Ridgeway Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to timely address and communicate significant weight loss. This deficiency was evident for one (Resident #5) of two residents reviewed for nutrition during this annual survey.The findings include:During a phone interview on 2/05/26 at 11:53 AM, Resident #5's family stated the resident did not receive adequate hydration, which resulted in multiple hospital transfers. As part of the investigation into this concern, the surveyor reviewed Resident #5's medical records regarding hydration and nutritional status.A review of medical records on 2/09/26 at 8:57 AM revealed a pattern of hospital transfers and readmissions: the resident was transferred on 9/08/25 and readmitted on [DATE]; then transferred again at the resident's request on 9/12/25 and readmitted on [DATE]. The medical record documented the following weights:9/02/25: 185 lbs (Bed scale)9/11/25: 161.4 lbs (Bed scale) - Significant loss…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 employee files and interviews, it was determined that the facility failed to implement a system to ensure nursing staff were competent in their respective skill sets. This deficiency was evident in 3 (Staff #29, #30, #31) out of 5 employee files reviewed for competencies during the recertification/complaint survey.The findings include:On 2/10/26 at 7:00 AM, the surveyor reviewed the competency records of five randomly selected staff members. The review revealed the following:-Staff #29: Hired in December 2024 as a GNA, resigned, and was rehired in December 2025. The employee file lacked documentation of competency upon their rehire in 2025.-Staff #30 and #31: Hired in December 2024 as RNs. The employee files for Staff #30 and #31 lacked records verifying clinical skill competency.During an interview on 2/10/26 at 7:18 AM, Staff #1 (Business Officer) stated that HR verifies competency records for new hires and that the nursing department conducts annual evaluations. However, upon a joint review of the files for Staff #29, #30, and #31, Staff #1 verified that 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation and staff interviews, it was determined that the facility failed to appropriately label and store drugs and biologicals in accordance with accepted professional standards. This was evident for 2 of 4 medicine (Med) carts, including the med room fridge observed on the nursing unit during the recertification/complaint survey.The findings include:On [DATE] at 10:20 AM the nurse med cart was checked in the pink hall with Staff #24 a licensed practical nurse (LPN). These meds were found with no labels to indicate when they were opened: -Fluticasone Propionate 50 mcg/inhale nasal spray 16gm-Tuberculin Purified Protein Derivative Diluted/Aplisol, 5 Tu/0.1 ml-5ml bottle These medications were also found expired in the pink hall med cart:-Levetiracetam 100mg/ml solution oral solution with expiration of [DATE]-H-Chlor 120.125% solution with expiration date of [DATE]. On [DATE] at 10:50 AM Observation of the med room with Staff #6 the assistant director of nursing (ADON) revealed expired meds kept 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review it was determined that the facility failed to obtain a dental consult and/or a dental visit for all residents. This was evident for one (#10) out of one resident reviewed for dental concerns. The findings include: This surveyor reviewed Resident #10's clinical record on 2/5/26. The clinical record review revealed that the resident was admitted on [DATE]. Further review revealed that there were no dental consults since admission in the clinical record. The Director of Nursing (DON) was interviewed on 2/9/26 at 3:30 PM. She was asked about the lack of dental consults. She replied that there have been no complaints from the resident or from the family, so a dental consult/visit was never obtained. This surveyor explained that the regulation states that an evaluation from an outside source needs to be done on an annual basis. She expressed an understanding of the findings.

Based on a review of meal service times and staff interview it was determined that the facility staff failed to ensure meals were served less than 14 hours apart. This was evident for all residents receiving a meal tray. The findings include: A review of meal service times revealed that the facility serves dinner with the last food cart having a delivery time of 5:20 PM and the first breakfast cart has a delivery time of 7:40 AM. This represents a 14 hour and 20-minute gap. The Food Service Manager (Staff #28) was interviewed on 2/11/26 at 10:30 AM. This surveyor shared the above finding with her. She stated that the time listed for the food cart that is delivered to the assisted living does not count. She said she understood the finding and would adjust the time the carts went up to reflect a time span of less than 14 hours.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that key essential personnel were present during monthly Quality Assurance (QA) meetings. This deficiency was evident in three of the eight monthly QA meeting attendance sheets reviewed during this recertification/complaint survey.The findings include:On 2/11/26 at 11:29 AM, the surveyor reviewed the facility's Quality Assurance and Performance Improvement (QAPI) meeting attendance sheets from February 2025 to the present. The review revealed that key essential personnel did not sign in for the following dates:-04/30/25: The Infection Preventionist was not in attendance.-06/25/25: There was no evidence of attendance by the Medical Director.-December 2025 (date not clearly documented): There was no evidence of attendance by the Director of Nursing.During an interview with the Nursing Home Administrator (NHA) on 2/11/26 at 12:40 PM, the NHA reviewed the QAPI attendance sheets with the surveyor and validated the absence of documentation regarding the attendance of these key…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was determined that the facility failed to 1), ensure that laundry staff utilize appropriate Infection control measures in the laundry room and 2), have hand sanitizers available in the resident's room for infection prevention in 14 of 31 residents' rooms. This was evident during the recertification/complaint survey.The findings include1) On 2/10/26 at 9:14 AM, an inspection of the facility's laundry room was conducted and on the clean folding table were observed personal items such as: a black handbag, an animal print material , 2 cells phones, one plugged into the wall socket and charging on the table, 2 clear 12 oz plastic soda cups, one containing a small amount of brown liquid, an open bottle of Pepsi cola about 3/4 full. On the dirty side were also observed the absence of a gown or mask for sorting/handling dirty laundry, only gloves were seen.In an interview with the laundry aid, Staff #21 on 2/10/26 at 9:20 AM, she was asked about the process for sorting laundry. She explained that dirty laundry are not sorted, because they come…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews and staff interviews, it was determined that the facility failed to implement a process for tracking nurse aide participation in required training. Specifically, the facility did not ensure all aides received the mandated 12 hours of annual training, including abuse prevention and dementia management, nor did it address areas of weakness identified in performance reviews. This deficiency was evident for two of two Geriatric Nursing Assistants (GNA #29 and #32) reviewed during the recertification/complaint survey.The findings included:On 2/09/26 at 11:23 AM, the surveyor reviewed randomly selected employees' files. The review revealed that as below:-GNA #29: Hired in December 2024, resigned, and re-hired in December 2025. There was no evidence to support the employee receiving dementia training upon re-hire.-GNA #32: Hired in April 2025. There were no records indicating the employee received dementia training upon hire.During an interview on 2/10/26 at 8:56 AM, Staff #25 (Regional Director of Nursing) stated that the previous Director of Nursing…

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

Based on staff interviews and record review, it was determined that the facility failed to follow up on a resident's statement of possible abuse during another investigation for abuse. This was evident for 1 (Resident #1 ) out of 1 resident reviewed for medical records during this complaint survey. The findings include:On October 14th, 2025, at 2 PM, during the review of records for Resident #11's facility-reported incident, it was found that Resident # 1 had stated yes to all the questions asked on the Resident Interview form for abuse. No comments were added, nor any additional information to the claim.On October 15th, 2025, at 1:15 PM, the DON was questioned about the reported incident and if she knew that there was a resident who responded that they thought abuse was occurring in the facility during that investigation. The acting DON stated that she was unaware of the resident's claim and that the prior DON was present during this investigation and would have asked the questions to the residents. The acting DON made the surveyors aware that the resident was still at the…

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

Based on record review and staff interview, it was determined that the facility failed to ensure care plans were reviewed and revised at least quarterly and as necessary to address changes in residents' conditions. This deficient practice was evident for 2 of 2 residents reviewed (Residents #1 and #2) during a complaint survey.The findings include:On 10/14/25 at 12:13 PM, record review for Resident #2 revealed the most recent care plan was dated 3/18/25. On 10/14/25 at 12:22 PM, record review for Resident #1 revealed the most recent comprehensive care plan was dated 4/9/25. During an interview with the Director of Nursing at 12:37pm, it was confirmed that the quarterly care plans were significantly past due for Residents #1 and #2.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with facility staff it was determined the facility failed to provide and maintain a safe, clean, and homelike environment for the residents. This was found to be evident when observations were made during tours of the building during the facility's survey. The findings include the following: An entrance tour was conducted on 10/27/24 at 9:15 AM and the following concerns were identified: Room # 200 was observed with marring noted on the wall Room # 201 was observed with marring noted on the wall behind each bed and near the door Room # 203 was observed with marring noted on the side of the walls Room # 204 was observed with marring noted on the walls, and the floor was dirty with a dark substance noted throughout the room Room # 205 was observed with marring noted on the side of wall around each bed and the wall near the door Room # 206 was observed with marring noted on the walls and around each of the beds Room # 208 was observed with a dirty floor with black substances…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with staff, it was determined that the facility failed to notify the resident or resident representative in writing of the reason for transfer to the hospital. This was found to be evident for 4 (Resident #55, # 37, # 41, #58) of 4 residents reviewed for hospitalizations during the investigative portion of the survey. The findings include: 1) On 10/30/24 at 07:30 AM, review of Resident #55's medical record revealed he/she was hospitalized on [DATE] and 9/24/24. On 10/30/24 at 11:25 AM, an interview with the [NAME] President of sister company (Staff #21) revealed they are unable to provide a copy of the written transfer form from the 9/21/24 hospitalization. On 10/30/24 at 11:39 AM, an interview with the Business Office Manager (Staff #27) revealed that the written transfer form is not sent to the family and if the resident would like to see it, they can request it from the office but that it is verbal and not automatically provided to them. On 11/06/24 at 2:50 PM, at the…

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

Based on observations, facility protocol, and staff interviews, it was determined that the kitchen failed to store food items so as to maintain the integrity of the specific item. This was evident in one of the kitchen refrigerators, the dry storage area and the cooking area. The findings include: 1. On 10/27/24 at 09:07 AM, an initial observation of one of the kitchen fridges revealed orange slices in a container labeled use by 10/24/24, dijon mustard labeled use by 7/14/24, a block of yellow american cheese opened and undated, an undated opened container of mayo, an undated opened container of relish, and undated opened container of chopped garlic. Further observation of items in the same kitchen fridge revealed a food that the surveyor was unable to identify that was used and undated. The surveyor requested the cook (Staff #25) to identify the food and he was unable to and threw out the food. 2. On 10/27/24 at 9:27 AM, an observation of dry storage foods revealed three opened pasta bags undated, a box of opened rice undated, an opened bag of croutons undated, two opened bags of…

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

Based on record review and interview with staff, it was determined that the facility failed to have a system in place to ensure that a copy of the resident's Advanced Directives documents had been obtained and maintained in the resident's medical record. This was evident for 1 (Resident #4) out of 3 residents reviewed for Advanced Directives. The findings include: Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Power of Attorney (POA) is a document that allows a person to appoint someone to act on their behalf with respect to certain matters, such as medical, financial, real estate, and business transactions. On 10/28/2024 at 11:01AM, a review of Resident #4's electronic medical record revealed no documentation of an Advanced Directives for the resident. On 10/29/2024 at 7:26AM, during a review of Resident #4's electronic medical record, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility reported incident (FRI), and interviews, it was determined that the facility failed to report an injury of an unknown source. This was evident for 1 (Resident #58) out of 11 residents investigated for allegations of abuse during the survey. The findings include: On 10/31/2024 at approximately 2:10PM during review of Resident #58's electronic medical record, the Surveyor discovered a Nurses Note written by Licensed Practical Nurse (LPN) #36, dated 9/23/2024 at 5:13AM, which stated that the resident was found in another resident's room and appeared to have bitten his/her lip, blood noted [on the resident's chin area]. There was no documentation of an assessment or change in condition note by LPN #36 in the resident's electronic medical record. On 10/31/2024 at approximately 2:17PM, the Surveyor reviewed the facility reported incident file of an alleged abuse for Resident #58. A review revealed that at 4:00AM the resident was found by Geriatric Nursing Assistant (GNA) #37,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interviews and record review, it was determined that the facility failed to include the resident care plan goals with the required documentation during a transfer. This was evident for 2 (#55 and #37) of 4 residents reviewed for hospitalization. The findings include: 1) On 10/30/24 at 07:30 AM, review of Resident #55's medical record revealed he/she was hospitalized on [DATE] and 9/24/24. On 10/30/24 at 09:05 AM, an interview with the Director of Nursing revealed that the care plans are not sent with the resident upon transfer from the facility. 2) On 10/30/24 at 07:35 AM, review of Resident #37's medical record revealed that he/she was hospitalized [DATE] and 10/25/24. On 10/30/24 at 09:05 AM, an interview with the Director of Nursing revealed that the care plans are not sent with the resident upon transfer from the facility. On 10/30/24 at 09:17 AM, an interview with Licensed Practical Nurse (LPN, Staff #12) and Licensed Practical Nurse (LPN, Staff #26) revealed the nurses go off of a transfer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with staff, it was determined that the facility failed to have system in place to ensure the residents and/or resident representatives are notified in writing of the bed hold policy at the time of discharge/transfer to the hospital. This was found to be evident for 3 (Resident #41, #55, and #37) out of 4 residents reviewed for hospitalizations during the survey. The finding include: 1) On 10/30/2024 at 8:05AM, a review of Resident #41's electronic medical record revealed that the resident was transferred to the hospital on 8/29/2024. Additional review of the electronic medical record failed to reveal documentation to indicate that Resident #41 had been notified in writing of the facility's bed hold policy upon transfer to the hospital. During an interview conducted on 10/30/2024 at 9:02AM with the Director of Nursing (DON) #2, the Surveyor expressed the concern that Resident #41's electronic medical record failed to reveal documentation that resident and/or their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff it was determined the facility failed to ensure that the coding of the resident assessment by the Minimum Data Set (MDS) Coordinator accurately reflected the resident status at the time the assessment was done. This was found to be evident for 1 (Resident # 12) of 1 residents reviewed for Activities of daily living (ADL's) during the investigation stage of the 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. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. On 10/28/24 at 10:31 AM Resident # 12 medical record was reviewed. Resident # 12 was admitted with the following but not limited to diagnosis: Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness to one side of the body) and history of Malignant Neoplasm of…

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

Based on record review and interview with staff it was determined that the facility failed to develop and implement a person-centered care plan for a resident who wanders and was at risk for elopement. This was evident for 1 (Resident #56) out of 5 residents investigated for accidents during the survey. The findings include: Wandering behavior is when a person becomes confused about their surroundings and stray from where they are supposed to be. Elopement risk describes an individual's behavior of leaving an area without permission or supervision. On 10/29/2024 at approximately 1:30 PM, a review of Resident #56's electronic medical record revealed a skilled progress note written on 9/23/2024 at 4:56 AM that stated the resident was walking up and down the hallways and in and out of various resident rooms. The resident refused redirection and aimlessly wandered. The resident stated that he/she wanted to go home. During further review of Resident #56's electronic medical record, the Surveyor discovered an Elopement Evaluation note with an elopement score of 3, indicating the 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 review of medical records, interviews and other pertinent documentation, it was determined that the facility failed to have an effective system in place to ensure accurate documentation of resident code status regarding Cardiopulmonary resuscitation (CPR). This was evident for 1 of 24 residents (Resident #37) reviewed. The findings include: Code Status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops. Cardiopulmonary resuscitation (CPR) refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. MOLST (Maryland Orders for Life Sustaining Treatment) refers to a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. When the MOLST form is updated, the MOLST form shall be voided and a new MOLST form prepared when there is a change to any 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 record review, observation, and interview, it was determined that the facility failed to ensure activities were provided to residents based on their preferences and as indicated in their care plan. This was found to be evident for 1 (Resident #20) out of 1 resident reviewed for activities. The findings include: On 10/27/24 at 01:31 PM, an observation of Resident #20 revealed she/he in bed looking straight ahead at the wall with no activity stimulation. On 10/29/24 at 09:00 AM, review of Resident #20's record revealed a care plan focus of cognitive deficits related to dementia and one of the interventions indicated the resident was to maintain involvement in cognitive stimulation. On 10/29/24 at 09:05 AM, an interview with Activities Director (Staff #16) revealed that she and her activities assistant (Staff #17) would visit residents 1:1 for those that do not like being around people so that they get the person contact, and that they go around to see everyone everyday. Further interview with Staff #16 revealed that they would document the visits and all activities 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 record reviews and interviews, it was determined that the facility failed to ensure: 1) a resident was accurately assessed and received immediate treatment after an injury of an unknown source, 2) orders were being implemented by staff and 3) staff were completing assessments of residents admitted or readmitted to the facility. This was evident for 3 (Resident #58, # 23, # 27 ) out of 26 residents investigated for allegations of abuse. The findings include: 1) On 10/31/2024 at approximately 2:10 PM during review of Resident #58's electronic medical record, the Surveyor discovered a Nurses Note written by Licensed Practical Nurse (LPN) #36, dated 9/23/2024 at 5:13 AM, which stated that the resident was found in another resident's room and appeared to have bitten his/her lip, blood noted [on the resident's chin area]. There was no documentation for an assessment or change in condition note in the resident's electronic medical record. On 10/31/2024 at approximately 2:17 PM, the Surveyor reviewed the…

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

Based on record review and interviews it was determined that the facility failed to ensure that all nursing staff had competency evaluations. This was evident for 3 (GNA #30, GNA #31, GNA #10) of 5 randomly selected nursing staff reviewed for competencies. The findings include: Nursing competence is defined by the American Nurses Association as an expected level of performance that integrates knowledge, skills, abilities, and judgment. A review of random staff files on 11/01/24 at 07:43 AM revealed the following: 1. Geriatric Nursing Assistant (GNA, Staff #10) was hired in March 2024. No competency evaluation was found for Staff #10. 2. Geriatric Nursing Assistant (GNA, Staff #30) was hired in August 2016. No competency evaluation was found for Staff #30. 3. GNA, Staff #31 was hired in June 2018. No competency evaluation was found. On 11/01/24 at 08:29 AM, an interview with the Director of Nursing (DON) revealed that competencies for staff should be annual, and for new hires it should be at the 90 day mark as well as the year mark. The surveyor requested for the competencies…

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

Based on observation it was determined the facility failed to post the required nursing staffing data on the Daily Staffing Schedule. This was evident for 6 out of 6 days observed during the survey. The findings included: On 10/27/24 at 9:00 AM, 10/28/24 at 7:15 AM, 10/29/24 at 7:00 AM, 10/30/24 at 7:00 AM, 10/31/24 at 7:30, and 11/01/24 at 7:00 AM, upon entrance into the facility, the surveyor made observations which revealed a posted staffing sheet for the shifts throughout the day but failed to reveal the facility's census as well as the actual and total number of hours worked by Geriatric Nursing Assistants (GNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). On 11/01/24 at 2:31PM, the surveyor reviewed the concern with the Chief Operations Officer (Staff #14) that the facility's daily staffing sheet does not meet the required nursing staff data.

Based on record review and interview with staff, it was determined that the facility failed to have a system in place to ensure that the attending physician and/or Director of Nursing had documented and signed in the medical record to show they have reviewed an irregularity or recommendation identified by the pharmacist. This was evident for 3 (Resident #19, #41, and #50) of 5 residents investigated for Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review during the survey. The findings include: A Medication Regimen Review (MRR) is when a consultant pharmacist completes a comprehensive review of each resident's medication regimen and clinical record. It must be completed at least monthly for each resident. It contains recommendations related to a resident's medication regimen that must be addressed by the resident's physician. 1. On 11/6/2024 at 9:45AM, a review of Resident #19's electronic medical record revealed the clinical pharmacist identified an irregularity during the resident's MRR and made a recommendation on 2/4/2024, 3/4/2024, 4/7/2024,…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that a psychotropic medication prescribed as needed (PRN), had an end date that was limited to 14 days. This was evident for 1 (#55) of 5 residents reviewed for medications. The findings include: On 10/31/24 at 07:48 AM, review of Resident #55's medical record revealed an active order for hydroxzine by mouth every 8 hours as needed with an order date of 9/19/24 but failed to be limited to 14 days. Hydroxyzine is used to help control anxiety and tension caused by nervous and emotional conditions. On 11/01/24 08:20 AM, review of the facility policy labeled Psychotropic Medication Use revealed that, PRN orders for psychotropic medications are limited to 14 days. On 11/01/24 at 08:29 AM, the surveyor reviewed the concern with the NHA regarding the facility's failure to ensure PRN psychotropic medications are limited to 14 days.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview with staff, it was determined that the facility failed to ensure that medication and medical treatment supplies were stored safely. This was evident for 1 of 1 medication room and 1 of 1 medical supply room observed during the survey. The findings include: 1. On [DATE] at 10:02 AM, the Surveyor observed the medication room located behind the nursing station. The Surveyor observed the following expired items: a box of Banatrol Plus with an expiration date of [DATE] on the shelf above the med cart and 3 packs of Curad Xeroform Petroleum dressing, with the expiration date of 4-2023, in the wound cabinet. Further observation of the medication room revealed Sodium Polystyrene Sulfonate ordered for two days for Resident #37 and a bag with 3 unopened vials of Ceftriaxone Sodium injection solution to be reconstituted and a opened and undated vial of Lidocaine ordered for 3 days for Resident #1. On [DATE] at 10:24 AM, during a review of Resident #37's electronic medical record, 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 interviews, it was determined that the facility failed to ensure that a resident was served a meal according to a predetermined menu that incorporated the resident's preferences. This was evident for 3 (Resident #32, #17, #8) of 5 Resident trays observed during a meal. The findings include: 1) An observation made on 11/01/24 at 11:51 AM in the kitchen during the tray line revealed Resident #32's meal ticket which indicated a regular diet and a peanut butter jelly sandwich was written in as a request. On 11/01/24 at 12:14 PM, the surveyor observed Resident #32 who was eating her/his food from their tray which failed to reveal a peanut and butter jelly sandwich. The surveyor observed GNA (Staff #23) near and requested that they look at the meal ticket together and she confirmed that the ticket indicated a peanut butter and jelly sandwich which was not on the tray. 2) An observation made on 11/01/24 at 11:51 AM in the kitchen during the tray line revealed Resident #8's meal ticket which indicated a regular meal but did not list rice which was the starch 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 observations, resident medical record review, and staff interview it was determined the facility failed to maintain accurate physician orders for the use of oxygen for Resident #15. This was evident for 1 resident out of 6 residents reviewed during the survey. The findings include the following: During observation rounds on 10/30/2024 at 9:30 AM Resident #15 was observed to be on 2 liters of oxygen by nasal cannula. During an interview and observation rounds on 10/30/2024 at 10:07 AM staff #18 verified and stated that Resident #15 was receiving 2 liters of oxygen by nasal cannula and that he/she was not able to find a physician's order stating that the resident was to be receiving oxygen, and the resident had been on oxygen for a long time and should be on oxygen continuously. Review of the Resident #15's medical record on 10/30/2024 at 10:45 AM revealed no physician orders for resident to receive oxygen. During an interview on 10/30/2024 at 11:00 AM staff #21 stated that there was no physician order for Resident #15 to receive oxygen and that the physician would be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have an Infection Preventionist Designee onsite at the facility to provide oversight to the facility's Infection Prevention and Control Program. This was found to be evident during the survey. Findings include: During the entrance conference on 10/27/24 at 10:52 AM with the Administrator (Staff # 1) and the Director of Nursing (DON) (Staff # 2) who were present, the Administrator stated that the DON had been working at the facility for approximately 1 month and would be going to an Infection Control training class. During the interim she stated that the facility was utilizing the Corporate Infection Control Designee (Staff # 3) who is certified, but she does not work in the building. The Administrator was made aware that it is a requirement that the Infection Control Designee needs to work onsite at the facility and not off-site in a corporate role. An interview was conducted with the Corporate Infection Control Designee on 10/27/24 at 1:45 PM and she 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.

Based on observation and interviews it was determined the facility failed to maintain patient care equipment in working and safe operating conditions. This was evident for 3 hand sanitizer dispensers and 1 out 2 DS Smart vital sign machines observed during the survey. The findings include the following: During observation rounds and interview on 10/31/2024 at 3:09 PM the Maintenance Director staff #29 verified that there were 3 hand sanitizer dispensers located outside of rooms #108 - #115 that did not have sanitizer and/or the dispensers were not secured on the wall. During observation rounds and interview on 11/01/2024 at 10:01 AM with staff #3, a DS Smart vital sign machine was not being used by staff, would not turn on and the machine connection wires did not fit properly into the machine. Staff #3 verified and stated that the machine was broken, and it would be replaced immediately. Staff #3 further stated that there was not enough working vital sign equipment on the floor for staff to use to obtain resident vital signs. During an interview on 11/01/2024 at 10:10 AM staff #12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 implement appropriate interventions formulated from resident assessments to potentially prevent further falls. This was evident during the review of 1 of 2 reviewed regarding falls (Resident #26). The findings include: During the medical record review of Resident #26 on 3/22/2021 at 10:25 AM during the investigative portion of the survey, it was determined that s/he was noted with a history of falls and was noted on the floor on 3/18/2021. Further review of the medical record for Resident #26 on 3/24/2021 at 10:08 AM revealed partial diagnosis including cerebral infarction affecting right dominant side, seizures, chronic pain, muscle wasting and atrophy and difficulty walking. Additionally, care plans were in place and implemented on 6/2/2020 related to the resident's history of falls, gait and transfer dysfunctions with interventions and revisions noted on 9/30/2020, 10/26/2020, 10/8/2020 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 observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and policies to prevent transmission and cross-contamination of germs and microorganisms within the facility by not properly discarding soiled items, not maintaining sanitary transport and storage of respitory equiment, and failing to ensure a resident had on proper personal protective equipment (PPE) prior to being in socail setting with others (Resident #27). This was found to be evident for multiple identified concerns that were observed during the facility's annual Medicare/ Medicaid survey. Findings include: Observations were made of the Observation Unit (where newly admitted residents are placed for quarantine for a designated time frame) and the following concerns were identified: 1. On 3/23/21 at 10:15 AM an observation was made of a dirty balled-up towel that was placed on top of a PPE bin in front of a resident's room. Staff # 7 was made aware at the time of the observation and she opened the towel and identified that food particles were…

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

Based on resident interview and observation it was determined the facility staff failed to treat a resident with respect and dignity by failing to: 1) ensure a urinary bag was covered; 2) provide an environment that promotes the dignity and respect of residents by addressing residents in an appropriate manner and 3). enhance and promote a resident's dignity by not providing the resident assistance with toileting and instead of placing a depend on the resident. This was evident for 3 of 23 residents reviewed during the survey (Residents#21, #5, #37) . The findings include: A foley catheter is a urinary collection system consisting of a tube inserted into the bladder via the urethra. A suprapubic catheter is a tube inserted directly into the bladder through the abdominal wall to drain urine. The urine then drains through the tubing into a drainage bag that is attached to the side of the bed or chair. A privacy cover is placed over the drainage bag to hide the contents thus ensuring privacy and preventing embarrassment for the resident, roommate, or visitors. The findings include: 1)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the review of a facility reported incident resident and staff interviews and review of medical record and other pertinent documentation. It was determined that the facility staff failed to ensure effective system(s) to maintain an environment free from neglect for vulnerable resident who is totally dependent on staff to provide all ADL care and services during for unknown time frame on the midnight nursing shift. This was evident for 1 out of 4 residents during investigative portion of annual survey (Resident #28) . The findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident's needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to ensure the information used to complete the Annual and Quarterly Minimum Data Set (MDS) assessment for medication usage was correct for 2 of 5 residents reviewed for unnecessary medications during the investigation stage of the long-term care survey process (Resident #15 and #26). 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. The findings include: 1. A review of the medical for Resident #15 on 3/24/21 at 8:33 AM revealed an order for Ambien a sleep aide classified as a hypnotic.Further review of the annual MDS assessment on 3/24/21 at 8:31 AM compared to the resident's electronic medication administration record (MAR) failed to document that the resident was receiving the prescribed Ambien. The MDS coordinator, Staff #12 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 medical record review and interviews with facility staff it was determined the facility failed to 1) develop a care plan specific for a resident (Resident #16) with a diagnosis of Dementia; 2) monitor a resident (Resident # 37) who is receiving antibiotic therapy in accordance with the resident care plan and 3) failed to develop and implement comprehensive person-centered care plan that included measurable objective to meet the Resident (Resident #25) This was found to be evident for 3 of 22 residents reviewed during the annual survey. Findings include: 1) A medical record review for Resident #16 was conducted on 3/25/21 at 9:40 AM and it revealed the resident has the following but not limited diagnosis: Unspecified Dementia without Behavioral Disturbance. Review of physician orders for resident # 16 on 3/25/21 at 10:00AM revealed the resident is on the following medications: Quetiapine 25 mg (0.5 tablet) po (by mouth) 1 time a day 8:00 am for anxiety/agitation. A review of a consultation note dated…

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

Based on medical record review and staff interviews is was determined that the facility failed to revise update care plan that addressed residents actual fall. This was evident 1 out of 5 resident's involving during the survey process Resident #28. The finding includes: The 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. Medical record review revealed Resident #28 was admitted to the facility from acute care hospital with diagnosis which included but not limited to S/p Fall; Rhabdomyolysis (seizures or muscle tremors); Cerebrovascular Accident and Acute Kidney Injury and other chronic health condition which requires ongoing treatment. A review of intake MD00161695 facility reported incident which occurred on 12/16/20 involving Resident #28 revealed that on 12/16/20 Resident #28 was not in s/his room during the 10:30 p.m.-7:00 a.m. shift and on 12/17/20 approximately 7:15 a.m. the resident was found lying on floor under the bed in hospital gown had experienced unwitnessed fall.…

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

Based on medical record review and interviews with facility staff it was determined the facility failed to monitor for signs and symptoms and the effectiveness of a medication after a resident was placed on antibiotic therapy following a surgical procedure. This was found to be evident for 1 of 22 residents reviewed during the investigation stage of the facility's annual Medicare/Medicaid survey (Resident # 37). The Findings include: Resident # 37 medical record was reviewed on 3/25/21 at 1:38 PM and it revealed the resident was on Cephalexin oral Capsule 500 mg 1 PO (by mouth) 4 times a day. Antibiotic therapy status post ORIF LLE (Open Reduction and Internal Fixation Left Lower Extremity). Further review of the Medication Administration Record (MAR) on 3/26/21 at 9:10 AM revealed the resident received the medication, however, there was no documentation of monitoring for side effects or effectiveness of the medication. An interview was conducted on 3/26/21 at 9:25 AM with the Corporate Nurse Consultant, Staff # 3 and the Administrator, Staff # 1 and they were asked to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident complaint, interviews and the sampling of two (2) test trays, it was determined that the facility failed to have a process in place to ensure resident trays are served at a palatable temperature. The findings include: Interview with Resident #5 on 3/23/2-21 at 10:19 AM revealed a concern that hot foods are not served hot. A test tray was requested from the dietary manager on 3/24/2021 in order to test the palatability and the temperature of the meal served at lunch. In preparation for the test tray surveyor placed thermometer in ice water to calibrate. Surveyor was notified on 3/24/2021 that the surveyor prepared test tray was ready and proceeded to the Pink hallway where Resident #5 resided to acquire the test tray. The tray was taken to the conference room to test for temperature and palatability, this occurred at 12:50 PM. The test tray was opened and was covered in saran wrap. The saran wrap was removed, and temperatures of the meal were taken: Fish 100 degrees Brussel sprouts 110 degrees Mashed potatoes 88 degrees Each were also taste tested and although…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 was determined that the facility staff failed to ensure that food was stored and prepared in sanitary manner. This practice has a potential of effecting all residents in facility. Finding includes: During the initial tour of the kitchen took place on 03/22/21 at 7:55 AM accompanied by the Certified Dietary Manager (CDM) staff member #9 who verified all surveyor observed finding. On 03/22/21 at 7:35 AM during breakfast hot food line from steam table to plate reviewed the Food Cook to Temperature line Temperature Log sheet revealed the line cook staff #35 did not record breakfast food temperatures for served hot oatmeal or ham and cheese quiche both temperatures where blank with no temperature reading visible on the log. On 03/22/21 at 7:40 AM during staff interview with staff member #35 who stated I thought I recorded the food temperatures with CDM Manager verified missing cooked food temperatures on the temperature log sheet. On same day at 7:46 AM the observed the CDM Manager take and record the current oatmeal and ham and cheese quiche…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for residents This was evident for 2 of 22 residents reviewed in the annual survey (Residents #30 and #28). ( The findings include: A medical record is an official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. The findings include: 1) The facility staff failed to maintain Resident #30 medical record in the most accurate form. A review of Resident #30's medical record on 3/24/21 revealed Resident #30 was admitted on [DATE] with a stage 2 sacral wound. The resident was ordered Calcium Alginate to be applied to the sacrum at 11:00 am every day. Calcium Alginate is primary dressings designed for use on wounds with moderate to heavy drainage. Further review 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.