was unable to find Staff #16's yearly evaluations. The Administrator returned on 4/23/25 at 1:55 PM. She confirmed that there were no yearly performance evaluations for Staff #16. An interview was conducted with the DON (Director of Nursing) on 5/1/25 at approximately 12:20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 during the initial tour of the main kitchen with facility staff it was determined that the facility staff failed to store food items in a manner that maintains professional standards of food service safety and prepare food under sanitary conditions. This was evident during 2 of 2 tours of the kitchen. The findings include: 04/21/2025 11:02 AM, a tour of the kitchen revealed the following: 1. Grease was layered in the tiles in the cooking area near the wall. 2. Paper, cupcake paper, plastic lids, parts of boxes, and other debris were found behind and under items in the kitchen. 3. There was dust and dirt on the floors under things and behind things. There was mouse traps set up throughout the kitchen, however no droppings were found. 4. The prep supply area was littered with debris and dirty. 5. Under the sink there was a pipe with insulation around it and the insulation was coming off near the bottom. 6. There was a mouse trap under the sink. 7. A piece of bread was lying next to the ice machine. Elbow noodles were laying on two gray carts and on the floor near…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 during tour of the facility's dumpster area, and smoking area it was determined the facility staff failed to dispose of garbage and refuse properly. This deficient practice has the potential to affect all residents. . The findings include: On 4/24/2025 at 12 PM, a tour of the Residents smoking area revealed the following: 1. The ground litter of cigarettes butts. 2. Broken Pallets and chairs sitting next to the side of the building in front of the back gate. 3. One of the front gates to the side has a latch hook that can be open by Residents and putting them at risk to elope. The gate does not close tightly. 4. The area by the back gate has a pile of plywood, broken air conditioner, buckets, and trash. 5. Another area in front of the back gate had more plywood, and 3 air conditioners. 6. The food serving cart was in disrepair in the back of the yard. 7. Commercial hair drying unit in the back yard leaning on metal doors. 8. Four air conditioners sitting in the back of the yard with 2 more food carts. 9. 2 ladders up against the wall. 10. The open shed was litter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined the facility Administration failed to establish and ensure: 1) a system was in place to evaluate staff performance and provide required education as determined by staff performance reviews and the facility assessment; 2) policies and procedures were available and accessible to all staff; 3) the facility had an effective pest control program. This was evident during the complaint survey and has the potential to affect all residents in the facility. The findings include: 1) The employee file for Staff #16, a GNA (Geriatric Nursing Assistant) was reviewed on 4/23/25 at 1:25 PM. The file revealed Staff #16 was hired on 5/30/18. Staff #16's electronic training transcript revealed her last training pertaining to Resident Rights was 1/16/24. She received 0.5 hours of training related to cognitive Impairment and 0.25 hours related to Dementia on 6/23/24. There was no evidence that Staff #16 was provided with additional training on cognitive impairment and mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility staff failed to maintain a quality assessment and assurance committee that included the Medical Director and an Infection Preventionist. This was evident during review of the Quality Assurance Performance Improvement program. The findings include: The attendance sheets for the QAPI (Quality Assurance Performance Improvement) committee meetings held from 4/2024 - 4/2025 were reviewed on 5/1/25 at 2:59 PM. The 2024 and 2025 QAPI meeting schedule reflected the dates of the monthly meetings and that Quarterly (Q) meetings were scheduled for January, April, July and October of both years. Review of the meeting sign-in sheets for each month revealed the following: 4/25/24 (Q) - The Infection Preventionist was not in attendance. 5/23/24 - The Infection Preventionist was not in attendance. 6/27/24 - The Medical Director and the Infection Preventionist were not in attendance. 7/25/24 (Q) - The Infection Preventionist was not in attendance. 8/29/24 - The Medical Director and the Infection Preventionist were not in attendance.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to maintain a safe and homelike environment for their residents. This was evident throughout the facility and had the potential to affect all residents. The findings include: An observation of the second floor on 4/23/25 at 11:38 AM revealed that the heaters in the hallway were covered with dust. In room [ROOM NUMBER] the bathroom door had scuff marks that ran up about 2 feet and the veneer was coming away from the door near the doorknob, the sink was dripping water, veneer was coming away from the door at the doorknob. In the resident's room the flooring was cracked in 2 places in the middle of the floor, the wall was damaged outside the bathroom and repaired with spackling but was damaged again and unpainted. The heating vent that was under the sink was caked with dust. On 4/21/25 at 10:44 AM an observation of room [ROOM NUMBER] revealed there were gaps where the pipes runs into the wall. The vent under the window…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to have an effective pest control program to ensure the facility was free of pest. This was evident throughout the facility and had the potential to affect all residents. The findings include: Review of the following complaints on 4/21/25 at 9:30 AM revealed: 1. In complaint #MD00199947, the complainant noted that the facility was mice infested, and mice feces could be found all over the resident's rooms. Unable to interview the complainant as they were anonymous. 2. In complaint #MD00205374, the complainant, who did not give their name, reported while visiting a family member in the facility they saw a mouse in their room. 3. In complaint #MD00210666, the complaint, who wished to remain anonymous, reported the facility had a history of pests in the building and there was presence of rodent droppings in the kitchen. An observation on 4/21/25 at 10:25 AM of the 2nd floor revealed a room that was used to store the clean…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures. This practice has the potential to affect all residents who eat food prepared by the facility. The findings include: On 4/28/25 at 11:57 AM, the surveyor conducted a lunch tray line observation and requested the Certified Dietary Manager (CDM) to include a test tray on the cart that was going to the unit. On 4/28/25 at 9:45 AM, the surveyor and the CDM followed the cart that was brought out to the unit to conduct the test tray. The cart was parked in one area in the hallway while the nursing staff were walking back and forth to the cart and to the residents' rooms to deliver the trays. The CDM proceeded to test the food on the test tray using the facility's food thermometer. The temperatures were as follows: Egg omelet with cheese 98 degrees Fahrenheit Sausage 90 degrees Fahrenheit Milk 2% 42 degrees Fahrenheit The CDM was informed of the…

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

Based on medical record review and interview with staff it was determined the facility staff failed to report an allegation of abuse to the State Agency in a timely manner. This was evident for 1 resident (#2) during review of 1 of 9 complaints related to Resident Rights and 2 (#10, #28) of 7 residents reviewed for abuse. The findings include: 1) Resident #2's medical record was reviewed on 4/28/25 at 10:53 AM. The record revealed a progress note written by Staff #11 the Attending Physician on 2/3/25 at 12:15 PM which included but was not limited to: Patient initially irate, angry that s/he is not allowed to smoke marijuana for pain management at the facility, states I am a long-term advocate for marijuana for pain management and I will sue this place if I become addicted to morphine. Further review of the medical record revealed a nursing progress note written by Staff #9 on 2/7/25 at 5:06 AM. The note included: . resident was cussing, yelling and screaming that his/her marijuana was stolen, I, the nurse then call the supervisor, supervisor and the nurse went into residents' room .…

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

Based on medical record review and interview with staff it was determined the facility staff failed to investigate an allegation of misappropriation of resident property for 1 (#2) of 6 residents reviewed for Resident Rights; and failed to conduct a thorough investigation and prevent other potential abuse or mistreatment while the investigation was in progress for 2 (#12 and #15) of 7 residents reviewed for abuse. The findings include: 1) Resident #2's medical record was reviewed on 4/28/25 at 10:53 AM. The record revealed a progress note written by Staff #11 the Attending Physician on 2/3/25 at 12:15 PM which included but was not limited to: Patient initially irate, angry that s/he is not allowed to smoke marijuana for pain management at the facility, states I am a long-term advocate for marijuana for pain management and I will sue this place if I become addicted to morphine. Further review of the medical record revealed a nursing progress note written by Staff #9 on 2/7/25 at 5:06 AM. The note included: .resident was cussing, yelling and screaming that his/her marijuana was…

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

Based on medical record review and interview it was determined the facility staff failed to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights. This was evident for 2 (#12 and #18) of 16 residents reviewed for Quality of Care. The findings include: 1) Review of a complaint on 4/21/25 at 9:22 AM revealed an allegation that the facility was not assisting Resident #12 to get to medical appointments outside of the facility. Resident #12s medical record revealed A Social Services Progress note dated 8/29/23 which indicated that a Dentist from Health Drive examined Resident #12 and recommended antibiotics and to have his/her 17th and 18th tooth extracted. The resident refused the antibiotic and refused to be transferred out. When Social Workers encourage him/her to be evaluated by an oral surgeon as recommended, he/she became very hostile and stated s/he wanted to be transferred to the University of Maryland Geriatric ER (Emergency Room). When informed that EMS would likely transport him/her to the nearest ER s/he became…

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

Based on medical record review and staff interview it was determined that the facility staff failed to provide an activities program to meet the needs and preferences of the residents and failed to develop a resident centered care plan related to activities with achievable goals and measurable objectives. This was evident for 1 (#11) of 5 residents reviewed for quality of life. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. On 4/18/25 at 2:52 PM, a review of complaint, MD00199947 alleged that activities were not provided for Resident #11. During the survey, intermittent observations of Resident #11 were made at various times on different days. During the observations, Resident 11 was found either in his/her room, or ambulating in the hallway. Resident #11 was never observed in engaged in an activity or having a one-to-one activity with facility staff. A review of the medical record on 4/24/24 at 4:10 PM, revealed Resident #11 resided in the facility for…

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

Based on medical record reviews and interviews, the facility staff failed to follow physician orders for a resident. This was evident for 1 (#18) of 1 residents reviewed for physician services during a complaint survey. The findings include: On 4/22/25 at 1:09 PM, a review of complaint MD00212978 alleged that the same ointment had been prescribed for a rash on Resident #18's shins (the front part of the leg between the knee and the ankle) 2 times and then the rheumatologist prescribed the same ointment for the rash. The complainant alleged that the resident still had the rash on 12/18/24, and there were no current treatments for the rash at that time. On 4/25/25 at 11:24 AM, a review of Resident #18's electronic medical record (EMR) was conducted. The medical record documented Resident #18 resided in the facility for long term care since June 2022, and had diagnoses which included dementia, hypertension (high blood pressure), and hypothyroidism (underactive thyroid). Further review of Resident #18's EMR, revealed documentation that since July 2024, Resident #18 had a recurrent rash…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined the facility staff failed to implement appropriate individualized interventions for residents identified at risk of developing pressure ulcers. This was evident for 1 (#14) of 16 residents reviewed for Quality of Care. The findings include: Resident #14's medical record was reviewed on 4/29/25 at 11:42 AM. The Resident was admitted to the facility on [DATE]. An admission nursing progress note dated 12/8/23 3:45 PM revealed Resident #14's skin was warm and dry with redness to groin and redness to buttock. The progress note did not include the character of the redness such as size, or if the areas were blanchable. admission Physician orders written on 12/8/23 included but were not limited to: Daily skin check, weekly skin check by Licensed Nurse on Tuesday, Braden Scale weekly x 4 start day of admission, Hydraguard (a moisture barrier cream) to buttocks redness every shift. A Braden Scale for Predicting Pressure Sore Risk is a tool used to assess a patient'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 medical record review and staff interview, it was determined that the facility staff failed to ensure that a psychotropic medication prescribed as needed was limited to 14 days. This was evident for 1 (#11) of 5 residents reviewed for quality of life during a complaint survey. The findings include: As needed (PRN) orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. On 4/21/25 at 2:00 PM, a review of complaint MD00213514 alleged concerns with the care Resident #11 received at the facility. On 4/25/25 at 3:00 PM, a review of Resident #11's medical record was conducted. Review of Resident #11's March 2025 Medication Administration record (MAR) revealed a 2/26/25 physician order for Lorazepam (Ativan) (anti-anxiety medication), administer 1 tablet by mouth one time a day PRN (as needed) 30 minutes prior to blood draw for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined that facility staff failed to ensure that all medications were stored in a locked compartment that was temperature controlled. This was evident for 1 (26) of 30 residents reviewed for complaints. The findings include: An observation on 4/23/25 at 11:50 AM of Resident (R)26's room revealed the resident had the following medications sitting out in the open on his/her over-the-bed table: 1 can of medicated spray, a container of Desitin (diaper rash cream), Pepto Bismol ultra, Liquid [NAME] pectate, severe congestion liquid medication, cough syrup. During this observation R26 was interviewed. The resident reported that s/he had these medications at his/her bedside because facility staff refused to get them for him/her. The resident reported that a family member purchased the medications and brought them to him/her. An observation on 4/29/25 at 11:15 AM with the Director of Nursing (DON) confirmed the resident had medications stored on his/her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 on record review of facility documentation and staff interview, it was determined that the facility staff failed to conduct and document an accurate and comprehensive facility-wide assessment. This was evident during a complaint survey and had the potential to affect all residents within the facility. The findings include: The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services during both day-to-day operations and emergencies. The assessment must be reviewed as necessary and at least annually. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual needs to perform work roles or occupational functions successfully. On 5/1/25, during an extended survey, a copy of the Facility Assessment was requested, and a binder with the facility assessment was provided. In front of the binder was a Facility Administrative Review Sheet that documented The contents of this policy manual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and interviews it was determined that the facility failed: 1) to have a process to prepare and update an inventory of all property that the resident brought to the nursing facility. Including whether the resident retained possession of each item or entrusted the item to the facility for safekeeping, and identification of items valued at $100 or more and, 2) to have accurate and complete documentation regarding resident's end of life choices. This was evident for 1 (#2) of 9 residents reviewed for Resident Rights and evident for 1 (#11) of 5 residents reviewed for quality of life during a complaint survey. The findings include: 1) Resident #2's medical record was reviewed on [DATE] at 10:53 AM during review of a complaint alleging that Resident #2 was not permitted to utilize his/her motorized wheelchair while residing in the facility. No inventory of personal items was found in the record. Further review of the record revealed a nursing progress note dated [DATE] 5:06 AM by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews of a closed medical record, and staff interview, it was determined that the facility failed to implement abuse prevention polices as evidenced by staff's failure to, 1) immediately notify the facility administrator of an allegation of resident abuse, sexual abuse, and misappropriation of resident property, 2) immediately initiate an investigation into the allegations of resident abuse, and 3) report the allegations of resident abuse to the State Regulatory Agency (Office of Health Care Quality). This was evident for 2 (Resident #1, #3) of 3 residents reviewed during a complaint survey. The findings include: Abuse, is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews of a closed medical record and staff interview, it was determined the facility failed to initiate an investigation into a reported allegation of abuse. This was evident for 2 (Resident #1, #3) of 3 residents reviewed during a complaint survey. The findings include: Abuse, is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse, is defined at §483.5 as non-consensual sexual contact of any type with a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. This was evident for 1 (Resident #1) of 3 residents reviewed during a complaint survey. The findings include: Review of complaint MD00205968 on 05/28/24 revealed an allegation that, on 05/18/24, Resident #1 was sent to the emergency room under emergency petition due to being witnessed for the second time in a 10-day period fondling the same female resident (hands down the resident's diaper) who is bed bound and demented. Resident #1 was evaluated in the emergency room and cleared for discharge back to the nursing facility on 05/19/24. The facility refused to have Resident #1 return from the hospital on [DATE]. In an interview with the facility administrator and director of nurses (DON) on 05/28/24 at 10:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to initiate the process to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (Resident #1) of 3 residents reviewed during a complaint survey. The findings include: Review of complaint MD00205968 on 05/28/24 revealed an allegation that, on 05/18/24, Resident #1 was sent to the emergency room under emergency petition due to being witnessed for the second time in a 10-day period fondling the same female resident (hands down the resident's diaper) who is bed bound and demented. Resident #1 was evaluated in the emergency room and cleared for discharge back to the nursing facility on 05/19/24. The facility refused to have Resident #1 return from the hospital on [DATE]. In an interview with the facility administrator and director of nurses (DON) on 05/28/24 at 10:30 am, the DON stated 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 reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to ensure safe and orderly transfer or discharge from the facility. This was evident for 1 (Resident #1) of 3 residents reviewed during a complaint survey. The findings include: Review of complaint MD00205968 on 05/28/24 revealed an allegation that, on 05/18/24, Resident #1 was sent to the emergency room under emergency petition due to being witnessed for the second time in a 10-day period fondling the same female resident (hands down the resident's diaper) who is bed bound and demented. Resident #1 was evaluated in the emergency room and cleared for discharge back to the nursing facility on 05/19/24. The facility refused to have Resident #1 return from the hospital on [DATE]. A review of Resident 1's closed medical record on 05/28/24 revealed that Resident #1 was admitted to the facility on [DATE]. On 03/06/24, the facility social worker initiated a care plan the indicated Resident #1 is to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to send a copy of the facility bed hold policy with a resident when the resident was sent to the emergency room. This was evident for 1 (Resident #1) of 3 residents reviewed during a complaint survey. The findings include: Review of complaint MD00205968 on 05/28/24 revealed an allegation that, on 05/18/24, Resident #1 was sent to the emergency room under emergency petition due to being witnessed for the second time in a 10-day period fondling the same female resident (hands down the resident's diaper) who is bed bound and demented. Resident #1 was evaluated in the emergency room and cleared for discharge back to the nursing facility on 05/19/24. The facility refused to allow Resident #1 to return to the facility after being evaluated and cleared in the hospital on [DATE]. In an interview with the facility administrator and director of nurses (DON) on 05/28/24 at 10:30 am, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a complaint, a closed clinical record and staff interviews, it was determined that the facility failed to permit a resident to return to the facility after a brief hospitalization. This was evident for 1 (Resident #1) of 3 residents reviewed during a complaint survey. The findings include: Review of complaint MD00205968 on 05/28/24 revealed an allegation that, on 05/18/24, Resident #1 was sent to the emergency room under emergency petition due to being witnessed for the second time in a 10-day period fondling the same female resident (hands down the resident's diaper) who is bed bound and demented. Resident #1 was evaluated in the emergency room and cleared for discharge back to the nursing facility on 05/19/24. The facility refused to have Resident #1 return from the hospital on [DATE]. In an interview with the facility administrator and director of nurses (DON) on 05/28/24 at 10:30 am, the DON stated that the facility did not accept the resident back from the hospital for the safety of the…

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

Based on surveyor observations during tour of the facility and staff interview, it was determined that the facility failed to ensure that Resident #10's and #100's urinary bag were covered from view from people walking past his/her room. This occurred in 2 of 53 sampled residents. The facility failed to ensure that Resident #10 and #100 urinary bag was covered. A urinary catheter is a medical device that bypasses the urethra and drains urine directly from the bladder. It drains into an attached urinary bag made with transparent plastic to allow staff to assess and measure the urine it contains. However, in consideration of a homelike environment, it is appropriate to cover the clear part of the bag with a cloth cover to prevent the resident from feeling exposed and to prevent other residents from feeling discomfort at being able to see another resident's urine. 1) During an observation that took place on 7/18/22 at 9 AM, Resident #100 was found asleep in his/her bed. The resident's urinary bag was found lying directly on the floor and uncovered. The urinary bag and its contents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview it was determined the facility failed to provide housekeeping and maintenance services to keep the resident's environment clean and in good repair. This was evident on 5 of 5 nursing units and impacted 9 of 58 residents (Resident # 115, #30, # 107, # 29, #4, #22, #73, #56, #376) reviewed during the annual survey. The findings include: 1. The following environmental concerns were observed during observation and follow-up rounds during the annual survey: During an observation of the facility on 7/18/22 at 9 AM the following was observed: 1a. room [ROOM NUMBER]: Smelled of a strong urine odor; large sticky spots were noted throughout the room floor; dirty towels were noted lying on the floor. 1b. room [ROOM NUMBER]: The trashcan was overflowing with isolation gowns and materials. 1c. Station #3 Hallway: The sink located in the hallway for handwashing was cracked and wet at the bottom with the partial board exposed. 1d. room [ROOM NUMBER]: The footrest was broken from 1 of 4…

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

Based on medical record review and interview it was determined the facility staff failed to notify the state agency in the required allotted time frame after being made aware of an allegation of neglect. This was evident in 1 of 10 residents (Resident #326) sampled for neglect/abuse during the annual survey. The finding includes: It is the requirement that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours to the state agency after the allegation is made. On 07/29/22 at 10:24 AM, a review of the facility's investigation of allegation of neglect related to Resident #326 revealed the facility failed to notify the state agency until three days after the facility was made aware of the allegation. The alleged incident occurred on 11/08/21 and was reported to the state agency on 11/11/21. On 07/29/22 at 10:38 AM, a review of the facility's investigation concerning the alleged incident revealed a Suspension Pending Investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility staff failed to transmit a resident's Minimum Data Set (MDS) assessment within 7 days after the assessment was completed. This was evident in 1 in 6 (Resident #1) resident charts reviewed during the survey for completed MDS assessments. The findings include: The Minimum Data Set (MDS) is a tool for implementing standardized assessment and for facilitating care management in nursing homes. The assessment is completed upon admission, annually, quarterly, during a significant change, and when a resident is discharged . On 07/26/22 at 3:05 PM, a review of Resident #1's medical record revealed the last MDS assessment was completed on 03/02/22. The most recent MDS assessment dated [DATE] was in process but was completed on 06/06/22 and was not transmitted to Centers for Medicare and Medicaid Services (CMS). The MDS assessment should have been submitted by 06/02/22. MDS Coordinator #3 was made aware of the concern. On 07/26/22 at 3:38 PM during an…

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

Based on administrative record review and interviews with facility staff, it was determined the facility failed to follow the resident care plan when providing care. This was found to be evident for 1 of 10 (Resident # 3) intakes reviewed for abuse during the facility's annual Medicare/Medicaid survey. Findings include: MD00176724 was reviewed on 7/29/22 at 10:00 AM in which Resident # 3 reported allegations of verbal abuse and threatening gestures by a staff member and abuse was unsubstantiated. Review of the resident medical record on the same date at 11:00 AM revealed the resident had a care plan in place for behavior problems related to Schizophrenia, Depression, Anxiety and Unspecified intellectual Disabilities, that was initiated on 3/3/2020. One of the approaches listed was that two staff members were to assist with care due to behaviors of false accusations by the resident. An interview was conducted with the DON on 7/29/22 at 2:00 PM and she was asked if there was a second staff present while the GNA was with the resident while providing care and the DON stated, no. The DON…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record reviews and interviews with the facility staff it was determined the facility failed to: 1.) update a care plan for a resident who refuses care (Resident #115) and 2.) update a care plan after a change in status (Resident #10). This was found to be evident for 2 of 59 residents observed during the facility's annual Medicare/Medicaid survey. Findings include: 1. Resident #115 was admitted to the facility with the following but not limited diagnosis: Unspecified Dementia with Behavioral Disturbance and Mood Disorder. On 7/18/22 while making resident observations at 1:15 PM, Resident #115 was observed with a large amount of facial hair and a full beard. Subsequent observations were made on 7/19/22 at 1:59 PM, and on 7/20/22 at 1:30 PM, and the resident was observed to continue to have a large amount of facial hair and a full beard and the resident was not shaved or groomed. A review of Resident #115's medical record on 7/18/22 at 2:15 PM revealed a Brief Interview of Mental Status (BIMS), a tool used to measure a resident cognition that assessed…

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

Based on administrative record review and interviews with facility staff it was determined the facility failed to: 1.) keep a resident with cognitive impairment from having access to sharp objects that were in the resident room (Resident #226); 2.) ensure that a resident's environment was reasonably free of hazards (Resident #73). This was found to be evident for 2 of 8 residents reviewed for accidents during the facility's annual Medicare/Medicaid survey. Findings include: 1. MD00176424 was reviewed on 7/22/22 at 11:23 AM for concerns regarding resident safety. According to the facility incident/accident investigation sheet that was included in the facility's investigation, on 2/8/2020 Resident #226 was chewing on a razor and attempted to attack. Resident was also noted with a sharp plastic piece. Further review of Resident #226's medical record on the same date at 1:30 PM revealed the resident had the following but not limited diagnosis: Dementia with Behavioral Disturbance, Major Depressive Disorder, and Bipolar Disorder and Poor Impulse Control. Review of the resident care plan…

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

Based on administrative record review and interviews with facility staff it was determined the facility failed to ensure that accurate records were maintained for Resident #50. This was found to be evident while investigating a facility-reported incident (MD00157390) during the facility's annual Medicare/Medicaid survey. Findings include: MD00157390 was reviewed on 7/26/22 at 10:40 AM for concerns regarding Resident #50 safety and a fall. Resident #50 has the following but not limited to diagnosis: Dementia with Behavioral Disturbance, Unspecified Psychosis, and anxiety disorder. On 7/26/22 at 11:00 AM a review of the facility investigation revealed that on 8/17/20 at 6:45 AM Resident #50 was observed lying on the floor in their room. The resident was ambulatory before the fall. An x-ray was done with the following result: Acute overlapping intertrochanteric of the right femur. Further review of the resident's care plan dated 1/16/19 revealed that the resident was at risk for falls/injuries related to osteoporosis (a disease that weakens the bones), poor safety awareness, 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 and staff interviews it has been determined that the facility failed to: 1.) follow infection control practices to prevent the spread of COVID-19 as evidenced by facility staff failing to have the needed Personal Protection Equipment (PPE) available in the supply carts in front of the rooms and 2.) ensure the zippered door closure to the COVID 19 Unit was secured to the wall and without compromise in material as evidenced by a large hole in the plastic on the left lower side. This deficient practice was found on 1 of 4 observations of the COVID-19 Unit; 3) ensure that Resident #10 and #100 urinary bags remained off the floor and away from sources of infectious microorganisms. This occurred in two of six residents reviewed for Foley Catheters. The findings: 1. On 07/18/22 at 09:44 AM, an observation outside the COVID-19 Unit revealed a plastic, zipped divider separating the COVID-19 Unit and the elevator. The zippered door closure to the COVID-19 Unit was not secured to the wall and a large hole was noted in the plastic on the left lower side. Further observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, it was determined the facility failed to have bedrooms that measure 80 square feet per resident. This was evident in 4 residents' rooms (room [ROOM NUMBER], 5, 6, 9) observed during the survey. The findings include: On 7/21/22 at 8:30 AM, the Administrator stated that the facility had a waiver related to room sizes and that no modification had been made to the rooms. On 2/20/20 the following observations/measurements were taken: 1. room [ROOM NUMBER] was measured to be 285 square feet, for four residents' beds which indicates 71.25 square ft of space per bed/resident. 2. room [ROOM NUMBER] was measured to be 222 ft for three residents' beds which indicates 74 square feet per bed/resident. 3. room [ROOM NUMBER] measured 217 square ft for three residents' beds which indicates 72.33 square feet per bed/resident. 4. room [ROOM NUMBER] measure 218 square ft for 3 resident beds which indicates 72.66 square feet per bed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined the facility failed to provide a safe, sanitary, and comfortable environment for residents located on Station 1's second and third floors. This has the potential to affect all the residents who reside on Station #1. The findings include: On 07/18/ 22 at 11:15 AM, observations on Station 1 revealed trim missing in the bathroom used by the residents on the second floor. There was no room number and resident name label outside of room [ROOM NUMBER]. The pay phone on the second-floor dining room had a broken and taped receiver and the phone did not work. On 07/26/22 at 11:50 AM during an interview with Licensed Practical Nurse (LPN) #23 revealed that if the staff have a maintenance problem, they put the problem into the TELS logbook and/or call maintenance at extension 7827. Maintenance comes to the unit many times during the shift to check the maintenance logbook. On 07/26/22 at 12:02 PM, while walking through the 3rd floor of Station 1 with Maintenance…

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

Based on administrative record review and staff interview, the facility failed ensure that Staff #20 received required yearly abuse, neglect, and exploitation training. This was evident in 1 of 35 employees reviewed during the facility's annual survey. The findings include: On 3/19/2022, the Office of Health Care Quality received a self-report of witnessed abuse MD00176543. The facility reported that the abuse incident took place on 3/16/2022 involving Geriatric Nursing Assistant (GNA)#20 being physically and verbally aggressive toward Resident #56. Witness #21 witnessed the abuse incident and provided video footage of the event. The facility investigation substantiated that GNA #20 abused Resident #56. GNA #20 was suspended from working in the facility on 3/17/2022 and terminated from the facility on 3/18/2022. On 7/26/22 at 7:10 AM, review of the facility investigation revealed the reported abuse incident dated 3/16/2022. The investigation packet contained GNA #20's training transcript for the time he/she worked in the facility. The training transcript revealed that GNA #20 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation throughout the annual recertification survey, it was determined that the facility staff failed to maintain a sanitary, orderly, and comfortable interior. Issues were identified on all resident units. The findings include: On 2/18/20 at 12:15 PM, Resident #128's bed sheet was observed to have an approximately 2 foot tattered edge on the side of the bed facing the window. Observation of the rest of Resident #128's room (49) revealed that the wall was in disrepair to the left of the door frame, resulting in approximately 1.5 ft x 1 inch of exposed drywall. room [ROOM NUMBER]'s bathroom was observed with rusted, exposed toilet bowl floor bolts. On 2/19/20 at 9:29 AM, observation of room [ROOM NUMBER] revealed an L-shaped scrape on the wall beside the resident's bed measuring approximately 4 x 3 inches. Both windows in room [ROOM NUMBER] were observed with dust and dirt on the window locks and frame. A 10:19 AM observation of room [ROOM NUMBER] on 2/19/2020, revealed a cabinet in…

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

Based on observation and staff interview, it was determined that the facility staff failed to properly store medications. This was observed twice on the station 3 nursing unit during the annual recertification survey. The findings include: 1) During an observation of station 3 nurses' station, on 02/18/20 at 2:01 PM, the surveyor observed an opaque gray plastic bag hanging from a shelf just above the station 3 printer. The opaque gray plastic bag was sealed but was available to anyone, staff, visitor or resident, entering the station 3 nurses' station. There were no staff members in the station 3 nurses' station at the time of this observation. Upon returning to the station 3 nurses' station, the unit charge nurse was asked what the contents of the bag were. The unit 3 charge nurse indicated the opaque gray plastic bag contained resident discontinued medications awaiting to be picked up and returned to the pharmacy. Examining the contents revealed medications from 5 different residents. None of the medications were of a schedule II nature. The charge nurse removed and secured 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 of the main kitchen and staff interview, it was determined that the facility failed to follow professional standards for food service safety. This deficient practice has the potential to affect all residents. The findings include: On 2/18/20 at 9:37 AM, a tour of the facility's main kitchen was conducted with the Dietary Manager (Staff #7). A leaking pipe under the dishwasher room sink was observed. Further observation revealed peeling paint on the walls of the prep room and soiled/dusty vents throughout the kitchen. Observation of Station 1's dining room during lunch service on 2/18/20 at 12:15 PM revealed Staff #12 using bare hands when handling and buttering bread for Residents #17 and #9. On 2/21/20 at 8:00 AM, another tour of the facility's main kitchen was conducted with the Dietary Manager. Paper towels were missing from the dispenser above the hand washing sink adjacent to the prep line and instead a roll of paper towels that had to be manually torn off were placed on a cart beside the hand washing sink. Interview with the Dietary Manager revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, it was determined that the facility failed to maintain kitchen and resident equipment in safe operating condition. This deficient practice has the potential to affect all residents. The findings include: During a tour of the main kitchen with the Dietary Manager, on 2/18/20 at 9:37 AM, a leaking pipe beneath the sink in the dishwasher room was observed. Further observation of the sink on 2/20/20 at 8:00 AM confirmed the presence of the leak. On 2/21/20 at 8:16 AM, a wheelchair was observed outside room [ROOM NUMBER] with tears and disrepair to the blue seat pad. These concerns were discussed with the Director of Nursing and Administrator during the exit conference on 2/27/20.

Based on observation, staff interview, and record review, it was determined that facility staff failed to ensure the dignity of residents who required assistance with eating during the dining experience. This was evident for 1 (#72) of 11 residents in the dining room. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. An observation of Resident #72 in the Station 1 dining room on 2/18/20 at 12:13 PM, revealed the resident was sitting at a table with two other residents. The Unit Manager (UM) #16 and Geriatric Nursing Assistant #12 served the other two residents at Resident #72's table and they began to eat. Resident #72 sat there with no food or drink until 12:29 PM. The UM #16 brought the resident's tray over and sat it down on the table, however, when Resident #192, who was sitting at the same table, stood up to walk down the hall, UM #16 accompanied…

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

Based on surveyor observation and interview with staff, it was determined the facility staff failed to ensure that resident's call bells were within reach. This was evident for 2 (#18 and #42) of 32 residents observed during initial resident sample observations. The findings include: 1) Resident #18 was observed on 2/19/20 at 10:43 AM lying in bed. A wheelchair was located approximately 3 feet away from the bed to the resident's left. The call bell activation button was draped over the wheelchair armrest and was not within resident #18's reach. At 10:50 AM on 2/19/20, Staff #13, a Licensed Practical Nurse (LPN) entered the resident's room. She was asked how Resident #18 would summon staff for assistance. She indicated that the call bell button should have been on Resident #18's bed clipped to his/her bed sheet and indicated Resident #18 was able to use the call bell but doesn't like to. 2) Resident #42 was observed on 2/19/20 at 12:06 PM. The resident, who is blind, was sitting in a chair with an overbed table in front of him/her eating lunch. The chair was located against the wall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to complete and transmit a discharge MDS assessment timely. This was evident for 1 (#1) of 1 resident reviewed for Resident Assessment. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. The findings include: Resident #1's record was reviewed on 2/26/20 at 12:51 PM. The Resident was discharged from the facility on 11/26/19. The record revealed that Resident #1's Discharge MDS was completed, signed by Staff #19 and transmitted on 2/18/20. Staff #19 (the MDS coordinator) was interviewed on 2/26/20 at 1:12 PM. She was asked to verify when Resident #1 was discharged . She indicated it's right here you're able to see it aren't you? She was then asked when the discharge MDS assessments are due. She indicated in a timely fashion and we try to get them done and sent as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determine that facility staff failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed accurately for a resident to ensure that the resident received appropriate services while in a long term care setting. This was evident for 1 (41) of 3 residents reviewed for accuracy of the PASRR. The findings include: A Preadmission Screening and Resident Review is completed to ensure that each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. A record review for Resident #41 conducted on 2/20/20 at 11:23 AM, revealed the Discharge summary dated [DATE], [from the acute care hospital] that documented Resident #41 was brought in (to acute care hospital) by a family member because the resident had been refusing medication, hallucinating,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 determine the facility staff failed to develop and implement a comprehensive person-centered care plan for each resident by failing to follow a plan of care for activities and failing to develop a Hospice plan of care. This was evident for 1 (#42) of 4 residents reviewed for Activities and 1 (#108) of 1 residents reviewed for Hospice. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1) Resident #42 was observed on 2/18/20 before and after lunch lying on his/her bed, and on 2/19/20 at 12:02 PM, eating lunch in his/her room. He/She was observed again lying on his/her bed on 2/19/20 at 1:14 PM, and on 2/21/20 at 1:54 PM while a nail painting, hand massage and movie activity were starting in the dining room, and again on 2/24/20 at 2:30 PM. Resident #42's medical record was reviewed on 2/25/20 at 9:42 AM. The resident's diagnoses included, but were not limited to, visual loss, both eyes, glaucoma,…

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

Based on review of the medical record and interview with staff, it was determined the facility staff failed to review and revise resident care plans. This was evident for 1 (#42) of 4 residents reviewed for Activities and 2 (#128 and #50) of 17 resident's reviewed for Accidents. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The findings include: 1) A. Resident #42 was observed on 2/18/20 before and after lunch lying on his/her bed, and on 2/19/20 at 12:02 PM, eating lunch in his/her room. He/She was observed again lying on his/her bed on 2/19 at 1:14 PM, on 2/21/20 at 1:54 PM, while a nail painting, hand massage and movie activity were starting in the dining room, and again on 2/24/20 at 2:30 PM. Resident #42's medical record was reviewed on 2/25/20 at 9:42 AM. The resident's diagnoses included, but were not limited to, visual loss, both eyes, glaucoma, anxiety and dementia. A plan of care (POC) was developed for activities. It indicated that the resident is a loner who…

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

Based on medical record review and interview with facility staff, it was determined the facility failed to maintain complete and accurately documented medical records by failing to document group activities offered and the resident's acceptance or refusal to attend. This was evident for 1 (#42) of 4 residents reviewed for Activities. The findings include: Resident #42 was observed on 2/18/20 before and after lunch lying on his/her bed, and on 2/19/20 at 12:02 PM eating lunch in his/her room. He/She was observed again lying on his/her bed on 2/19 at 1:14 PM, on 2/21/20 at 1:54 PM, while a nail painting, hand massage and movie activity were starting in the dining room, and again on 2/24/20 at 2:30 PM. Resident #42's medical record was reviewed on 2/25/20 at 9:42 AM. The resident's diagnoses included, but were not limited to, visual loss, both eyes, glaucoma, anxiety and dementia. A plan of care was developed for activities. It indicated that the resident was a loner who prefers to stay in his/her room. The resident's goal included: [Resident #42] would participate actively in…

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