Frederick Villa Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of complaint 337259 and the facility's pest problem logs and interview with facility staff, it was determined that the facility failed to maintain an effective pest control program. This deficient practice had the potential to impact all residents.The findings include:Review of complaint 337259 on 8/25/25 at 12:13 PM revealed that the facility was infested with roaches and rodents.The surveyor requested the facility's pest logs from 2025 on 8/27/25 at 7:42 AM. Review of the Pest Problem Log on 8/27/25 at 9:42 AM revealed the following entries in patient care areas:11/13/24 room [ROOM NUMBER]: roaches, mice11/13/24 room [ROOM NUMBER]: roaches, mice1/21/25 room [ROOM NUMBER]: roaches2/6/25 Medication room [ROOM NUMBER], 2, 3: ants, roaches, mice, mice droppings4/21/25 Rooms 118, 115, 120, 116, 117: roaches4/21/25 Rooms 217-220: roaches, mice4/22/25 Rooms 105, 106, 111, 112: roaches4/23/25 Break room: ants4/25/25 Front area: roaches5/2/25 Rooms: 207-209: water bugs5/2/25 Rooms: 100, 109: mice5/15/25…

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

Based on review of facility reported incidents (Intake #2578127, # 337212 and #337236), record review, and interview, it was determined that the facility failed to ensure that all alleged resident violations were reported in a timely manner, including: abuse, neglect, exploitation or mistreatment. This was evident for 6 (Resident #86, # 143, #71 #101, #2, and #140) of 76 Residents that were part of the survey sample.The findings included: 1) On 08/19/2025 at 9:04 AM, during the initial screening phase of the survey, Resident #86 alleged to the surveyor that “on the last Sunday night shift (8/17/2025) a nurse was very mean and rough with the resident during care and when her attitude was brought to her attention by Resident #86, she just left the room and never came back. When asked if the incident was reported to anyone, Resident #86 stated “no”. The resident’s roommate (Resident #143) confirmed that nurse was rough with her during care pushing Resident #86 roughly towards the bedrail. The nurse was described as “African” by both residents. On 08/19/2025 at approximately 9:10 AM,…

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

Based on a medical record review, facility investigation review, and staff interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse in a timely manner. This was evident for 5 residents (Resident #86, #143, #71, #131 and #73) of 8 residents reviewed for abuse during this recertification/complaint survey.The findings Included: 1) On 08/19/2025 at 9:04 AM, during the initial screening phase of the survey, Resident #86 reported to the surveyor that “on the recent Sunday night shift (8/17/2025) a nurse was very mean to her during care and when the nurse’s attitude was brought to the nurse’s attention, she just left the room and never came back. When asked if the incident was reported to anyone, Resident #86 stated “no”. The resident’s roommate (Resident #143) confirmed that the nurse was rough with her during care. The nurse was described as “African” by both residents. On 08/19/2025 at approximately 9:10 AM, during the initial screening phase Resident #143 reported to the surveyor that the staff were “mean, and they have very bad attitude,…

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

Based on a review of resident medical records, and interviews with facility staff, it was determined that the facility failed to: 1) review and revise the resident's care plan as required, 2) hold or document interdisciplinary team care plan meetings at the time of quarterly revisions, and 3) to ensure participation in the care planning process by the required interdisciplinary team (IDT) members. This was evident for 7 (Resident #10, #74, #8, #13, #15, #68, and #130) of 34 residents reviewed during the investigation phase of the facility's recertification/complaint survey. The findings included: Care plans are developed to guide the care residents receive and must be created within seven days of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). An interdisciplinary team, including the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (when practicable), is required to develop and revise these plans. 1) On…

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

Based on observation and interviews with residents and facility staff, it was determined that the facility failed to ensure that the environment of resident care was maintained in a manner that minimized the potential spread of infection. This was evidenced by: 1) an isolation sign for a COVID-19 positive resident was not posted, 2) antiviral medication for the COVID-19 positive resident was not administered in a timely manner, and 3) staff in the laundry failed to use standard precautions when they handled contaminated linens. This was evident for two (Resident #46 and #67) of two residents reviewed for COVID-19 positive and was also observed in the laundry room during the survey.The findings included: 1) Isolation SignageDuring an entrance conference with the Director of Nursing (DON) and Regional Clinical Director (Staff #1) on 8/19/25 at 8:15 AM, they stated the facility had two active COVID-19 cases. The DON said, the resident's isolation is completed today.During an initial tour of the facility on 8/19/25 at 8:22 AM, the surveyor observed that Staff #9 (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 and staff interview, it was determined the facility staff failed to treat a resident in a dignified manner by leaving a urinal that contained urine hanging on the bedrail during meal time. This was evident for 1 (Resident #49) of 74 residents reviewed during a recertification / complaint survey. The findings include: During an observation of Resident #49 on 8/19/2025 at 8:40 AM, the surveyor observed the resident sitting in bed eating breakfast. Hanging on the resident's left upper bed rail was a urinal containing clear yellow urine (about 1/3 full). When asked if the resident had used the urinal prior to breakfast, s/he said yes. Resident #49 stated that s/he had used the urinal a while back. S/he added that when staff served him breakfast the urinal containing urine was hanging on the bedrail but they did not empty it.On 8/19/2025 at 8:45 AM, Surveyor observed Geriatric Nursing Assistant (GNA #4) come into the room and left without removing the urine containing urinal at the resident's bedside. Surveyor immediately interviewed GNA #4 who stated that she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of medical records and interviews, it was determined that facility staff failed to 1) ensure that two physicians' certificates of incapacity were obtained and that Advance Directives were completed in accordance with the Health Care Decisions Act. This failure occurred before allowing resident representatives to make informed health care decisions on a resident's behalf. The Facility also failed to 2) provide written information to all residents concerning the right to formulate an Advanced Directive (AD). This was evident for 2 (Resident #8 and Resident #11) for 32 residents records reviewed for advance directives during the initial pool phase of the survey. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form that includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. According to the Health Care Decisions Act: 5-602 (d) (1) states that…

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

Based on complaint intake, record review and staff interviews, it was determined that the facility failed to 1) notify the Power of Attorney when a resident fell out of bed and 2) notify the physician of a missed medical appointment. This was evident for 1 (Resident #127) of 42 Intakes reviewed during a recertification/complaint survey.The findings include:1) On 8/26/25 at 8:15 AM review of a complaint intake #337221 had that resident fell out of bed and the facility failed to notify the Power of Attorney (POA) until 36 hours later when the POA found out from the physical therapist.Review of the nurses progress note on 8/26/25 at 10:15 AM had that resident was found on the floor and stated s/he was trying to reach at something on the floor by the bedside. No pain or injury was noted. Further review of the medical records did not show that the resident's POA were notified of the fall Incident.In an interview with the Director of Nursing (DON) On 8/26/25 at 11:10 AM, she was asked who was notified when a resident had an incident. She stated that if the resident have a POA, then 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 surveyor observation and interviews with residents and facility staff, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. This was evident for 2 (Resident #15 and Resident #133) of 44 residents reviewed from the complaints and facility reported incidents investigated during the facility's recertification survey. The findings include: 1) On 8/19/25 at 11:16AM. 11:46 AM and 1:52PM during an initial tour of the facility the surveyor noticed the presence of flies and gnats in rooms [ROOM NUMBERS]. Residents in both rooms complained of flies and gnats flying around in their rooms all the time. In room [ROOM NUMBER]B, Resident #15 also said that flies and gnats always fly around their room and bathrooms. Further review of a complaint incident #337246 had that the” Nursing Facility has issue with Pest Control. There are ants, fruit flies, gnats, and mice within the facility”. In an interview with Staff #18 a Maintenance Director on 8/21/25 at 12:19 PM,…

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

Based on record review, review of the facility investigation of intake #337244, review of facility policy on Conduct and Behavior, resident interview, and staff interview it was determined that the facility staff failed to ensure a resident was free of misappropriation of property. This was evident for 1 (Resident #104) out of 75 residents who were part of the survey sample.The findings include:The review of the facility investigation of intake #337244 on 8/26/25 revealed Staff #34 used Resident #104's bank card and bank account information to access money for his own benefit. Staff #34 admitted to withdrawing money at the resident's request. It was confirmed that he withdrew $100 at the request of the resident but he denied making other withdrawals. The police were called, and their investigation revealed 28 transactions starting 1/28/24 to 4/8/24 with Staff #34's name on it for withdraw via the cash app. The facility investigation file included notice of the police having signed a warrant for Staff #34's arrest. This surveyor reviewed the bank transactions from 8/1/23 to 12/31/23.…

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

Based on record review and interviews, it was determined that the facility failed to provide documented evidence to support that each resident was free from unnecessary medication administration. This was evident for 1 (Resident #74) of 5 resident's assessed for unnecessary medications during the recertification/complaint survey.The findings included:On 08/20/2025 at 10:34 AM, a review of Resident #74's medication list revealed that the resident had orders for a scheduled antianxiety medication once per day and a separate anti-anxiety medication every 6 hours as needed. However, there was no documentation to suggest that the facility adequately monitored Resident #74's behavior to ensure that psychotropic medications were administered appropriately. On 08/21/2025 at 4:13 PM, in an interview with the Director of Nursing (DON), the surveyor requested documentation of Resident #74's behavior monitoring. After further review of the resident's chart the DON stated that there was no documentation to support that the facility monitored the behavior of the resident. The DON was asked by 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 complaint intake # 337241, medical record review, and staff interview it was determined that the facility failed to ensure the resident's discharge papers were completed. This was evident for 1 Resident (#127) of 4 residents reviewed for discharge during a recertification / complaint survey.The findings includes:Review of an attachment to a complaint intake #337241 on 8/27/2025 at 10:24 AM was reviewed and the complainant stated that on 1/23/2025 the discharge papers for Resident #127 were not completely filled out.On 8/27/2025 at 10:53 Resident # 127's closed medical record was reviewed. The resident was discharged on 1/23/2025. The discharge documentation titled Engage Discharge Planning Tool was reviewed and surveyor noted that the following areas were blank:1. Section B. responsible parties' information2. Section C. Primary physician information3. Section O. Staff Signature and Residents or Responsible Party Signature4. Section R. Medication list5. Section R -Question #7. May attach pharmacy print out of medication regimen in lieu of completion of this section. Yes, No,…

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

Based on medical record review and staff interview, it was determined the facility failed to accurately code a diagnosis in the Minimum Data Set (MDS). This was evident for 1 (Resident #15) of 8 resident reviewed for Antipsychotic medication ( a type of drug primarily used to treat symptoms of psychosis, such as hallucinations and delusions, by blocking dopamine in the central nervous system) use and related diagnosis reviewed during the recertification/complaint survey. The findings include: The Minimum Data Set (MDS) is a comprehensive, federally mandated assessment tool used to evaluate a resident's functional, cognitive, and health status to create individualized care plans, monitor quality of care, and support reimbursement for Medicare and Medicaid certified facilities.Active diagnoses documented on the MDS assessment are attending provider-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure a baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP) and documented in the medical record. This was evident for 2 (Resident #126 and #122) out of 36 residents reviewed during the investigation phase of the facility's recertification survey.The findings include:A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP and current medication list must be given to each resident and/or his/her representative and documented in the medical record. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and interviews with facility staff, it was determined that the facility failed to provide the required level of assistance for a resident to perform their Activities of Daily Living. This was evident for 1 (Resident #122) out of 36 residents reviewed during the investigation phase of the facility's recertification survey.The findings include:Activities of Daily Living (ADLs) are the basic, essential self-care tasks people need to perform to maintain their health, safety, and well-being, such as bathing, dressing, eating, and toileting.Brief Interview of Mental Status (BIMS) is a standardized test used to assess a resident's cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. The Minimum Data Set (MDS) is a federally mandated, standardized assessment tool used to comprehensively evaluate a resident's health status, functional abilities, and needs. It is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complaint incidents, record reviews, and staff interviews, it was determined that the facility failed to provide quality of care services to residents in their facility. This was evident for 2 (Residents #135 and #127) of 42 intakes reviewed during the recertification/complaint survey.The findings include:1) On 8/20/25 at 10:19AM, review of a complaint Intake #337242 had that Resident #135 complained of pain at their J-tube feeding site and that resident had multiple issues when their feeding tube was clogged because it was not flushed. The complainant stated that some days, Resident #135 was not fed at all and that they were later taken to the hospital and diagnosed with a clogged J-tube.A review of the physician's order regarding tube feeding on 8/20/25 at 10:19 AM read:1/10/24: Every shift enteral feeding formula: osmolyte 1.2; Rate: 55; start at 1 pm time and run until 1100 MLs has infused; Tube type: J tube; Size of Tube: 22 F. Flush with water: Amount: 55 ml q 4 hrs. Monitor Q shift1/10/24: Every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to:1) provide timely, consistent care and treatment for a resident with pressure ulcers, 2) ensure a wound consult was completed timely, 3) provide services to promote healing of pressure ulcers, and 4) have interventions on plan of care for pressure ulcers. This was evident for 2 Resident (Resident #126 and Resident #5) of 3 residents reviewed for Pressure Ulcers during the facility's recertification/complaint survey. The findings included: A pressure ulcer also known as pressure sore or bed sore, is any lesion caused by unrelieved pressure that results in damage to the underlying skin. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (partial thickness loss of skin presenting as a shallow open ulcer), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with exposed tendon, muscle or bone) 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 record review, resident and staff interview, it was determined the facility failed to adequately assess urinary incontinence and implement a care plan to restore continence to the fullest extent possible. This was evident for 1 (Resident #107) of 1 residents reviewed for Bladder and Bowel Incontinence during the recertification/complaint survey. The findings include:On 08/19/2025 at 9:08 AM, in an interview with Resident #107, stated he/she had been waiting for 2 to 3 hours since early morning and was completely soaked. The resident stated that the staff reported no one was there yet, and that waiting to be changed occurred often.On 08/26/2025 at 7:39 AM, a review of Resident #107's medical record revealed a Bowel and Bladder assessment dated [DATE], three days after the resident's admission to the facility. The direction to complete the assessment included; If resident is Continent of both Bowel and Bladder-evaluation Complete. If resident is Incontinent of either Bowel and/or Bladder-Continue with…

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

Based on record review, resident interview, review of complaint intake #337241 and staff interviews, it was determined that the facility failed to 1) monitor a resident for pain and schedule an appointment for pain management following hospital discharge, and 2) ensure that a resident was given pain medication consistent with professional standards of practice. This was evident for 3 (Resident #107, #127, and #68) out of 76 residents reviewed during the recertification/complaint survey. The findings include: 1) On 08/19/2025 at 9:09 AM in an interview with Resident #107, the resident reported “I have pain from my feet to my thighs and have requested pain medication, but no one has responded yet.” On 08/21/2025 at 9:56 AM a review of Resident #107’s medical record revealed the following: -On 07/21/2025 at 5:42 PM, a Discharge Summary from Hospital documented that Resident #107 was recommended to follow up with his/her pain management clinic and spine specialist after discharge. -On 7/22/2025 at 11:59 PM a physician placed an order to follow up with his/her pain management clinic 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 review of employee files and staff interview, it was determined that the facility failed to perform annual performance reviews for the Geriatric Nursing Assistants (GNA). This was identified for 3 (GNA #38, GNA#43, and GNA #44) of 5 GNAs reviewed during a recertification / complaint survey.The findings include:Review of GNA #38, GNA #43, and GNA #44's employee files on 8/28/2025 at 8:52 AM revealed no performance appraisals were included for the years 2022 and 2023.On 8/28/2025 at 9:26 AM, an Interview was conducted with the Human Resources Manager, staff # 33, who confirmed that the annual GNA performance appraisals for 2022 and 2023 were missing. Staff #33 stated that if the performance appraisals were not in the GNA files, then they were not done.The Director of Nursing (DON) stated on 8/28/2025 at 11:00 AM that the GNAs should have an annual performance evaluation. The DON agreed that the missing performance appraisals for year 2022 and 2023 were a concern.

Based on medical record review and interview, it was determined the facility staff failed to ensure a resident was free from unnecessary medications. This was evident for 1 (Resident #49) of 74 residents reviewed during a recertification/complaint survey.The findings include:On 8/20/2025 at 8:55 AM, a review of Resident #49's medical record revealed an Annual MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 5/26/2025 that indicated under Section M (skin conditions) that the resident had no pressure ulcer and/or skin issues. On 8/20/2025 at 10:10 AM review of weekly skin sheet documentation from May 2025 through August 2025 revealed Resident #49's skin was intact, No wounds present.On 8/20/2025 at 10:22 AM, review of nursing progress note dated 7/15/2025 at 14:12 (2:12 PM) revealed the following documentation: Note Text: Skin sweep completed by [Name ] wound CNP (Certified Nurse Practitioner), no areas noted. RP and MD notified.On 8/20/2025 at 10:26 AM, review of physician orders revealed an active order with a start date of 11/2/2024 for Prostat three times a day 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 observation and interview it was determined facility staff failed to safely store medications and dispose of expired medications and patient supplies. This was evident on 2 of 3 nursing units observed for Medication Storage and Labeling during a recertification survey.The findings include:On 8/25/2025 at 9:45 AM, A review of Medication cart #1 on Unit 2 was conducted in the presence of Licensed Practical Nurse (LPN #26), for Medication Storage and Labeling observation. The following items were found to be expired:- 1 opened box of COVID-19 At home Test kit (Rapid antigen test for ages 2 and up) with expiration date of 4/14/2025 noted on the box. There were 3 test packs in the box, one of them opened. The packs each had an expiration date of 5/11/2025.- 1 bottle of Pro-Stat Wild Cherry Punch that was about a third full: expired on 8/6/2025.LPN #26 verified and confirmed that the above items were expired. She removed them and stated that she was going to discard them. On 8/25/2025 at 10:15 AM Observation of Med-cart #2 on Unit 2 in the presence of Registered Nurse (RN #25),…

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

Based on record reviews and interviews, it was determined that the facility failed to assist the resident in making appointments and arranging transportation to and from the dental services locations. This was evident for 2 (Resident #5 and Resident #10) of 3 residents reviewed for dental services during the recertification/complaint survey. The findings include: 1) On 08/20/2025, at 10:45 AM, a review of Resident #5's Physician orders revealed that there was no indication of an appointment scheduled for a dentist. Further review of Resident #5's medical record revealed that progress note documented as below: -On 8/10/2025 at 10:59 PM, Resident #5 complained of pain in the right mouth gum, which interfered with eating. The doctor was notified and ordered a dental consult. -On 8/10/2025 at 11:05 PM, the primary physician placed an order as Dental consult in AM. -On 8/11/2025 at 20:32 (8:32 PM), a progress note stated, Resident #5 reported right mouth gum pain, which interfered with eating. -On 08/14/2025 at 9:34 PM a progress note stated, upon assessment, it was noted that the…

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

Based on observation and interview with facility staff, it was determined the facility failed to ensure food items were stored under sanitary conditions. This deficient practices was observed in the dry storage area during the recertification/complaint survey.The findings include:On 8/19/25 at 8:17 AM the surveyor observed 2 big bins in the dry storage area. The bins were lined with a white plastic bag. Each of the bags had areas that were ripped and soiled with brown and black stains. Neither bin was labeled with what the item was nor any date. On 8/19/25 at 8:21 AM in an interview with the Dietary Director (DD #2), during a dual observation, when asked what the food items in the bins were, she stated flour and sugar and that she knew they were not labeled. During the interview, she stated that she had just put them in there this morning and forgot to come back and label them. The surveyor pointed to the plastic bags and when asked if she would say the bags/bins were clean, she stated no. When asked why she put brand new bags of flour and sugar into dirty containers, DD #2 stated,…

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

Based on record review, a facility reported incident (Intake #2578127) and interviews, it was determined that the facility failed to maintain medical records on each resident that were complete and accurately documented. This was evident for 2 (Resident #74 and Resident # 127) out of 76 resident records reviewed during the survey process. The findings included: 1) On 08/27/2025 at approximately 5:00 PM, a review of facility reported incident #2578127 revealed that on 07/29/2025 at 3:24 PM, Resident received a one-time dose of Narcan due to the resident unresponsiveness to call and drowsiness. The nurse contacted the physician, and he ordered a dose of Narcan to be administered to the resident. A review of the 7/29/2025 3:36PM Nursing Progress Note stated: Narcan was administered due to sleeping excessively and resident was alert to person, place and time. Denied pain no discomfort noted. Will continue to monitor. On 08/28/2025 at 2:10 PM, in an interview with the Director of Nursing (DON) she was asked to explain the circumstances surrounding the above-mentioned event. 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 a record review and staff interviews, it was determined that the facility failed to collect all the necessary information for monitoring its antibiotic stewardship program. This was evident in the review of all seven months of antibiotic stewardship records during this recertification/complaint survey.The findings included: Antibiotic stewardship requires a facility to develop and implement policies, procedures and/or protocols to ensure residents who need antibiotics are treated appropriately. This is to reduce the risk of residents having adverse reactions to antibiotics, receiving them unnecessarily and/or developing antibiotic-resistant organisms. A facility-wide process must be in place to monitor the use of antibiotics so the results/feedback can be reported to nursing staff and prescribing clinicians.On 8/27/25 at 8:10 AM, the surveyor reviewed facility's antibiotic stewardship program from January 2025 to July 2025. The review revealed that the facility used spreadsheets for monitoring antibiotic use with resident name, infection type diagnosis, last treated,…

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

Based on a review of clinical records and staff interviews, the facility failed to offer a resident a pneumonia vaccine upon admission. This was evident for one resident (Resident #68) out of the five reviewed for immunizations during this recertification/complaint survey.The findings included: On 8/26/25 at 11:44 AM, the surveyor reviewed five residents' electronic medical records for their immunizations. The review showed that Resident #68, admitted in October 2022, had no record of the pneumococcal vaccine.In an interview with Staff #19 (unit manager) on 8/27/25 at 1:12 PM, she stated that all unit managers are supposed to monitor residents' immunization status for influenza, pneumonia, and COVID-19 upon admission.On 8/27/25 at 1:16 PM, Staff #3 (Regional Clinical Educator) submitted Resident #68's vaccine declination form, which was dated 10/10/24. The form documented the resident's refusal of the influenza, Pneumovax23, and COVID-19 vaccines for personal reasons. Staff #3 stated that facility staff had reviewed Resident #68's paper chart and found this form.The surveyor asked…

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

Based on medical record review and staff interview, it was determined the facility failed to 1) document providing education regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents, and 2) maintain documentation related to COVID-19 vaccination status for staff. This was evident for 1 (Resident #2) of 5 residents and two (Staff #36 and #38) of five staff reviewed during this recertification/complaint survey. The findings include:A COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2, the virus that causes coronavirus disease.1) A surveyor reviewed five residents' immunization records on 8/26/25. The review found that Resident #2, who was admitted in July 2025, refused the COVID-19 vaccine on 7/18/25. However, the resident's record showed no for the education provided session.When interviewed on 8/27/25 at 1:12 PM, Staff #19, a unit manager, stated she had offered and educated the resident's family about the vaccine but failed to document it by not clicking box 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 reviews of a facility reported incident, reviews of administrative records, and staff interviews, it was determined that the facility failed to provide abuse education to geriatric nursing assistant (GNA) upon their hired date. This was evident for 1 (Staff #39) of 5 GNAs abuse education reviewed during a recertification/complaint survey.The findings included:On 8/20/25 at 12:42 PM, the surveyor investigated Facility Reported Incident #337205. The report showed that Resident #119 claimed to have been sexually abused by a GNA of the opposite gender on 4/07/23.A further review of the facility's investigation revealed that they assessed Resident #119 and obtained statements from residents and the staff member. Resident #119 later confessed to the Nursing Home Administrator and a physician that the accusation was false.A review of the education records for Staff #39, who was falsely accused, on 8/20/25 at 1 PM revealed the staff member was hired on 10/03/22. However, the staff members' required training, such as infection control, dementia care, and abuse training, was not…

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

Based on observation and interview it was determined that the facility staff failed to store and serve food according to professional standards. This deficient practice has the potential to affect the residents with meal service within the Candlelight Dining Room. The findings include: On 04/04/23 at 8:04 am, during the initial walk-through of the kitchen with the Certified Dietary Manager #5 there was an outdated container of lunch meat dated 02/28/23 and a box of Zucchini that was spoiled in the freezer. On 04/04/23 at 12:20 PM, during a dining observation during lunch in the Candlelight Dining Room, the staff were observed serving drinks and plates of food without gloves on their hands. The surveyor observed four staff serving the residents. During an interview with Geriatric Nursing Assistant (GNA) #6, he/she verbalized they didn't know they were supposed to wear gloves. After the surveyor's intervention, all the staff except Registered Nurse (RN)#4 began to serve the residents food and drinks with gloves. There were 21 residents being served lunch in the dining room. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility staff failed to provide a safe, comfortable homelike environment for the residents. This deficient practice has the potential to affect all the residents who reside in Unit #2 [NAME] Way. The findings include: On 04/04/23 at 8:44 am during the initial walk through of the facility the surveyor discovered multiple maintenance problems on [NAME] Way, Unit #2. 1. In room [ROOM NUMBER] there was a hole in the wall behind the television and chipping drywall in the corner near the television. 2. In room [ROOM NUMBER] The front of the air conditioning unit was partially off and on the floor. GNA # 6 confirmed the surveyor's findings. 3. The adjourning bathroom sink in room [ROOM NUMBER] was slowly draining. Housekeeper #8 confirmed the surveyor's findings. 4. The trim behind 211-B, Bed B was missing. There were two non-working light bulbs in the bathroom and there was a hole in the wall to the right of the light fixture. The anterior top portion of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility staff failed to maintain an effective pest control program as evidenced by numerous alive and dead bugs seen throughout the facility during the annual survey. This deficient practice was observed throughout the building on multiple units, hallways, bathrooms and resident rooms. The findings include: On 04/12/23 at 7:07 am surveyor observed a large black dead bug in the middle of the hall outside Rooms 113-114 on Unit #1. The surveyor observed two large black dead bugs in the hallway of Unit 2, [NAME] Way. There was an alive bug near the nurse's station. At 7:15 am During an interview with Assitant Director of Nursing (ADON) #17 she verbalized that when the housekeeping staff comes to work, they will clean the hall and the rooms. When asked if housekeeping was the only staff that could get the dead bugs up, she verbalized that the Geriatric Nursing Assistants can pick them up. Multiple staff were observed at various times walking past dead…

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

Based on observations and interviews with facility staff it was determined the facility failed to ensure that the resident's call light was within reach to allow access to assistance when needed. This was found to be evident for 2 (Resident # 36 and # 48) of 102 residents observed during the facility's annual Medicare/Medicare survey. Findings include: An observation was made on 4/5/23 at 11:05 AM of residents that resided on the first floor. The call light for Resident #36 was observed wrapped multiple times around a wall basket that contained a box of gloves. At the same time, observation in the same room of Resident #48's call light revealed it was attached to the same wall basket. The call lights were not accessible to the residents. The Certified Medication Aide (CMA) #14 was summoned by the surveyor as she walked near the resident's room. CMA #14 was shown that the call lights were not within reach for the residents to use. At that time, CMA #14 pulled the cord from the basket and attached it next to Resident #36 on the bed, and retrieved the call light for Resident #48 from…

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

Based on a review of pertinent documentation, medical records, observations, and staff interviews it was determined the facility failed to ensure that a Minimum Data Set (MDS) was completed accurately for a resident with urinary retention. This was found to be evident for 1 resident (Resident # 36) that was reviewed for catheters during the facility's annual Medicare/Medicaid survey. Findings include: The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A matrix is a form completed by the facility to identify pertinent care categories for residents that reside in the facility. Upon review of the facility's matrix on 4/5/23 at 12:40 PM, under the care category for indwelling catheter there was a check mark in the box for Resident # 36. Review of Resident #36's medical record on 4/11/23 at 10:04 AM and a Quarterly MDS with Assessment Reference Date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to: 1.) consistently implement a care plan that addressed Resident (#52's) need for anticoagulant therapy; 2,) update a resident care plan to meet the needs of a Resident (#36) with urinary retention; and 3.) ensure residents had an interdisciplinary care plan meetings while residing in the facility (Residents #25, #43, #87). This was evident for 5 of 50 residents reviewed during the facility's annual Medicare/Medicaid survey. The findings included: 1. The facility failed consistently implement a care plan that addressed Resident (#52's) need for anticoagulant therapy, 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. Heparin injection is a blood-thinning medication used to treat and prevent blood clots. A Medical record review on 4/11/23 at 10:41 AM revealed Resident #52 was readmitted to the facility in March of 2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to ensure nursing staff stayed awake during their tour of duty. This was evident for 2 of 3 units observed during the survey process. The findings include: During an early morning observation inspection on 4/13/23 at 3 AM the following was observed: 1. GNA (Geriatric Nursing Assistant) # 31 was observed in a recliner chair in front of an emergency room with blankets pulled up sleeping on unit one. Review of the staff assignment board revealed GNA #31 was scheduled to go on break at 3:30 AM. 2. GNA #40 was observed in a recliner chair near the entrance door to unit 3 with a sheet covering her while sleeping. Next to GNA #40, GNA #39 was observed sitting in a separate reclining chair (eye open) with a blanket and covering her. The Supervisor RN (Registered Nurse) #33 and the Charge nurse LPN (Licensed Practical Nurse) #41 were observed sitting at the nurse's station which was approximately 4 steps from where the staff were sleeping and/or sitting in the reclining chairs. Review of the staff assignment…

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

Based on medical record review and interview, the facility staff failed to review provider notes for treatment accuracy. This was evident for 1 of 5 residents (Resident #1) reviewed for nutritional deficiencies. Findings include: On 4/7/2023 at 1:43 PM, the surveyor reviewed resident #1's medical records which revealed the resident was admitted to the facility February 2023 for long term care after worsening symptoms of Parkinson's Disease, a neurological disorder which may cause involuntary physical movement. The surveyor reviewed provider progress notes for 3/24/23 which revealed the provider's plan of care was to increase Amantadine, a medication which helps to control involuntary physical movements. Review of medication orders on 4/7/23 at 2:36 PM revealed no evidence of an increase in resident #1's Amantadine dosage on 3/24/23. Further review of medication orders on 4/7/23 at 2:40 PM revealed resident #1's Amantadine dosage increased from 100 mg daily to 200 mg daily on 3/10/23 by administering a 100 mg tablet twice a day. Interview with the Director of Nursing (DON) on 4/10/23…

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

Based on record review and interview with facility staff it was determined the facility failed to address and identify the use of a medication in a resident's plan of care. This was evident for one of five residents (Resident #52) reviewed for unnecessary medications. The findings include: Heparin injection is a blood-thinning medication used to treat and prevent blood clots. On 4/11/23 at 9:26 AM, review of the medical record for Resident #52 revealed s/he required a necessary anticoagulant medication: Heparin. The facility's medication order for Heparin stated the medication was to be given to the resident for a blood thinner. Nurse Practitioner #52, documented via progress notes as having seen Resident #52 on the following date 3/29/23 after a hospital readmission from 3/24/23. Nurse Practitioner #52's progress note for visit occurring on 3/29/23 revealed that Heparin use was identified as a medication that the resident was receiving; however, there is no indication for usage and did not address a plan of care for the heparin usage. During an interview on 4/11/23 at PM with…

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

Based on observation and interview it was determined the facility staff failed to keep waste properly contained in dumpsters with lids that could be closed. This deficient practice involved two dumpsters on the facility property. The findings include: On 04/13/23 at 6:46 am during an inspection of the loading dock and surrounding area, the surveyor and Dietary Supervisor #46 observed two dumpsters with opened lids that were overflowing with waste. During an interview with Dietary Supervisor #46, she stated the dumpsters used to be emptied daily but was not sure when the cycle changed. Dietary Supervisor #46 was uncertain when the dumpsters were last emptied. On 04/13/23 at 8:19 am during an interview with Maintenance Director #16 reported he thinks the dumpsters are emptied three times a week and he started working at the facility at the beginning of March 2023. He also revealed he reports to the administrator about the building concerns and they speak almost daily. The Maintenance Director #44 confirmed the dumpsters are emptied Monday, Wednesday, and Friday.

Based on medical records review and interview and it was determined that the facility failed to: 1.) document accurate and complete information on a resident's Fall Incident Report after the resident was found on the floor with difficulty breathing (Resident #52); and 2.) ensure that resident records were accurate and complete for a resident (Resident #36). This occurred in 2 of 50 residents reviewed during the facility's annual Medicare/Medicaid survey. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current, and complete documentation in the medical record is an essential component of quality resident care. 1. Review of Resident #52's medical record revealed a diagnosis that included a Tracheostomy, lack of coordination and Respiratory failure. According to the medical record the resident was cognitively intact based on a BIMS (Brief Interview of Mental Status) score of 15 out of 15. On 4/3/23 at 9 am during observation rounds, the resident reported having been hospitalized after a fall in March 2023. Review 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.

2. On 5/22/19 review of Resident #8's medical record revealed the resident had been receiving a diuretic medication daily since February 2019. Review of the MDS, with an assessment reference date of 5/1/19, revealed that it failed to assess the resident's use of a diuretic. On 5/22/19 at 11:27 AM surveyor reviewed the concern with the MDS Nurse #11 that the resident had orders for a diuretic since February 2019 and no documentation was found on the MDS assessment that a diuretic had been administered. On 5/22/19 at 11:44 AM MDS Nurse #11 confirmed that the MDS was incorrectly coded for the diuretic usage for this resident. 3. On 5/21/19 review of Resident #54's medical record revealed the resident had resided at the facility for several years and whose diagnosis includes quadriplegia (loss of use of all four limbs). Further review of the medical record revealed MDS assessments with assessment reference dates of 2/7/19 and 5/1/19. The February 2019 MDS assessed the resident as requiring extensive assistance for bed mobility and transfers. The May 2019 MDS assessed the resident 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.

Based on medical record review and interview with staff it was determined that the facility failed to ensure that a copy of the resident's Maryland Medical Orders for Life Sustaining Treatment (MOLST) was accurate. This was found to be evident for 1 of 5 residents reviewed (Resident #45) in the investigative stage of the survey. The findings include: Resident #45's MOLST was reviewed on 5/20/19 at 10:49 AM. The front of the MOLST stated that the resident's representative/surrogate selected in the event of cardiac or pulmonary arrest to have no cardiopulmonary resuscitation, palliative and supportive care only. In the event of an arrest, do not intubate or use CPAP or BiPAP (continuous positive airway pressure and Bilevel Positive Airway Pressure, non-invasive mechanism to deliver pressurized air) and allow death to occur naturally. Further review of the back of the MOLST form where it was noted that the resident's representative/surrogate choose option 2c. May use only CPAP or BiPAP for artificial ventilation as medically indicated. The discrepancy that was noted was brought to the…

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

Based on medical record review and interview with the facility staff, it was determined that the facility failed to provide notification to residents that their Medicare coverage was ending. This was evident in 3 of 3 residents (Resident #80, #308 #42) reviewed during beneficiary protection task. The findings include: The Notice of Medicare Non-Coverage (NOMNC) letter is intended to notify a Medicare member, in writing, that the member's Medicare health plan and/or provider have decided to terminate the member's covered services, and, because of the termination of services, the member has appeal rights. On 5/28/18 the surveyor requested Resident #80, #302 and #42's Notice of Medicare Non-Coverage (NOMNC) from the facility. 1. Review of Resident #80's record revealed that the last covered day for skilled rehabilitation/nursing for the resident was 4/23/19, further review revealed that the facility failed to give the resident the NOMNC. 2. Review of the Beneficiary Protection and Notification for Resident #308 revealed that the last covered day was 3/6/19. The facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews it was determined that the facility failed to maintain the physical environment of the facility in good repair as evidenced by multiple cracked and damaged floors. This was found to be evident in the hallways and the dining room and has the potential to affect all residents. The findings include: On 5/20/19 at 8:17 AM observation of the dining/activity room revealed the floor consisted of planks approximately six inches in width. Several areas were noted with approximately 1/4-inch gaps where the planks did not meet together. Additionally, near the entrance closest to the vending machines, damage to the flooring was noted of approximately 6 inch x 3 inch x 7 inch triangle area. On 5/28/19 observation of the floor tiles on Unit 1 revealed five tiles in the hall near room [ROOM NUMBER] to have cracks. On 5/28/19 observation of the floor tiles at beginning of Unit 2 revealed more than 25 tiles with multiple cracks. Additionally, 3 tiles with cracks were observed at the entrance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the review of a facility reported incident (FRI), review of pertinent records and interview with facility staff, it was determined that staff failed to report an allegation of abuse. This was found to be true for 2 out of 2 residents (Resident #108 and #39) reviewed for an allegation of abuse in the investigative stage of the survey. The findings include: Review of the FRI #MD00140405 revealed an allegation where Resident #39 hit Resident #108 in the back. The report further documents that Resident #108 reported the allegation to Staff #17 and Staff # 18 after the incident occurred on 3/4/19. The report went on to further state that the Director of Nursing (DON) became aware of the incident on 3/5/19 when Resident #108 reported the incident to her. Prior to 3/5/19 the DON had no knowledge of the incident and from 3/5/19 initiated a full investigation into the allegation. According to the employee files of Staff #17 and Staff #18, they were both trained on hire regarding the facility abuse policy and educated 1:1 after the incident regarding the need to report any allegation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and interview with facility staff it was determined that the facility failed to develop person-centered individualized comprehensive care plan as evidenced by: 1) failure to develop a care plan to address a resident activities, 2) failure to develop a care plan to address the resident pain, 3) failure to develop a care plan to address the resident diagnosis and 4) failure to follow the care plan to administer pain medication. This was found to be true for 3 out of 30 residents (Resident #2, #44 and #36) reviewed during the investigation stage of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1. On 5/28/19 Resident #2's medical records were reviewed; this review revealed the resident was readmitted to the facility in May 2019 for long term care and with diagnosis which included traumatic brain injury (a disruption in the normal function of…

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

Based on observations, interviews of facility staff and medical record review it was determined the facility failed to update a resident care plan to include an open area that was being treated. This was found to be evident for 1 resident (Resident #36) reviewed for non pressure areas during the facility's annual survey. Findings include: An observation was made of Resident #36 on 5/21/19 at 10:00 AM and gauze was noted to the right side of the resident face near the ear. There was a small amount of heme (blood) noted to the gauze. An interview was conducted with the Director of Nursing (DON) on 5/24/19 at 3:20 PM and s/he was asked if the resident had an open area present and s/he responded, no. The DON stated that Resident #36 had a non-pressure area to the right ear that resolved. Record review on 5/28/19 revealed a physician order for bacitracin 500 unit/ointment, apply to right ear every shift. Review of the care plan for Resident #36 for skin breakdown revealed the following approaches; 1. d/c 12/14/17 apply treatment as ordered 2. d/c 12/14/17 medihoney to right ear 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.

Based on observations of residents, review of medical l records and staff interview it was determined that the facility staff failed to ensure residents are provided with activities that meet the resident's needs based on their assessment. This was evident for 1 out of 5 residents (Resident #2) reviewed for activity during the investigation stage of the survey. The findings include: This surveyor observed Resident #2 to be in bed without the television or radio on as well as not being transported to an activity on 5/20/19, 5/21/19 and 5/22/19. The surveyor attempted to interview the resident, but the resident did not respond. Resident #2's medical records were reviewed and revealed the resident was readmitted to the facility in May 2019 for long term care and with diagnosis which includes: traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury) with loss of consciousness and respiratory failure. Further review of the medical records revealed that the resident is non-verbal and…

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

Based on medical record review, observation and interview with staff it was determined that the facility failed to ensure resident's received treatment and care in accordance with professional standards of practice as evidenced by: 1) failure to follow physician orders regarding frequency of primary care visits (Resident #8); 2) failure to complete ordered therapy evaluations and failure to ensure orders for wound treatments were documented in the medical record (Resident #54); 3) failure to follow a physician order related to a splint (Resident #69); 4) failure to administer a resident the prescribed amount of pain medication, assess the effectiveness of the pain medication and failed to notify the physician that additional pain medication was unavailable (Resident #36) and 5) failure to ensure all documentation related to patient's pain management was complete and accurate (Resident #90) This was found to be evident for 5 out of the 30 residents reviewed during the investigation stage of the survey. The findings include: 1. On 5/23/19 review of Resident #8's medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews it was determined that the facility failed ensure restorative nursing services were provided in accordance with residents' care plans. This was found to be evident for 2 out of the 4 residents (Resident #47 and Resident #76) reviewed for activities of daily living but has the potential to affect all residents with restorative nursing needs. The findings include: 1. On 5/23/19 review of Resident #47's medical record revealed the resident to be totally dependent on staff for activities of daily living. The resident had been discharged from occupational therapy in December 2018 with recommendations for restorative nursing services for passive range of motion (PROM) and the application of left upper extremity splint for 4-6 hours following the PROM. The recommended frequency and duration of the program was 6 times a week for 12 weeks. Review of the restorative aide documentation failed to reveal documentation that the resident consistently received the restorative…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews with the residents and facility staff, it was determined the facility failed to: 1) follow-up to ensure that the resident pain was managed appropriately; 2) administer medication in accordance to the physician orders and resident needs; 3) to assess a resident's pain. This was found to be true for 3 out of 5 residents (Resident #36, #6 and #90) reviewed for pain management during the investigative stage of the survey. Findings include: 1. An interview was conducted on 5/21/19 at 10:14 AM with Resident #36 and s/he was asked if s/he had any concerns. The resident stated to the surveyor that s/he had pain, described as a little discomfort. The resident went on to say that s/he had not received pain medication because they were all out and had to get more. Record review on 5/28/19 revealed Resident # 36 with a physician order for Tramadol 50 mg (2 tablets) PO (by mouth) twice daily for pain. Review of the Medication Administration Record (MAR) revealed no missing…

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

Based on interview with residents, observation and review of resident council meeting minutes it was determined that the facility failed to: 1) put in a system to effectively answer and respond to residents needs timely when the call light is turned on and 2) have sufficient staffing to provide restorative nursing services in accordance with residents' care plans. This was found to be evident for 1 out of the 4 residents (Resident #47) reviewed for activities of daily living but has the potential to affect any resident with a care plan for restorative nursing services and all residents who use call lights. The findings include: Review of complaint MD00138992 revealed an allegation that the facility is short staffed and that call lights go unanswered for long periods of time. 1. During initial tour and the screening process with several residents, multiple residents verbalized complaints regarding staff delay in responding to the call bell. Resident #45 stated on 5/20/19 at 9:41 AM that s/he pushed the call bell for assistance with breakfast and the staff came in turned off the light…

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

Based on review of facility policy and interview with staff it was determined that the facility failed to ensure the required components were included in the medication regimen review policy. This was found to be evident during the review of unnecessary medications and has the potential to affect all residents. The findings include: On 5/23/19 review of the facility's policy regarding the pharmacist's medication regimen review (MRR) failed to reveal a timeframe as to when the physician needed to address the pharmacist recommendations. The policy also failed to include what the pharmacist was required to do if an urgent issue was identified. On 5/23/19 at 8:41 AM, surveyor requested from the Assistant Director of Nursing (ADON) any policy/procedure that addressed timeframes for the medication regimen review and what to do if an urgent issue was identified. On 5/23/19 at 11:22 AM the ADON confirmed that they did not have a policy that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview with residents and facility staff it was determined that the facility failed to: 1) monitor a resident's blood pressure as ordered by the physician and 2) prevent duplicate medication therapy. This was evident in the review of 2 of 5 residents (Resident #45 and Resident #60) reviewed during the investigative stage of the survey. The findings include: 1. Review of the medical record for Resident #45 on 5/22/19 at 9:16 AM revealed an order for 3 different blood pressure medications. The medications were ordered and prescribed for 3 different times of the day. In addition, along with the administration of the medications was an order to monitor the residents blood pressure prior to the administration of each medication and to hold the medication if the blood pressure result was outside of specific parameters. Review of Resident #45's Medication Administration Record (MAR) failed to reveal that during the administration of the blood pressure medication scheduled at 10:00 PM that a blood pressure was checked for the months of March through May…

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

Based on observation and interview it was determined that the facility failed to ensure medications were kept in a secured location as evidenced by the observation of various medications awaiting pick up by pharmacy kept at the open nursing station. This was found to be evident on 1 of the 3 nursing units. The findings include: On 5/20/19 at 11:23 AM surveyor observed an open bag hanging on the chart rack of the unit one nursing station. Review of the contents of this bag, with Nurse #8, revealed a variety of medications including, but not limited to, more than 10 punch cards containing multiple doses of Warfarin. Warfarin is an anticoagulant medication and its use needs to be monitored very closely due to the risk of bleeding. On 5/20/18 at 11:28 AM Nurse #8 reported that the medications are normally stored in this same manner daily for pharmacy to pick up. On 5/20/19 at 1:38 PM follow-up interview with Certified Medicine Aide (CMA) #7 who reported she put the medications on top of the tote [a hard sided container] and indicated this was located under the counter of the nurse'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 the review of a facility reported incident (FRI) and review of pertinent facility documentation and observation it was determined that the facility provided a resident (Resident #69) with a meal containing items on his/her allergy list. This was evident during the investigative portion of the survey. The findings include: Review of the FRI #MD00123596 on 5/24/19 at 10:59 revealed that on 2/27/18 the resident was served a meal that potentially had fish containing product in it. Further review of the Resident #69's medical record revealed that on the resident's initial admission to the facility there was documentation in the resident's record including dietary slips regarding an allergy to shellfish and fish containing products. On 2/27/18 while a family member was there to feed the resident, as s/he is unable to feed her/himself, the family member reported to staff concern that there may be tuna in the meal. Upon staff being notified, the meal was removed immediately, and the resident was assessed for any potential reaction. Further review of the facility 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.

Based on medical record review and interview with staff it was determined that the facility failed to ensure medical records were maintained in accordance with accepted professional standards as evidenced by failure to: 1) ensure staff only document medications that they actually administered; 2) document when medication was administered and 3) failed to ensure that a resident pain assessment and evaluation of the pain was documented in the resident medical record. This was found to be evident for 4 out of 30 residents (Resident #8, #47, #36 and #6) reviewed during the survey. The findings include: 1. On 5/22/19 review of Resident #8's medical record revealed the following two orders for pain patches: 2/21/19 Lidocaine 5% patch, apply bilateral [both] hip every 12 hours on at 10 AM and off at 10 PM; 5/21/19 Lidocaine pain relief 4% patch, apply to bilateral hip ever 12 hours for pain, on in AM off at bedtime. Review of the Medication Administration Record (MAR) revealed the 5/21/19 order had been added to the Certified Medication Aid (CMA) MAR and had been documented administered 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.