Chestertown Nursing And Rehab

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure the Minimum Data Sheet (MDS) accurately reflected a resident's status. This was evident for 1 (Resident #5) of 3 residents reviewed for pressure ulcers/wounds.The findings include:The Minimum Data Set (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 must be accurate to ensure that each Resident receives the care they need.On 08/04/2025 at 5:13 PM review of Resident #5's medical record revealed a documented skin check dated 4/23/25 that indicated the resident had four wounds. At the same time, further review of the skin check document revealed two of the wounds (the left hip and right heel) were documented as present on admission (the resident had the wounds prior to being admitted to the facility).On 08/04/2025 at 5:19 PM, review of Resident #5's medical record revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that facility staff failed to provide evidence that a level 1 preadmission screening and resident review (PASARR) was completed prior to admission, or at the time of admission for a resident with a mental disability. This deficient practice was evident for 1 (Resident #6) of 2 residents reviewed for PASARR during the annual survey. The findings include: The PASARR process requires that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders, intellectual disabilities and related conditions. This initial screening is referred to as Level I Identification of individuals with MD or ID and is completed prior to admission to a nursing facility. The purpose of the Level I pre-admission screening is to identify individuals who have or may have MD/ID or a related condition, who would then require PASARR Level II evaluation and determination prior to admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility staff, it was determined that the facility failed to 1) initiate a care plan for residents receiving oxygen therapy, 2) initiate a care plan for a resident with Clostridioides difficile (C. Diff), and 3) initiate a care plan for a resident with colostomy. This was evident for 3 residents (Residents #19, #20 and #98) out of 3 resident records reviewed for care plans during the Medicare/Medicaid recertification survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider.Clostridioides difficile (C. Diff) is the currently accepted scientific name, replacing the former Clostridium difficile (C. Diff). Both names refer to the same bacterium, which is a common cause of…

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

Based on review of a facility reported incident , record reviews and staff interviews, it was determined that the facility failed to 1) revise a care plan to accommodate the need after medication was increased and 2) revise a care plan after a facility reported incident. This was evident for 1 resident (Resident #69) out of 3 residents reviewed for care plans during the Medicare/Medicare recertification survey.The care plan provides an opportunity to see if it meets the residents' needs by reviewing what strategies are working and which are not. It can also identify changes in the resident's condition or behavior that will require revisions of the care plan. Care conferences are usually held on a regular basis, often quarterly, but can be scheduled more frequently if needed based on the resident's condition. 1) On 08/06/2025 at 9:57 AM, during a review of Resident #69’s order in his/her electronic health records, it revealed that the Medical Director, Staff #32 had given an order on 07/09/2025 for “Seroquel Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day”…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to follow physician's orders and professional standards of quality when administering blood pressure medication. This deficient practice was evident for one resident (#9) reviewed for professional standards during the annual survey. The findings include: On 08/05/25 at 4:51 PM, a review of Resident #9's medication administration record (MAR) for July 2025 revealed a physician's order dated 12/31/24 for Metoprolol 25 milligram (mg) to be administered twice daily for hypertension with instruction to hold the medication if the systolic blood pressure was less than 100 mmHg. The MAR showed that the Metoprolol was administered twice daily for the entire month of July 2025. However, review of the resident's blood pressure readings revealed that it was only recorded on 7/3/25, 7/8/25, 7/16/25, and 7/21/25. On 8/6/25 at 10:45 AM, during an interview with licensed practical nurse (LPN) #5, the survey asked about the process for administering blood pressure medications. The LPN #5 explained that 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.

Number of residents sampled: Number of residents cited: Based on interviews and record reviews, it was determined that the facility staff failed to provide appropriate treatment to maintain the resident's ability to perform activities of daily living. This deficient practice was evident for 1 (Resident #6) of 2 residents reviewed for vision and hearing. The findings include: During an interview with Resident #6 on 08/04/2025 at 10:56 AM, the resident expressed concerns about their vision and hearing and stated that the facility did not address the concerns. A review of Resident #6's medical records revealed that the facility referred the resident to 360 Care for an ear exam due to decreased hearing. The exam was completed on 07/08/25. The audiologist documented that the resident's exam was abnormal due to impacted cerumen (earwax) and recommended Debrox (earwax removal aid) for the resident's left ear. Review of the resident's physician orders failed to show an order for Debrox or documentation explaining why the recommendation was not followed. On 08/05/25 at 9:43 AM, during an…

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

Number of residents sampled: Number of residents cited: Based on interviews and record reviews it was determined that facility staff failed to assist a resident who was dependent on staff for activities of daily living (ADLs) for showers. This deficient practice was evident for 1 (#38) resident reviewed for ADL care during the annual survey. The findings include: During an interview with Resident #38 on 08/04/25 at 11:20 AM, the resident stated they are to receive showers on Wednesday and Saturday during the evening shift. However, staff fail to provide showers and instead offered a bed bath. The resident stated they would prefer showers and reports that staff sometimes document that they refused showers, which the resident stated was not true. On 08/04/25 at 11:30 AM, during an interview with the Unit Manager #7 (UM), the surveyor asked where staff documented residents showers. The UM #7 stated that some staff documented showers in Point Click Care (PCC), and other staff recorded them in the unit's shower log. The surveyor reviewed the shower logbook which revealed that 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 Number of residents sampled: Number of residents cited: Based on interviews, observations, and record reviews it was determined that staff failed to 1.) adequately monitor and assess urinary output and 2.) ensure pain was assessed and managed per the physician's order. This deficient practice was evident for one Resident (#38) reviewed for quality of care and one (#94) of two residents reviewed for pain management during the annual survey.The findings include: 1. On 08/04/2025 at 11:20 AM during an interview, Resident #38 reported that the urine in their foley catheter bag was often dark, bloody with clots and staff fail to irrigate the foley catheter tubing. The resident further stated they were hospitalized in April 2025 for urinary tract infection since staff failed to irrigate the foley catheter tubing. The surveyor observed amber colored cloudy urine in the resident's foley catheter bag. On 08/06/25, a review of Resident #38 medical record revealed a progress note dated 04/27/25 at 10:28 PM, documented by…

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

Number of residents sampled: Number of residents cited: Based on interview and record review, it was determined that the facility failed to ensure a resident received services consistent with professional standards of practice to prevent new pressure ulcers/wounds from developing. This was evident for 1 (Resident #5) of 3 residents reviewed for pressure ulcers/wounds.The findings include:On 08/04/2025 at 8:20 AM, an interview with Resident #5 revealed that the facility staff did not always turn him/her from side to side every two hours, and as a result, he/she developed two new pressure ulcers/wounds in the facility. He/she further indicated he/she was unable to reposition himself/herself and was dependent on staff for repositioning. On 08/04/2025 at 5:07 PM, a review of Resident #5's medical record revealed a resident assessment with an ARD dated of 2/21/25 that indicated the resident had a Brief Interview for Mental Status (BIMS) of 15. A recent resident assessment with an ARD of 8/6/25 indicated the resident had a BIMS of 14.A Brief Interview for Mental Status (BIMS) is a tool…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 Complaint Number 310737, medical records, and interviews with facility staff, it was determined that the facility failed to ensure proper colostomy care was provided and documented for a resident (Resident #98), who had a colostomy. This deficiency was identified during the complaint investigation at the facility's Medicare/Medicaid recertification survey An ostomy is a surgery that makes a temporary or permanent opening in the skin called a stoma. A stoma is a pathway from an internal organ to the outside of your abdomen. A colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the skin of the abdomen. A colostomy bag, also called a stoma bag or ostomy bag, is a small, waterproof pouch used to collect waste from the body. The Minimum Data set (MDS) assessment is a federally mandated assessment tool that nursing home staff use…

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

Based on surveyor observation, review of the medical record, and interview with facility staff, it was determined the facility staff failed to provide residents with respiratory care consistent with professional standards by 1) failing to date and label the oxygen tubing, nasal cannula and the humidifier bottle and 2) failing to follow the physicians' order for the oxygen administration. This was evident for 1 resident (Resident #19) out of 1 resident observed on oxygen therapy during the Medicare/Medicaid recertification survey.The findings include:Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider.Oxygen saturation or SpO , is a medical measurement that indicates the percentage of oxygen-carrying hemoglobin in the blood compared to the total amount of hemoglobin. It is a key indicator of how well oxygen is being distributed from the lungs to the rest of the body.Oxygen tubing is a clear, flexible, medical-grade tube used to deliver…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on interview and record review, it was determined that the facility failed to ensure 1) pain management was provided to a resident based on professional standards of practice and the comprehensive person-centered care plan, and 2) adequate pain management by assessing pain as ordered. This was evident for 2 (Resident #8 and #94) of 2 residents reviewed for pain management. The findings include: 1) On 08/04/2025 at 9:17 AM, an interview with Resident #8 revealed that he/she was always in pain due to his/her back, and that his/her pain was not managed by his/her current medication regimen. On 08/04/25 at 4:56 PM, review of Resident #8's medical record revealed a progress note titled, nurse practitioner follow up note, dated 7/30/25 at 10:30 PM by Nurse Practitioner (Staff #40), which indicated the resident reported he/she had low back pain all of the time due to arthritis. At the same time, further review of the resident's medical record 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 Number of residents sampled: Number of residents cited: Based on interview and record review, it was determined that the facility failed to ensure that the physician reviewed a resident's total plan of care at each visit. This was evident for 1 (Resident #8) of 2 residents reviewed for hospitalization during the annual survey.The findings include:On 08/04/2025 at 9:17 AM, an interview with Resident #8 revealed that he/she was always in pain from his/her back. He/she indicated their pain was not managed by their current medication regimen.On 08/04/25 at 4:37 PM, review of Resident #8's medical record revealed that he/she was hospitalized on [DATE].On 08/04/25 at 4:46 PM, further review of Resident #8's medical record revealed the discharged summary from the hospital dated 7/29/25, which indicated that the resident had been seen by palliative medicine. Further review of the discharge summary revealed that the resident had back pain and that the resident was recommended by palliative medicine to have transdermal…

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

Number of residents sampled: Number of residents cited: Based on interviews and record reviews, it was determined that the facility staff failed to conduct annual nursing aide performance reviews. This was evident for 5 out of 5 nursing aide performance appraisals, reviewed during the annual survey. The findings include: During an interview with the Assistant Director of Nursing (ADON) on 08/11/25 at 11:46 AM, the surveyor inquired about the process for conducting annual performance reviews. The ADON explained annual training was offered to nursing aides and stated the surveyor should speak with Human Resource (HR) #4 regarding annual performance reviews. The surveyor requested employee files including annual performance reviews, for geriatric nursing assistant (GNA) #45, GNA #46, GNA #22, GNA #47, and GNA #48. On 08/11/2025 at 12:30 PM, the ADON provided the surveyor with employee files for GNA #45, GNA #46, GNA #22, GNA #47, and GNA #48. A review of the files failed to show evidence that a performance review had been conducted within the past 12 months. The surveyor informed ADON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observation and interviews, it was determined that facility staff failed to post the actual hours worked per shift for Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Medication Aide (CMA), Geriatric Nursing Assistant (GNA). This deficient practice was evident for 2 (Chesapeake and [NAME]) out of 2 units reviewed for posted nurse staffing information. The findings include: During the initial tour of Chesapeake Unit on 08/04/25 at 7:35AM, the surveyor observed a white board hanging on the wall dated 08/04/25. The whiteboard listed Nurse Unit Manager (UM) #7, six GNA's with their room assignments, LPN #35, LPN #9, and RN #11. However, the actual hours worked were not listed for any of the staff. A Resident Care Staffing Report sheet was taped to the white board, which included a sections for day, evening and night shifts, unit census, and nursing staff assignments. The area designated for actual hour worked was left blank. Multiple…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of narcotic record books and interviews with facility staff, it was determined that the facility failed to ensure narcotic record books were consistently signed by both incoming and outgoing nurses. This was evident for 5 out of 5 narcotic books reviewed during the facility's Medicare/Medicaid recertification survey. On 08/05/2025 at 7:40 AM, during a medication administration observation on the [NAME] Unit, the surveyor reviewed the narcotic record book and noted multiple missing signatures dating back to May 2025. More recent omissions included the weekend shifts from 08/01/2025 through 08/03/2025. At 7:44 AM on 08/05/2025, the unit manager Staff #5 was called for dual observation. She confirmed the missing signatures. When asked about facility protocol, she stated that narcotics were to be counted at the beginning and end of each shift by both the outgoing and incoming nurse, and that both nurses were required to sign the record. She acknowledged that the absence of signatures 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.

Number of residents sampled: Number of residents cited: Based on record review and staff interviews, it was determined that the facility failed to ensure that resident Medication Regimen Review (MRR) recommendations were addressed by the provider. This was evident for 3 (Resident #5, #6, and #69) of 5 residents reviewed for unnecessary medications. The findings include: 1) Gradual Dosage Reduction (GDR) refers to the process of systematically reducing the dosage of medications, especially psychotropic drugs, over time, while carefully monitoring a patient's response to reduce reliance and dependence on certain medications, to find the lowest effective dose and to avoid unnecessary medication. On 08/06/2025 at 9:50 AM, review of the pharmacy medication regimen review (MRR) for Resident #69 showed that in June 2025 the pharmacy recommended a gradual dose reduction (GDR) of Alprazolam 0.25 mg one time a day, Alprazolam 0.25 mg every 12 hours, Gabapentin 600 mg two times a day and Quetiapine 50mg (Seroquel) two times a day. Further review revealed that Resident #69 was last seen for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews with facility staff, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medications. This was found to be evident for 1 (Resident #69) out of 2 residents reviewed for unnecessary medications during the facility's Medicare/Medicaid recertification survey. The findings include: Brief Interview for Mental Status (BIMS) is a standardized assessment tool used in long-term care facilities to screen residents for cognitive impairment. The BIMS assessment helps identify potential cognitive decline, including early signs of dementia and can help determine if further evaluation is needed. Gradual Dosage Reduction (GDR) refers to the process of systematically reducing the dosage of medications, especially psychotropic drugs, over time, while carefully monitoring a patient's response to reduce reliance and dependence on certain medications, to find the lowest effective dose and to avoid unnecessary medication. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility failed to ensure the 1) appropriate labeling and storage of medications and 2) appropriate temperature monitoring was maintained for the medication refrigerator. This was evident in 2 out of 5 medication carts observed and 1 out of 2 medication storage rooms observed during the facility's Medicare/Medicaid recertification survey.House Stock Medications are medications kept readily available on-site for general use by residents or patients, not specifically ordered for an individual. 1) On 08/05/2025 at 10:06 AM, during a medication administration observation on the [NAME] Unit, the surveyor observed one opened bottle each of Melatonin tablets, Vitamin B12 tablets, Magnesium Oxide tablets, and Guaifenesin extended-release expectorant that were not dated. At 10:10 AM on 08/05/2025, in an interview with Licensed Practical Nurse LPN #17, when she was asked for the expectation regarding dating house stock medications, she stated that whenever…

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

Number of residents sampled: Number of residents cited: Based on interviews and record reviews, it was determined that facility staff failed to refer a resident with worn down dentures for dental services in a timely manner. This deficient practice was evident for one resident (#10) reviewed for dental services during the annual survey. The findings include:During an interview with Resident #10 on 08/04/25 at 8:52 AM, the resident expressed concerns regarding their dentures. The resident stated that someone was supposed to schedule an appointment; however, the resident was unsure who was responsible for scheduling it or when the appointment would take place. On 08/04/25, a review of Resident #10's medical records revealed a progress note dated 04/6/24, by the Registered Dietitian (RD) #10. The RD documented that the resident reported missing teeth and stated that their dentures were causing difficulty with chewing and eating. During the visit, the resident also reported that their gums were sore and request soft textured food. The RD documented that she informed the kitchen, speech…

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

Number of residents sampled: Number of residents cited: Based on record reviews and interviews, it was determined that the facility staff failed to ensure 1) resident medical records were complete and accurate, and 2) resident medical records were maintained. This was evident for 3 (Resident #5, #6, and #80) of 4 residents reviewed for Preadmission Screening and Resident Review (PASARR), and 1 (Resident #97) of 42 residents reviewed during the annual survey. The findings include: 1a) Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. On 08/05/2025 at 8:00 AM, a review of Resident #6's PASARR dated 09/16/21, revealed that in section…

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

Number of residents sampled: Number of residents cited: Based on observation and interview, it was determined that the facility failed to ensure linen was stored and processed to prevent the spread of infection. This was evident during 1 of 1 observation of the laundry room.The findings include:On 08/12/2025 at 10:31 AM, an initial observation of the laundry room revealed two separate rooms, one with exposed dirty linen in bins and one with clean linen that was folded on tables exposed without covering. The two rooms had a door in between which failed to be closed to prevent the spread of infection while linens were processed and stored. On 08/12/2025 at 10:35 AM, an interview with Director of Housekeeping (Staff #28) revealed that the door was kept open between the two rooms when he had started working at the facility, and it had been kept that way. He was unaware that it was an infection control concern. On 08/12/2025 at 11:21 AM, the surveyor reviewed the concern with the Director of Nursing, he understood the concern.

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure residents had or were screened for the pneumococcal and influenza vaccinations as indicated. This was evident for 2 (Resident #43, #78) out of 5 residents screened for immunizations.The findings include:1) On 08/12/2025 at 7:53 AM, review Resident #43's immunization record failed to reveal any documentation of pneumococcal and influenza vaccinations.2) On 08/12/2025 at 7:55 AM, review of Resident #78's immunization record failed to reveal any documentation of the pneumococcal vaccination. On 08/12/2025 at 9:25 AM, the surveyor reviewed the concern with the Director of Nursing. He indicated he was aware the facility did not have a good process in place for resident immunization records and understood the concern.

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure that each resident was screened for and offered the COVID- 19 vaccination. This was evident for 2 (Resident #43, #78) out of 5 residents screened for immunizations.The findings include:1) On 08/12/2025 at 7:53 AM, review Resident #43's immunization record failed to reveal any documentation that indicated the resident was screened for and offered the COVID-19 vaccination.2) On 08/12/2025 at 7:55 AM, review of Resident #78's immunization record failed to reveal any documentation that indicated the resident was screened for and offered the COVID-19 vaccination.On 08/12/2025 at 9:25 AM, the surveyor reviewed the concern with the Director of Nursing. He indicated he was aware the facility did not have a good process in place for resident immunization screening and documentation, and understood the concern.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on observations and interviews, it was determined that the facility failed to ensure a safe and comfortable environment for residents and staff. This was evident during observations on the Chesapeake and [NAME] units during the annual survey. The findings include:1) On 8/4/25 at 11:31 AM, an observation of the Chesapeake unit revealed a locked closet with a 3-11 linen sign on the 300-teens hallway, which looked like a section of the door fell off next to the door code box/handle. This crack revealed the door latch exposed where staff and residents could see from the hallway.2) On 8/4/25 at 11:32 AM, further observation of the Chesapeake unit revealed a soiled utility room next to the 3-11 linen room on the 300-teens hallway. Inside the soiled utility room revealed cracked tiles on the floor in front of the square tub-looking drain.3) On 8/5/25 at 6:30 AM, an observation of the [NAME] unit shower room revealed the first shower stall in the shower room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with the facility staff, it was determined that the facility failed to ensure effective pest control measures were implemented to prevent and control flies in food service and resident care areas. This was found to be evident during the observations of the facility's kitchen food service operations and in two residents (Resident #84 and #78) rooms during Medicare/Medicaid recertification survey.On 08/04/2025 at 7:44 AM, a surveyor observed multiple flies flying around Resident #84's room (room [ROOM NUMBER]) while the resident was resting in bed. When the surveyor asked if flies were often present, Resident #84 replied, Yes.On 08/04/2025 at 7:51 AM, during the continued initial tour of the kitchen, this surveyor observed multiple flies inside the kitchen. When asked why there were many flies, Staff #1 stated the back door was often left open, which allowed flies to enter, since the refuse area was located directly outside the door. At the time of the observation, 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.

Number of residents sampled: Number of residents cited: Based on interviews and administrative record reviews, it was determined that the facility failed to provide staff with the required Quality Assurance and Performance Improvement (QAPI) training. This deficient practice was evident for 7 out of 7 employee files reviewed during the annual survey. The findings include: During an interview with the Assistant Director of Nursing (ADON) on 08/11/25 at 11:46 AM, when asked about the process for training staff, she explained that she conducts ongoing training twice per month. She further explained that the facility held its annual competency skills fair in May 2025. The surveyor requested employee files to include education verifying that geriatric nursing assistant (GNA) #45, GNA #46, GNA #22, GNA #47, GNA #48, Licensed Practical Nurse (LPN) #35, and Registered Nurse (RN) #36 completed the required annual QAPI training for 2024.On 08/11/2025 at 12:30 PM, the ADON provided the surveyor with employee files for GNA #45, GNA #46, GNA #22, GNA #47, GNA #48, LPN #35, and RN #36. A review…

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

Number of residents sampled: Number of residents cited: Based on interviews and administrative record reviews, it was determined that the facility failed to provide staff with mandatory infection prevention and control training. This deficient practice was evident for 7 out of 7 employee files reviewed during the annual survey. The findings include: During an interview with the Assistant Director of Nursing (ADON) on 08/11/25 at 11:46 AM, when asked about the process for training staff, she explained that she conducts ongoing training twice per month. She further explained that the facility held its annual competency skills fair in May 2025. The surveyor requested employee files to include education verifying that geriatric nursing assistant (GNA) #45, GNA #46, GNA #22, GNA #47, GNA #48, Licensed Practical Nurse (LPN) #35, and Registered Nurse (RN) #36 completed the required infection prevention and control training for 2024.On 08/11/2025 at 12:30 PM, the ADON provided the surveyor with employee files for GNA #45, GNA #46, GNA #22, GNA #47, GNA #48, LPN #35, and RN #36. A 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.

Number of residents sampled: Number of residents cited: Based on interviews and administrative record reviews, it was determined that the facility failed to provide staff with compliance and ethics training. This deficient practice was evident for 7 out of 7 employee files reviewed during the annual survey. The findings include: During an interview with the Assistant Director of Nursing (ADON) on 08/11/25 at 11:46 AM, when asked about the process for training staff, she explained that she conducts ongoing training twice per month. She further explained that the facility held its annual competency skills fair in May 2025. The surveyor requested employee files to include education verifying that geriatric nursing assistant (GNA) #45, GNA #46, GNA #22, GNA #47, GNA #48, Licensed Practical Nurse (LPN) #35, and Registered Nurse (RN) #36 completed compliance and ethics training for 2024.On 08/11/2025 at 12:30 PM, the ADON provided the surveyor with employee files for GNA #45, GNA #46, GNA #22, GNA #47, GNA #48, LPN #35, and RN #36. A review of the files failed to show evidence 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.

Number of residents sampled: Number of residents cited: Based on interviews and administrative record reviews, it was determined that the facility failed to provide geriatric nursing assistants (GNA) with the required annual in-service training. This deficient practice was evident for 5 out of 5 GNA files reviewed during the annual survey. The findings include: During an interview with the Assistant Director of Nursing (ADON) on 08/11/25 at 11:46 AM, when asked about the process for annual training for GNA staff, she explained that she conducts ongoing training twice per month. She further explained that the facility held its annual competency skills fair in May 2025. The surveyor requested employee files to include education verifying that GNA #45, GNA #46, GNA #22, GNA #47, and GNA #48 completed the required annual in-service training for 2024.On 08/11/2025 at 12:30 PM, the ADON provided the surveyor with employee files for GNA #45, GNA #46, GNA #22, GNA #47, and GNA #48. A review of the files failed to show evidence of required annual in-service training. The surveyor informed…

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

Number of residents sampled: Number of residents cited: Based on interviews and administrative record reviews, it was determined that the facility failed to provide staff with dementia training. This deficient practice was evident for 7 out of 7 employee files reviewed during the annual survey. The findings include: During an interview with the Assistant Director of Nursing (ADON) on 08/11/25 at 11:46 AM, when asked about the process for training staff, she explained that she conducts ongoing training twice per month. She further explained that the facility held its annual competency skills fair in May 2025. The surveyor requested employee files to include education verifying that geriatric nursing assistant (GNA) #45, GNA #46, GNA #22, GNA #47, GNA #48, Licensed Practical Nurse (LPN) #35, and Registered Nurse (RN) #36 completed dementia training for 2024.On 08/11/2025 at 12:30 PM, the ADON provided the surveyor with employee files for GNA #45, GNA #46, GNA #22, GNA #47, GNA #48, LPN #35, and RN #36. A review of the files failed to show evidence of dementia training. The surveyor…

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

Based on record review and staff interview it was determined that the facility staff failed to develop and implement policies and procedures for a Quality Assurance Performance Improvement (QAPI) program to ensure that residents received quality care that was safe and effective. This was evident throughout the survey and has the potential to affect all residents residing in the facility. The findings include: During an interview with the Administrator on 09/28/23 01:43 PM a copy of the facility's QAPI plan was requested to be submitted to the surveyor. At 3:15 PM on 09/28/23 the administrator stated that she had forgotten to have individual attendees sign the QAA Committee attendance sheets since March 2023. Additionally, no written documentation was provided regarding the topics discussed during the last six months within the QAA committee related to quality improvement projects. The facility also failed to provide the following documentation related to QAPI activities: 1. The procedures for the system they use to identify, collect, and use feedback and input from direct care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, records reviews, and staff interviews, the facility failed to provide and maintain a clean, comfortable/homelike environment for all residents of the facility. This was evident throughout the facility impacting all residents. Findings include: On 9/10/23 review of MD00195781 received by the Office of Health Care Quality on 08/21/23 at 1:28 PM revealed residents had been without hot water from 08/17/23 through 08/21/23. The complaint alleged that one shower room had been closed down since May 2023. Also, the residents on the Chesapeake units had to travel through a long hallway, through the facility lobby in order to use the shower room on the [NAME] side of the facility. On 09/10/23 at 17:30 during interview, the Administrator and the maintenance director #7 confirmed that the facility had experienced problems with two water heaters within the facility during the months of July and August 2023. Staff #7 was requested to provide documents detailing how the facility provided 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, interviews, and observations it was determined that the facility staff failed to 1.) provide twice weekly showers to residents 3 (#7, #10, #16) of 24 residents reviewed per the residents' schedule, individual needs, and preferences and 2.) provide working telephones to all the residents. This was evident for 48 of 76 residents. The findings include: 1.) On 9/10/23 at 3pm during observation rounds Resident #7 stated s/he has been unable to take a shower due to the shower being closed. S/he stated the facility has one shower that is working, and it's located on the other side of the building. Review of the shower schedule for the resident revealed s/he was scheduled for showers on Thursdays and Sundays during the day shift. On 9/11/2023 at 9am during an interview with Resident #10 s/he stated, I haven't had a shower since April of 2023. S/he stated the shower is broken. They have a shower on unit one, but I don't want to go other there to take a shower. Review of the shower schedule for the resident revealed s/he was scheduled for showers on Mondays and…

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

Based on observation, medical record review and staff interview it was determined the facility failed to ensure a resident was free of significant medication error as evidenced by failure of the nurse to verify the correct dosage of a medication prior to administration. This was evident for 1 (Resident # 8) of 5 residents reviewed during the survey for medications. The findings include: Pregabalin is a nerve pain medication. It is used to treat nerve and muscle pain. Record review revealed Resident #8 was admitted to the facility with diagnoses that included but were not limited to Polyneuropathy (is when multiple peripheral nerves become damaged) and Parkinson's Disease The resident was alert and oriented and cognitively intact. During a medication pass observation on 9/26/23 at 9am RN (Registered Nurse) #50 stated she was not able to administer the medication Pregabalin to Resident # 8 due to the incorrect dosage being in the medication cart. During review of the Pregabalin medication dosage that was in the medication cart revealed a blister pack of medication with 200mg tablets.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with facility staff it was determined the facility failed to document adequately on the dishwasher and three compartment sink logs, properly label and store food to ensure the food is properly maintained and does not expire and prevent flies from entering the stored food. This was found to be evident during an initial tour of the facility during the facility's Medicare/Medicaid survey. Findings include: An initial tour of the kitchen was done on 9/10/23 at 2:40 PM with the Dietary Cook, staff # 9 present and the following concerns were identified: Review of the September Three Compartment Sink Log showed a discrepancy in the diagram that was posted on the wall, of PPM (Parts Per Million). The PPM is the number of units of mass contaminant per million units of total mass. The surveyors asked staff # 77 to explain the discrepancy and she was unable to do so. Inside the dry storage area were the following observed concerns: 1. A large bag of Harvest Elbow Macaroni (1/4 left in…

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

Based on resident interview and observation it was determined the facility staff failed to treat residents with respect and dignity. This was evident for 4 (#16, #48 #75, #228) of 24 residents reviewed during the survey. The findings include the following: A urinary catheter bag attaches to a catheter that is inside a person's bladder that collects urine and is covered to discreetly to hide the urine. A urinary catheter bag is to be kept below a person's bladder to prevent infection. 1. During observation rounds on 09/10/23 at 3:00 PM the Resident #16 was found to be sitting outside of his/her room in the hallway in a chair with a urinary catheter bag sitting next to him/her. The urinary catheter bag was uncovered above his/her bladder and yellow white tinged fluid was noted inside the urinary catheter bag. The Unit Manager #26 was made aware of the findings on 9/10/23 at 3:10 PM. 2. During observation rounds on 09/20/23 at 10:35 AM the Resident #48 was being transported in the hallway by GNA (Geriatric Nursing Assistant) #34 on a shower bed/stretcher with his/her urinary catheter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview it was determined that the facility failed to provide written notice to a resident prior to changing the room assignment and failed to provide the resident with room assignment options. This deficient practice was evidenced in 1 (#228) of 2 resident records reviewed for room assignment changes. The findings include: During observation rounds on 09/10/23 at 9:57 am the surveyor noticed Resident #228 was assigned room [ROOM NUMBER]. On 09/15/23 at 11:25 am during an interview with Resident #228 who was in room [ROOM NUMBER], he/she made the surveyor aware the facility staff told him/her that morning he/she had to be moved to another room. He/she did receive written notice before being moved to another room and was not given an option to choose an available room and/or roommate. He/she was told a male resident needed to be isolated, so he/she had to be moved to another room. On 09/21/231:23 pm during an interview with Admissions Director # 44 he/she stated if the facility has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff, resident interview and review of facility policy and procedure it was determined the facility failed to provide the ability for Resident (#58) to have access to his/her personal funds on the same day funds were requested. This was evident for 1 resident (#58) out of 58 residents reviewed during the annual survey. The findings include the following: During observation rounds on 09/14/2023 at 02:15 PM a letter addressed to all residents was found posted outside on the door of the Business Office stating that the facility petty cash account policy banking hours are from 9:00 AM to 4:00 PM on weekdays excluding holidays. During an interview on 09/14/2023 at 02:20 PM Resident (#58) stated that he/she does not have access to his/her money on the weekends. During an interview on 09/15/2023 at 09:43 AM the facility Administrator (#1) stated that money is not accessible to the residents on the weekends and that it will be fixed that they do. Review of the facility Resident Funds Policy and Procedure on 09/15/2023 at 10:00 AM stated that a resident's request 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 observations and interviews with the resident and facility staff it was determined the facility staff failed to ensure that the resident right to privacy was maintained by delivering mail unopened to the resident. This was found to be evident for 1 (Resident # 46) of 58 residents reviewed during the survey. Findings include: An interview was conducted with Resident # 46 on 9/15/23 at 9:30 AM to discuss concerns that s/he were having. The resident stated that mailed is delivered open when s/he receives it. An interview was conducted with the Administrator on 9/15/23 at 9:40 AM and she was made aware of the resident concerns. The Administrator stated that the facility opens two residents mail and that Resident # 46 is one of them due to suspicion of paraphernalia, which is sent into the facility to this resident. The Administrator went on to say that Resident # 46 is present when the facility opens the mail. The survey team asked the Administrator if this process of opening resident's mail with the resident present is documented and/or care planned, and she stated that she…

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

Based on record review and interview it was determined the facility failed to give Resident #49 at least 48 hours' notice before the end of his/her Medicare covered Part A facility stay. This was evident for 1 resident (#49) out of 3 residents reviewed for discharges during the survey. The findings include the following: On 9/28/23, review of Resident #49's notices of Medicare Non-Coverage on 09/28/23 at 09:09 AM revealed that Resident #49's Medicare coverage was ending on 08/08/2023. Resident #49 was given notice that was signed by Resident #49 on 08/08/2023 therefore it was not 48 hours prior to his/her Medicare coverage ending. During an interview with the Social Worker on 9/28/23 at 10am she verified the notice of Medicare Non-Coverage was not given 48 hours prior to Resident #49's Medicare coverage ending.

Based on administrative record review and interviews with facility staff it was determined the facility failed to keep a resident safe from verbal abuse. This was found to be evident for 1 (Resident # 176) of 12 residents reviewed for abuse during the facility's survey. Findings include: MD00160134 was reviewed on 9/27/23 at 12:00 PM for allegations of abuse. According to the facility's investigation, Licensed Practical Nurse (LPN) #64 admitted to being frustrated and yelling at Resident #176. According to a typed interview in which LPN #64 signed the form, she indicated that she may have been upset at the time and raised her voice. The LPN #64 stated that she told the resident that because the resident did not ring the call bell for assistance, she now has a lot of paperwork to complete and must work until 2-3:00 AM and may not make it to her appointment in the morning due to having to stay to complete the paperwork. The facility's investigation revealed the resident roommate was interviewed and confirmed that that the LPN (#64) yelled at the resident and another staff member (#65)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 with the resident family and facility staff, it was determined the facility failed to report allegations of abuse immediately to the state agency. This was found to be evident for 1 (Resident # 51) of 12 residents reviewed for abuse during the facility's Medicare/Medicaid survey. Findings include: A call was placed on 9/19/23 at 12:00 PM to Resident #51's family member. The family member told the survey team that they were informed by Registered Nurse (RN)/Unit Manager # 28 and Licensed Practical Nurse (LPN)/Unit Manager #33 that Resident # 51 had bruises noted on both hands and along both forearms. The family member went on to say that the facility was doing an investigation into this matter. At this time two surveyors went to the RN #28 and LPN #33 and asked if they would bring Resident # 51 to the resident room. An observation was made at that time of Resident # 51 hands and both hands had a large area of bruising noted to the anterior aspect of the hand. Additional bruises were noted along both forearms. One area was covered with a dressing. 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 reviews and interviews it was determined the facility failed to complete a thorough investigation of an alleged employee to resident verbal and physical abuse incident and failed to report the alleged physical and verbal abuse to the police. This deficient practice was evident for 1 (#54) of 12 residents reviewed for alleged abuse during the survey. The findings include: On 09/11/23 at 10:30 AM review of facility incident report (FRI) MD00175409 revealed allegations of employee abuse towards Resident #54 but the resident requested that the police not be notified at the time of an incident on 4/12/22. The facility report was completed by an employee, the director of nursing, staff # 2, who was currently employed by the facility. On 09/11/23 at 11:44 AM in interview with Resident #54, the resident did not recall the incident that occurred on 04/12/22. On 09/18/23 at 11:23 AM the surveyor requested the facility related incident folder with all documentation related to Resident #54 from the director of nursing. The documentation was reviewed with the director of nursing…

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

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 1 (resident #48) of 3 residents reviewed for transfers. The findings include: Review of the medical record for Resident #48 on 9/26/23 at 2pm revealed that on 9/10/23 the resident was sent to an acute care facility for a change in his/her medical condition. Further review of the medical record failed to produce written evidence that the resident and /or the resident representative were given written notice of the bed hold policy. During an interview with the Social Worker (staff # 17) on 9/26/23 at 5:50pm she stated the resident was given the reason for the transfer; however, she was unable to produce written evidence that the resident/resident representative was given written notice of the bed hold policy.

Based on record review and interviews it was determined that the facility failed to have Quarterly care plan meetings as required for resident (#52) and failed to update the resident care plan to include the resident is non-compliant with treatment regimen (#46). This was evident for 2 of 58 residents (#52 and #46) reviewed during the survey. The findings include: 1. During an interview with Resident #52 on 09/13/23 at 9:59 am the resident was unable to verify the facility arranged quarterly care plan meetings. On 09/21/23 at 12:05 pm a review of Resident #52's electronic medical record (EMR) revealed that there were no care plan meeting notes to review in the EMR. On 09/22/23 at 9:05 am during an interview Social Services Director #17 stated he/she was hired with the expectation of completing care plan meetings every 90 days. He/she had been working to get them done. She indicated there were a few residents who have not been seen and he/she is trying to get the ball rolling so the meetings can be held every 90 days and that prior to his/her coming to the facility some were not done…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review and staff interview it was determined the facility failed to ensure that medication was administered to a resident within a timeframe of professional standards of practice. This was evident for 1 resident (#330) out of 10 residents reviewed for medications during the survey. The Findings Include: Metoprolol Succinate ER (Extended Release) and Lisinopril are medications that are used to treat Hypertension (high blood pressure) to lower a person's blood pressure. Digoxin (Digoxin) is a medication that is used to treat Atrial fibrillation (AFIB) (irregular heart rhythm) to manage a person's heartbeat. Review of resident #330's medical record on 09/25/2023 at 01:49 PM revealed the following: 1. A physician ordered on 01/07/2023 to administer medication Metoprolol Succinate ER (Extended Release) 24-hour 200mg give 1 tab by mouth one time a day for Hypertension. Review of the January 2023 Medication Administration Audit Report revealed that on 01/21/2023 the ordered administration time of medication was 08:00 AM but this medication was given at 14:43 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews with family, observations, interviews with facility staff and a review of facility video footage, it was determined the facility failed to supervise residents with wandering and known aggressive behaviors. This was evident for 3 residents (#51, #33 and #9) of 58 residents reviewed during the survey. Findings include: 1. A call was placed on 9/19/23 at 12:00 PM to Resident #51's family member regarding a concern that they had involving Resident #51. The family told the survey team that they were informed by Registered Nurse/(RN) Unit Manager #28 and Licensed Practical Nurse (LPN)/Unit Manager #33 that Resident (# 51) had bruises noted on both hands and along both forearms. At this time two surveyors went to the two nurses, RN# 28) and LPN (# 33) and asked if they would bring Resident (# 51) to the resident room. An observation was made at that time of Resident #51's hands and both hands had a large area of bruising noted to the anterior aspect of the hand. Additional…

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

Based on medical record review and interview it was determined that the facility failed to have an effective system in place to ensure communication of assessment information was conveyed between the nursing facility and the offsite dialysis center. This was found to be evident for 1 of 1 resident (#10) reviewed for dialysis. The findings include: Dialysis is a treatment to clean your blood when the kidneys are not able to perform the function. On 9/15/23 at 10 am Resident #10's clinical records were reviewed and revealed that the resident was admitted to the facility with diagnosis which included End Stage Renal disease and high blood pressure. Further review of the resident's clinical records revealed that the resident attended dialysis at an offsite dialysis center three times a week. During an interview on 9/15/23 at 10:30 am the unit manager #28 reported that prior to sending a resident out for dialysis they take vital signs and complete the top portion of the form (Dialysis Communication Record) which is sent to dialysis with the resident. Upon return the resident is assessed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility failed to ensure staffing information was complete and accurate. This deficient practice was evident for 1 of 2 units observed during the Medicare/Medicaid survey. The findings include: On 09/10/23 at 5:40 pm during observation rounds the surveyor observed the assignment board on [NAME] was not updated to reflect the current shift. During an interview with GNA #6 he/she reported the nurses usually update the assignment board. On 09/11/23 at 9:52 am while on the [NAME] Unit the surveyor observed the assignment board was not updated to reflect the nurse who were assigned to the unit. On 09/12/23 at 8:25 am the surveyor observed the assignment board on [NAME] was not updated to reflect the name of the nurse and GNA's who were working on the unit. RN #28 confirmed that the assignment was not completed. On 09/13/23 at 9:43 am the surveyor observed that the assignment board on [NAME] was not updated to reflect the current date. 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.

Based on a review of the medical record and interviews with facility staff it was determined that the facility failed to respond to the pharmacy recommendations after a monthly clinical review was done. This was found to be evident for 1 (Resident # 46) of 5 residents reviewed for unnecessary medications during the facility's Medicare/Medicaid survey. Findings include: Resident #46 medications were reviewed on 9/19/23 at 11:00 AM for unnecessary medications. Upon review of the Consultant Pharmacist Medication Regimen Review Medical Director Report dated 8/24/23 it indicated the following: Physician Recommendation: Ordered: Risperdal 0.5 mg BID for Psychosis since 4/27/2023. Resident is due for a Gradual Dose Reduction (GDR) to find the lowest effective dose. Please consider a trial dose reduction. If the medication cannot be reduced at this time, please provide a rationale below related to the gradual dose reduction being clinically contraindicated at this time and make a brief clinical rationale note that benefits outweigh the risks. There was no response indicated on the form.…

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

Based on medical record review and interviews it was determined that the facility physician prescribed an antibiotic to a resident without adequate indication of use. This deficient practice was evident in 1 (#226) of 5 resident records reviewed for unnecessary medications. The findings include: On 09/13/23 at 12:04 pm, review of Resident #226's medical record revealed the resident was prescribed an antibiotic for a suspected urinary tract infection (UTI). Per the medication administration record (MAR) on 09/11/23 at 9 pm the resident was ordered Cipro 250 mg by mouth two times a day for a low-grade fever for 7 days. The medication was signed off as given on 09/12/23 at 9 am. The antibiotic was discontinued on 09/13/23 at 12:37 pm. On 09/15/23 at 9:47 am. review of the Electronic Medical Record (EMR) revealed a urine specimen was collected from Resident #226 on 09/12/23 at 6:00 am. The results were reported on 09/13/23 at 2:12 pm which revealed that the resident did not have a urinary tract infection. On 09/20/23 at 10:54 am, during an interview with Director of Nursing (DON) #2…

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

Based on medical record review and interviews with facility staff, it was determined the facility failed to keep a resident free from unnecessary psychotropic medications. This was found to be evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medications during the facility's recertification survey. The findings include: On 9/18/23 at 4pm, Resident #7's medical records were reviewed and revealed the resident was admitted to the facility with the following, but not limited to diagnosis: bipolar disorder. Review of the medical records revealed an order for Seroquel 50 milligram two times a day for schizophrenia. Further review of resident #7's medical record revealed a consultant pharmacist medication regimen review dated 8/24/23 which documented the following: The resident was ordered Seroquel 50 mg bid for schizophrenia since 10/14/22. The Resident is due for a gradual dose reduction in an attempt to find the lowest effective dose. Please consider a trial dose reduction. Continued review of the medical record failed to reveal any documentation that the pharmacist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication administration observation, medical record review, and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5%. This was evidenced by 7 errors observed during the medication administration of 25 opportunities for errors, that resulted in a medication error rate of 28%. This was found to be evident for 1 resident (R #8) out of 5 residents observed during the medication administration. The findings include: On 9/26/23 at 10:40 am, a surveyor observed a pink medication administration screen during medication administration. The surveyor asked what that color screen indicated, and RN # 50 revealed that it meant the medication was late or they hadn't signed off the medicine administration. On 9/26/23 at 10:45 am, RN #50 was observed on the Chesapeake Nursing Unit preparing the following medications for Resident #8: 1.Wellbutrin SR 150mg (milligrams) by mouth due at 8am for depression, given at 10:51am, signed off at 11:21am. 2.Aripiprazole 0.5mg by mouth due at 8am for bipolar disorder, given at 10:51am, signed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to secure a narcotic medication and limit access to unauthorized persons. This was evident for 1 resident (#329) out of 5 residents reviewed for medications during the annual survey. The findings include the following: Morphine is a medication that is used for pain and is classified as a narcotic. Narcotic medications are always to be kept secured and locked up when not in use by authorized staff. Review of Resident #329's medical record and facility investigation for Facility Reported Incident MD00148275 on 09/25/2023 at 11:00 AM revealed that during stay at facility, Resident (#329) was ordered Morphine which was in liquid form and dispensed to facility by the pharmacy in a bottle. On 09/11/2019 during the 3:00 PM to 11:00 PM shift it was documented in facility investigation notes that LPN (#61) left Resident #329's bottle of Morphine unsecured on the table in Resident #329's room which allowed access to unauthorized person's that included residents. On 09/12/2019 a Counseling/Warning Report was given…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 administrative record reviews and interviews with facility staff it was determined the facility failed to ensure that the Dietary Manager License was active and not expired. This was found to be evident when the survey team reviewed the Dietary Manager credentials during the facility's Medicare/Medicaid survey. Findings include: An initial tour of the facility was conducted on 9/10/23 at 2:40 PM and the survey team identified concerns found during the tour to include opened food without the appropriate in and out dates, food not stored properly and sealed, and flies found around food that was open. At this time the survey team requested a copy of the Dietary Manager (DM) credentials from the staff. The staff was unable to provide the requested documents at that time. On the same date at 4:55 PM the Administrator told the survey team that the DM was currently out of the facility due to medical concerns. The Administrator was asked to provide the survey team with a copy of the DM credentials on 9/11/23 at 10:30 AM and upon review of the DM credentials it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 menus were being followed when preparing food for the residents. This was found to be evident when observations were made of the kitchen during the facility's Medicare/Medicaid survey. Findings include: An observation was made on 9/28/23 at 8:30 AM of the kitchen and the food was being prepared by the Kitchen Cook, (Staff # 9). The cook was preparing carrot cake but did not have a menu to follow. When the surveyor asked the [NAME] where the menu was for the cake that he was preparing, he stated that carrot cake was on the menu, but he was preparing it from scratch without a menu. He stated that the menu was somewhere out front, but he was not following it. The survey team immediately alerted the Administrator and the Dietitian, and they stated that they would go into the kitchen to make sure that the staff is following the menu. The Dietitian stated that there is a menu, and that staff should be following the menu. The survey team asked the Administration team who 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 observation, record review, and interviews it was determined that the facility staff failed to: 1.) document the temperature of the refrigerator on the unit [NAME] and 2.) ensure that staff documented while providing one to one monitoring for a resident (#9) with known aggressive behaviors. This was evident for 1 of 2 units observed and 1 of 58 residents reviewed during the survey. The findings include: 1.) On 09/10/23 at 3:17 pm observation of the Nourishment Room on the unit [NAME] and review of the first 10 days of the September 2023 Temperature Log for the refrigerator revealed the AM and PM temperatures were not documented for 09/08/23 and the PM temperature was not documented on 09/09/23. On 09/28/23 at 3:40 pm the surveyor received a copy of the September 2023 Temperature Log for the refrigerator in the Nourishment Room on the unit [NAME]. The log was for the last half of the month, days 16-30. The temperature was not recorded in the PM on 09/16/23, AM or PM on 09/17/23, or PM on 09/18/23,…

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 observation and staff interview it was determined that the facility failed to correctly store clean personal protective equipment for resident's rooms (#109, #404) to prevent infection and failed to use infection control practices while providing wound care to a resident (#226). This was true for 1 of 58 residents reviewed during the survey and 2 resident rooms. The findings include the following: Personal protective equipment (e.g., gloves, gowns, masks) is to be used by staff while providing direct care to residents and should be stored in a clean manner that is free of dust and dirt to prevent contamination. If contaminated personal protective equipment is used on a resident, this could cause a resident to obtain an infection. 1. During observation rounds of facility on 09/10/2023 at 17:30 PM outside of resident room (#404), a three-draw black bin, missing all four wheels, containing clean gloves, gowns and masks was found sitting directly on the floor. During an interview on 09/10/2023 at 17:50 PM the facility Administrator (#1) was made aware of the observation outside…

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

Based on medical record review and interview it was determined that the facility failed to offer all residents the opportunity to receive the pneumococcal vaccines. This deficient practice was evident in 1 (#51) out of 5 resident records reviewed for required vaccines. The findings include: On 09/25/23 at 10:47 am, a review of Resident #51's electronic medical record revealed that the resident was admitted to the facility in December 2021. A review of the resident's immunization record revealed the resident did not have the pneumococcal vaccine. On 09/25/23 at 1:06 pm during an interview with Director of Nursing #2 he/she stated, the facility offers the residents the COVID, pneumonia, influenza, and Tdap vaccines for all the residents. and the main one's offered are COVID, pneumonia, influenza, and tuberculosis. The DON #2 also advised that the facility staff were not doing yearly audits to determine if all the residents had been offered and received the vaccines and they intend to start an audit today. Additionally, when a nurse does an admission the question about immunizations 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.

Based on record review and staff and Responsible Party interviews it was determined the facility failed to notify 1) a court appointed guardian when Resident #5 developed a pressure injury; and 2) the Responsible Party when Resident #122 had a change in condition. This was evident regarding Resident #5 for 1 of 3 residents investigated for pressure ulcers/injuries during the survey and regarding Resident #122 this was evident for 1 of 8 residents reviewed during the survey process. The findings include: 1) On 2/11/19 at 9:57 AM during an interview with a complainant, she stated the court appointed guardian for Resident #5 was not notified when the resident first developed a pressure injury. The complainant stated that the court appointed guardian was contacted on 4/12/18 for verbal consent to debride the pressure ulcer but had not been told the resident had developed a pressure ulcer. Debridement is a medical procedure in which dead and/or infected tissue is removed from a wound. Documentation in a change of condition nurses' note on 3/4/18 stated, During care noted a 3 centimeter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interviews, the facility staff failed to send the Care Plans with Residents #54, #71 and #73 when they were sent to the hospital. This was evident for 3 of 3 residents reviewed for hospitalization during the survey. The findings include: 1) On [DATE] Resident #54 was noted to have blood in the Foley bag. After flushing the bag, the urine in the Foley bag was now dark red with clots, also blood tinged urine in the nephrostomy. An order was given to send the resident to the emergency room (ER). The note in the resident's chart did not reveal much of the required information. On [DATE] around 10:55 AM, during an interview with staff #8 it was revealed that the facility does not send all of the required paperwork with a resident when sending them out to the hospital. When the surveyor asked the nurse, What information is sent with the resident to the hospital; the nurse replied that the face sheet is sent and the list of medications. A Comprehensive Care Plan assists 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 the medical record and staff interviews, the facility staff failed to provide necessary written notices for Resident #54, or the Resident's responsible party, of a transfer out of the facility. This was evident for 1 out of 3 residents investigated for hospitalization during the survey process. The findings included: On 2/14/19 around 10:55 AM while reviewing Resident #54's medical record for a recent hospitalization, it was noted that on 12/21/18 the resident was observed to have blood in the Foley bag. After flushing the bag, the urine in the Foley bag was now dark red with clots, also, blood tinged urine in the nephrostomy. An order was given to send the Resident to the emergency room ( ER). Review of the hospital transfer information in the resident's chart did not reveal that the below required information was done. 1. Written notice to the Resident or the Resident's responsible party. 2. Notification to the Ombudsman of the hospital visit.

Based on the medical record and staff interviews, the facility staff failed to provide the required written notice to Resident #54, or the resident's responsible party, of the bed hold policy during a transfer out of the facility. This was evident for 1 out of 3 residents investigated for hospitalization during the survey process. The findings included: On 2/14/19 around 10:55 AM while reviewing Resident #54's medical record for a recent hospitalization, it was noted that on 12/21/18 the resident was observed to have blood in the Foley bag. After flushing the bag, the urine in the Foley bag was now dark red with clots, also blood tinged urine in the nephrostomy. An order was given to send the resident to the emergency room (ER). Review of the hospital transfer information in the resident's chart did not reveal that a bed hold policy was given to the resident prior to leaving the building. This policy educates/informs the resident on whether a bed can be held during the resident's absence, and/or if not, the possibility of having to private payer to hold the resident's bed, until…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to implement a baseline care plan for Resident #221. This was evident for 1 out of 29 residents. The findings include: Resident #221 was admitted to the facility in January 2019 for rehabilitation services after suffering a broken right ankle. During the interview process of the survey, it was noted that the resident had edema noted on bilateral lower legs. Edema had not been addressed by the physician or staff. There were no medications for the edema and no care plan. The admission assessment, dated 1/31/19, indicated that the resident had edema noted on his/her right lower leg. On 2/14/19, staff # 6 went to the resident's room and assessed the resident. Staff #6 did in fact find that the resident had 2 plus edema on the right lower leg and 3 to 4 plus edema on the left lower leg. A call was placed to the physician (Dr) by staff member # 6. The physician came into the facility on 2/14/19 after surveyor intervention and assessed the resident. At that time, he ordered Lasix 20 mg 1 time per day by mouth for edema,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interview it was determined that the facility failed to develop a care plan for pain management for Resident #52. This was evident for 1 of 29 residents investigated during the survey. The findings include: On 2/12/19 at 12:09 AM during an interview with a surveyor, Resident #52 was complaining of being in pain all over her body. Beginning on 2/12/19 the medical record was reviewed, and the resident was found to be receiving pain management care but had no care plan for pain. A review of the February 2019 Treatment Administration Record (TAR) revealed that nurses were assessing the resident's pain every shift and documenting the results. The start date for this was 11/16/17 meaning nurses had been assessing pain every shift since that date. On 2/12/19 following surveyor intervention, the physician was called, and new orders were received to administer Tramadol Hydrochloride (HCL) 50 milligrams (mg)s twice a day for generalized pain and to discontinue Tramadol 50 mg every 8 hours prn (as needed or requested for pain (initiated 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 2) 02/14/19 11:01 AM Resident # 221 was admitted to the facility on [DATE] for rehabilitation after suffering a broken right ankle. During the interview process of the survey, it was noted that the resident had edema noted on bilateral lower legs. The edema had not been addressed by the physician or staff. There were no medications for the edema and no care plan. The admission assessment dated [DATE] indicated that the resident had edema noted on the right lower leg. On 2/14/19, staff # 6 went into the resident's room and assessed the resident. The resident was found to have 2 plus edema on the right lower leg and 3 to 4 plus edema on left lower leg. A call was placed to the Doctor (Dr.) by staff member #6. The Dr. came into the facility on 2/14/19 after surveyor intervention and assessed the resident. At that time, he ordered Lasix 20 mg 1 time per day by mouth for edema, Potassium chloride E.R. 20 meq. 1-tab by mouth. per day for supplement, Potassium chloride E.R. 1 tab 2 times per day for 7 days and labs,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that: 1) An accurate refrigerator temperature log was kept in the month of January 2019. 2) Facility staff members followed infection control practices in the kitchen area. This practice has a potential of effecting all residents in facility. The findings include: During the initial tour of the kitchen, that took place on 2/12/18 at 9:15 AM, the surveyor was accompanied by the Certified Dietary Manager (CDM) staff member #3 who verified all of the surveyor's observed findings. 1. On 2/12/18 at 10:29 A.M. the temperature logs were observed in the Refrigerator & Freezer, of Ice Cream and Milk temperatures that were recorded on the sheet hanging outside of the refrigerator in the kitchen. It revealed that the kitchen staff failed to document the required temperatures on 01/13/19 for the A.M. shift and on 01/27/18 on the P.M. shift. 2. On 2/11/19 at 6:25 P.M. the surveyor observed staff member #1 entering the kitchen returning a dirty food cart without wearing a hair net to cover his/her hair.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep a complete and accurate medical record. Specifically, the facility failed to document a resident's fall in the facility. This was evident in 1 out of 7 medical records reviewed involving resident's (R#122) during the survey process. The findings include: Medical record review revealed that Resident #122 was admitted to the facility with diagnoses which included but was not limited to Cerebral Infarction for rehabilitation services with other chronic health conditions which require ongoing treatment. Review of complaint #MD00133622 with medical record review revealed that Rresident #122 had fallen out of bed on 11/2/18 without injury. Continued medical recod review revealed that staff failed to document or complete a physical assessment on the resident until 11/6/18, four days after the resident fell. On 2/13/19 at 2:30 A.M. during an interview with the Administrator, the Admimnistrator verified that the facility staff delayed performing the post fall physical assessment after…

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