Autumn Lake Healthcare At Chevy Chase

Based on administrative record review and interviews with facility staff it was determined the facility failed to ensure the safety of a resident after the resident reported allegations of staff abuse for Resident #146, and failed to ensure a thorough investigation was conducted for a Facility Reported Incident (FRI) regarding Resident #165. This was found to be evident for 2 of 19 residents reviewed for abuse during the survey. Findings include, 1) MD00204470 was reviewed on 4/18/25 12:00 PM for allegations of staff abuse. The abuse was unsubstantiated. A review of the facility's investigation revealed a discipline in which staff (#34) received a written warning about the following infraction: Employee (# 34) who is a nurse, was directed to leave the facility immediately and was on off duty due to an allegation of abuse made by Resident #146. The employee was told to leave the building by the Administrator and DON on 4/8/24 at approximately 12:30PM. The employee was found on another unit documenting on a resident at 2:12 PM and did not leave the building until after about 2:20 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 record review and staff interview, it was determined that the facility failed to include the resident comprehensive care plan goals with the required documentation during a transfer. This was evident for 1 (Resident #86) of 2 residents reviewed for hospitalization. The findings include: On 04/21/25 at 07:42 AM, a review of Resident #86's medical record revealed that the resident was hospitalized on [DATE]. On 04/22/25 at 08:38 AM, an interview with Registered Nurse/ Unit Supervisor (Staff #16), revealed that resident comprehensive care plan goals were not sent with residents upon transfer. On 04/22/25 at 08:45 AM, an interview with Licensed Practical Nurse (Staff #7) revealed that resident comprehensive care plan goals were not sent with residents upon transfer. On 04/22/25 at 11:19 AM, the surveyor reviewed the concern with the Director of Nursing (Staff #2).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that facility staff failed to ensure written notification of transfer were provided to the resident and responsible representative upon a transfer. This was evident for 1 (Resident #86) of 2 residents reviewed for hospitalization. The findings include: On 04/21/25 at 07:42 AM, a review of Resident #86's medical record revealed that the resident was hospitalized on [DATE]. On 04/22/25 at 08:38 AM, an interview with Registered Nurse/ Unit Supervisor (Staff #16), revealed that resident representatives were verbally notified of resident transfer and reasoning, but that it was not written notification. On 04/22/25 at 08:45 AM, an interview with Licensed Practical Nurse (Staff #7) revealed that resident representatives were verbally notified of resident transfer and reasoning, but that it was not written notification. On 04/22/25 at 11:19 AM, the surveyor reviewed the concern with the Director of Nursing (Staff #2).

Based on medical record review and interviews with facility staff it was determined the facility failed to ensure accuracy when coding a resident Minimum Data Set (MDS). This was found to be evident for 1 (Resident # 107) of 6 residents reviewed for accidents during the survey. Findings include: The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The Matrix is used to identify pertinent care categories for :1) Newly admitted residents in the last 30 days who are still residing in the facility and 2) All other residents. The facility is responsible for completing this form. Column # 10 is to be completed if the resident has a Fall (F), Fall with injury (FI), Fall with Major injury (FMI). Review of the facility's matrix on 4/16/25 at 12:45 PM revealed resident # 107, column # 10 for Falls indicated F, and FI. Review of the MDS Quarterly Assessment…

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

Based on record reviews and interviews, it was determined that the facility failed to develop a care plan to manage bowel and bladder incontinence for a resident. This deficient practice was evident for 1 (#106) resident reviewed for comprehensive care plans during the survey. The findings include: On 04/17/25 at 8:20 AM, a review of Resident #106's medical records indicated that the resident is incontinent of bowel and bladder. Further review of medical records failed to show that a care plan was developed to address bowel and bladder incontinence. During an interview with Director of Social Worker (SW) #3 on 04/22/25 at 10:46 AM, the surveyor asked who was responsible for auditing resident's medical records to ensure residents' care plans accurately address plan of care. The SW #3 explained that an interdisciplinary team meets quarterly and annually to review each resident's plan of care, and the nurse unit manager is responsible for ensuring the nursing portion of the plan is up to date. On 04/17/25 at 11:05 AM, a review of Resident #106's Minimum Data Set (MDS) section bowel…

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

Based on interviews, observations, and record reviews it was determined that facility staff failed to assist residents who are dependent on staff for activities of daily living (ADLs) such a bathing. This deficient practice was evident for 1 (#66) of 5 residents reviewed for ADL care during the survey. The findings include: During an interview with Resident #66 on 04/16/25 at 10:37 AM, he/she stated they had only received one shower during the month of April 2025 but reported receiving daily bed baths from staff. The resident stated they would prefer more showers in the shower room. On 04/21/25 at 09:05 AM, during an interview with the Director of Nursing (DON) #2, she stated that staff are expected to provide showers to residents as ordered and should not substitute a bed bath in place of a shower. If a resident refuses a shower, staff are expected to document the refusal in the medical records. On 04/21/25 at 1:48, a review of Resident #66's treatment administration record (TAR) revealed an ordered for showers Mondays and Thursdays. Further reviews showed that the resident…

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

Based on observations, staff interviews, and record review, it was determined that the facility failed to ensure that residents with a limited range of motion receive appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 out of 1 resident observed for limited range of motion during this survey. The findings include: Contracture management is a variety of techniques aimed at preventing or improving limited joint movement due to shortening of muscles, tendons, or surrounding tissues. These methods include physical therapy, splinting, medication, and in some cases, surgery. Early intervention and consistent management are crucial for maximizing functional outcomes. Review of medical record revealed Resident #101 was a long-term care resident who has the following but is limited to medical history: morbid obesity, protein-calorie malnutrition, and a PEG tube. Resident #101 was bed-bound with a limited ROM to all extremities. On 4/17/25 at 12:13 PM, Resident #101 was observed in bed resting comfortably. The surveyor observed that the…

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

Based on record reviews, and interviews, it was determined that facility staff failed to ensure a resident who is incontinent of bowel/bladder received appropriate treatment and services. This deficient practice was evident for 1 (Resident #106) of 1 resident review for incontinent care during the survey. The findings include: On 04/17/25 at 8:20 AM, a review of Resident #106's medical records indicated that the resident had a stage 4 sacral pressure ulcer, was incontinent of bowel and bladder, and needed assistance with personal care. Further review of treatment administration records, physician orders, and resident care plan failed to show that treatment, or services were in place to address bowel and bladder incontinence. During an interview with Director of Social Worker (SW) #3 on 04/22/25 at 10:46 AM, the surveyor asked who was responsible for auditing resident's charts to ensure residents are receiving appropriate services and treatment. The SW #3 explained that an interdisciplinary team meets to review each resident's plan of care, and the unit manager is responsible 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 record review and interview, the facility failed to ensure that an antipsychotic medication was ordered with adequate monitoring. This was evident for 1 (Resident #16) of 5 residents reviewed for unnecessary medications. The findings include: On 04/18/25 at 10:53 AM, review of Resident #16's medical record revealed an active order for Bupropion (an antidepressant) to be administered once a day, with a start date of 3/24/2025. An antidepressant is a medication used for mental health. The medication can cause side effects that could be serious and monitoring can help identify side effects. On 04/18/25 at 10:54 AM, further review of the residents medical record failed to reveal an order for antidepressant monitoring until 4/16/2025. On 04/21/25 at 09:07 AM, an interview with the Director of Nursing (Staff #2) revealed that the expectation was for side effect monitoring to be ordered when an antipsychotic (like Bupropion) was ordered for a resident.

Based on observation and interview it was determined the facility failed to ensure residents were served their preferred hot drink beverage at breakfast. This omission of serving the resident the drink item listed on their meal ticket impacted 3 (Resident #131, #105, #26) out of 5 residents reviewed. The findings include: On 04.21.25 at 08:13 AM the surveyor interviewed and observed the breakfast meal in the presence of the charge nurse who was also working as the unit manager and the medication nurse on the Arcadia unit. The two dietary food carts were delivered to the unit at 08:15 AM by the dietary aide. During an interview with the unit manager, the surveyor was informed that there were currently seven (7) residents who required maximum assistance with feeding at meal times by the unit manager. On 04.21.25 at 08:25 AM, the unit manager called the dietary department to request the cart with the coffee, tea, and condiments. The cart with the coffee, tea, and condiments arrived within five minutes (08:30 AM) on 04.21.25. The unit manager assisted the staff with the distribution of…

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

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 out of 1 observation of test tray temperatures on 1 unit of 32 residents who eat food prepared by the facility out of 4 units of within the facility. The findings include: On 04.25.25 at 11:45 AM the surveyor toured the facility kitchen with one other surveyor, the regional food service director, staff #14, the facility food service manager, staff #15, and the registered dietician, staff #13. The surveyor requested the facility food service manager, staff #15 assist with setting up a test tray for Garden View unit for the lunch meal. The two surveyors were informed while in the kitchen observing the tray line set up for the unit that the lunch menu consisted of the following food items for a regular diet: fish cakes, herbal rice, blended mixed vegetables. The temperatures were: fish cake: 164 degrees, herbal rice: 163 degrees, mixed vegetables: 170 degrees, the pureed meat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, review of administrative documents, and interviews it was determined that the facility failed to: 1) store food items at the appropriate temperature, repair broken kitchen equipment, place dry food items in appropriate storage containers, and to remove food items that were not stored at an appropriate temperature, and 2) ensure that the resident's meal matched the items listed on the resident's meal ticket. These was evident during 2 of 3 facility observations and for 2 (#35, #81) of 2 residents reviewed for food preparation during the survey. The findings include: 1) On 04/16/25 at 07:34 AM the surveyor initiated the tour of the kitchen dietary aide, staff # 26 opened the kitchen door without a nametag present on his/her uniform. Walk-in refrigerator #1 had temperature of 42 degrees Fahrenheit per log completed by staff#37. Freezer #1 had a temperature of -5 Fahrenheit degrees based on outside thermometer and documented on the AM temperature log sheet dated 4/16/25 and signed by staff…

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

Based on record reviews and interviews it was determined that the facility failed to provide an accurate facility assessment for direct care staff to resident ratios. This deficient practice was discovered during the survey. The findings include: On 04/16/24 at 1:46 PM the surveyor received a copy of the facility assessment from Administrator #1. On 04/24/25 at 7:40 AM, a review of the facility assessment revealed the facility assessment was completed in June 2024 and reviewed by the quality assurance committee in July 2024. Further review of the facility assessment revealed a staffing template that contained the facility's staffing for both licensed nurses and direct care staff separated by skilled rehab units and long-term care units. The surveyor asked the Administrator to explain the overall staffing plan described in the assessment. The Administrator stated that she was unable to explain the staffing plan at that time and would need to review the facility assessment before providing an explanation. On 04/24/25 at 7:45 AM, the administrator informed the surveyor that the…

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

Based on observations, staff interviews, and record review, it was determined that the facility failed to ensure that medical records were complete and accurately documented. This was evident for 2 residents (Resident #101, #108) out of 54 residents reviewed for medical records during the survey. The findings include: 1) On 04/17/25 at 10:42 AM, review of Resident #108's medical record revealed an active order with a start date of 10/03/2023, which indicated for the resident to receive a shower on Tuesdays and Fridays. On 04/17/25 at 10:43 AM, further review of the resident's medical record revealed an active kardex task which indicated the resident was to receive a shower on Mondays and Thursdays. On 04/21/25 at 11:34 AM, an interview with the Director of Nursing (Staff #2) revealed that a resident's kardex task regarding showers should reflect the resident's shower order. 2) On 4/22/25 at 8:40 AM, review of records revealed that Resident #101 was bed-bound with limited ROM to all extremities and was provided Physical Therapy (PT) and Occupational Therapy (OT) services 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 observations and interviews it was determined that facility staff failed to keep isolation cart stocked with personal protective equipment (PPE) for enhanced barrier precaution (EBP) residents. This deficient practice was evident for 2 out of 5 units observed during the survey. The findings include: On 04/16/25 at 7:34am, during the initial observation on the units Annapolis and Gardenview, the surveyor observed the following: 1. An EBP sign was posted on the door of room [ROOM NUMBER], however, no isolation cart was present. 2. An EBP sign was posted on the door of room [ROOM NUMBER]. Upon review of the isolation cart, the surveyor noted that gloves were missing. 3. An EBP sign was posted on the door of 38. A review of the isolation cart revealed that gloves were missing, and a resident's medication Santyl was located inside the cart. 4. An EBP sign was posted on the door of room [ROOM NUMBER]. Review of the isolation cart revealed missing gloves. On 4/16/25 at 7:46 am, during an interview 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 observations, review of administrative documents, and interviews it was determined that the facility failed to repair broken kitchen equipment, These factors were found evident to be true during three of multiple observations facility observations of the kitchen made during the survey. The findings include: 1) On 04/16/25 at 07:34 AM the surveyor initiated the tour of the kitchen dietary aide. Refrigerator number # 3, labeled Back Room, the temperature outside the refrigerator read 51 degrees Fahrenheit. When the door of refrigerator #3 was opened by the surveyor, the shelves and the food containers were warm to touch. The contents within the refrigerator were applesauce, grape jelly, soy sauce, mayonnaise and iced tea. Refrigerator # 3 temperature was not in compliance with the food safety storage procedures. Refrigerator #4 labeled back room, appeared to be unplugged and the outside temperature was 65 degrees. Within the interior of refrigerator #4 were dry goods, such as pasta, noodles, large cans of tomato sauce, grape jelly, and bread. The surveyor observed that…

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

Based on observation and interview, it was determined that the facility failed to ensure a resident's mattress properly fit the bed frame. This was evident for 1 (Resident #108) of 1 resident bed observed during a random observation of the Annapolis Unit. The findings include: On 04/18/25 at 11:42 AM, an observation of Resident #108 in bed revealed that his/her mattress was hanging over the bed frame approximately 8 inches on the right side of the bed. On 04/18/25 at 12:19 PM, the surveyor and the Director of Maintenance observed Resident #108's mattress hanging over the right side of the bed frame. He indicated that the mattress was too big for the bed frame.

Based on the review of complaints, interview with complainants, review of facility policy and interview with facility staff, it was determined that the facility failed to provide a resident's medical records to the identified and established representative in a timely manner. This was evident during the review of 1 of the 2 complaints regarding access to medical records (Resident #162). The findings include: Interview with a complainant on 4/23/25 at 8:53 AM regarding the complaint MD00206860 revealed concerns that upon the request for their loved one's medical records it took over 40 days. On 4/23/25 at 9:50 AM staff # 24, the Business office manager was interviewed. She reported to this surveyor at that time that requests for records would go through her. The process includes the requestor would need to fill out the appropriate paperwork, the paperwork goes to the legal department so they can determine if that individual has authorization to the records, then the legal department will let the facility know if the records can be released. The records can then be gathered for the…

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

Based on medical record review, the review of a complaint and interview with facility staff, it was determined that the facility failed to ensure the timely scheduling with an Infectious Disease consultant for a resident that was admitted with multiple comorbidities requiring specialty consultation. This was evident for 1 of 3 residents (Resident #162) reviewed with orders for outside services/consultations. The findings include: The complainant for MD00206860 was interviewed on 4/23/25 at 8:53 AM. Amongst other concerns, he/she reported that regarding their loved one, Resident #162, had multiple care concerns surrounding the evolving status of a wound. The complainant reported to this surveyor and acknowledged that Resident #162 admitted to the facility with the wound, however, verbalized concern over the worsening status of the wound. Resident record review continuing from 4/23/25 at 8:19 AM revealed admission diagnosis in March of 2024 including infection following fasciotomy (a surgical procedure to cut through the fascia surrounding a group of muscles to relieve pressure)…

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

Based on administrative record review and staff interview, it was determined that the facility staff failed to report allegation of abuse in timely manner to Office of Health Care Quality (OHCQ). This finding was evident for 4 of 4 residents reviewed for abuse (#101, #84, #111, and #113). The findings include: 1. This finding was identified during the investigation of Faciltiy Reported Incident #MD00163103: On 03-24-2021, administrative record review revealed Resident #101 alleged Geriatric Nursing Assistant (GNA) staff #2 hit him/her while providing care on 8-19-2020 at approximately 1:30 PM. Further review of facility administrative records revealed no evidence of reporting to OHCQ within two hours of incident. On 03-25-2021 at 10:33 AM, an interview with the facility Administrator revealed that the facility did not have record of email confirmation of when the initial report was sent to OHCQ. 2. This finding was identified during the investigation of Faciltiy Reported Incident #MD00157446: On 04-28-2020 Resident #113 reported to the Director of Social Services an allegation that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical records and interviews with facility staff, it was determined that the facility failed to ensure residents and/or the responsible parties were provided with written notification of the residents' hospital transfers. This finding was evident for 2 of 4 residents selected for the Hospitalization review (#56, #92). The findings include: 1. On 03-23-21 at 10:30 AM, surveyor review of the clinical record revealed that resident#56 was transferred to the hospital on [DATE]. Nurse's note on 03-03-21 at 12:02 PM, revealed resident representative was called and made aware of the transfer. However, there was no evidence that written notification was provided to resident #56's representative regarding the transfer. On 03-23-21 at 11:10 AM, surveyor interviewed the Director of Nursing (DON) who said notification to the resident representative was given by telephone; no written notification was given to resident #56 or the representative when the transfer occurred. The Director of…

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

Based on surveyor observation and staff interviews, it was determined that the facility staff failed to keep accurate record and timely dispose of controlled and non-controlled medications. This finding was evident in 1 of 5 units (Garden View). The findings include: On 03-25-2021 at 2:00 PM surveyor inspected one of two medication carts in Garden View unit. Surveyor found Lorazepam 0.5mg tabs (controlled drug) count 12 with an expiration date of 7-13-2020 in the narcotic box. It was labeled for Resident #114 who was discharged on 3-15-2020. There was no record of the drug in controlled drug record book. In addition, surveyor also found 5 capsules of florastor (probiotic capsule) and flonase 50mcg nasal spray with no labels in the medication cart. On 03-25-2021 the facility policy and procedure for disposal of discontinued drugs revealed all controlled and noncontrolled drugs were to be disposed within 30 days when the physician discontinued the medications. Further review of the policy revealed, nursing staff should return noncontrolled drugs to the pharmacy and should destroy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the clinical record and facility staff interview, it was determined that the facility staff failed to monitor Resident #51 for adverse consequences of psychotropic medications. This finding was evident in 1 of 6 residents selected for review of unnecessary drugs during the survey. (#51). The findings include: Psychotropic medications are any medication capable of affecting the mind, emotion and behavior. On 03-24-18 at 2:20 PM surveyor review of the clinical record revealed that Resident #51 was on multiple medications including but not limited to psychotropic medications. Resident #51 medications included the following: Divalproex 250 mg for (medication for behavior/mood disorder) two times a day, Zoloft 25 mg (medication for depression) and Trazadone 50 mg (medication for depression). However, there was no evidence in Resident #51's clinical record to indicate that the resident was being monitored for extrapyramidal symptoms (physical symptoms including tremor, slur speech, paranoia, and anxiety) or that Resident #51's behavior was being monitored. On…

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

Based on surveyor review of the clinical records and interview of facility staff, it was determined that the facility failed to ensure that as needed (PRN) orders for psychotropic drugs were limited to 14 days. This finding was evident in 1 of 6 residents selected for review of unnecessary drugs during the survey. (#92). The findings include: On 03-24-21 at 11:10 AM surveyor review of the clinical record of Resident #92 revealed a physician's order on 1-22-21 for Ativan (anti-anxiety) 0.25 milligram two times a day as needed for behavior/restlessness. However, surveyor review of Resident #92's physician order sheets and medication administration record (MAR) on March 24, 2021 revealed that Ativan 0.25 mg was still on the resident's medication list to be administered. There was no evidence in the clinical record that the attending physician or the prescribing practitioner documented the rationale for the extended use beyond the 14 days as required. On 03-24-21 at 11:40 AM, surveyor interview with the Director of Nursing (DON) revealed no additional information

Based on surveyor observations and staff interviews, it was determined that the facility staff failed to label drugs in accordance with accepted professional standards. This finding was evident in 1 of 5 (Garden View unit) medication storage rooms and 1 of 9 medication carts (Garden View unit). The findings include: On 03-25-2021 at 2:00 PM, surveyor inspected 1 of 2 medication carts in the Garden View unit. Surveyor found 5 capsules of florastor (probiotic) with no label and no visible expiration date, unsealed flonase 50mcg nasal spray with no label, and albuterol sulfate 90 mcg HFA inhaler with an expiration date of December 2020. Further, surveyor inspection of medication storage room in Garden View unit revealed an open vial of Acetylcysteine 20% solution (inhaler) stored in a refrigerator. The vial had an instruction stating, discard after 96hrs after opening. However, the vial was not dated with an open date. On 03-25-2021 at 2:10 PM, an interview with Registered Nurse (RN) staff #3 revealed no additional information. On 03-26-2021 at 12:00PM, an interview with Director of…

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

Based on surveyor observation and staff interviews, it was determined that the facility staff failed to implement proper infection control and prevention practices. This finding was evident in 1 of 5 units (Chesapeake unit) during meal distribution observation. The findings include: On 03-22-2021 at 12:52 PM surveyor observed Geriatric Nursing Assistant (GNA) staff #1 passing meal trays on the Chesapeake unit during lunch. Staff #1 was observed taking trays to rooms 90, 94, 97, 92, and 93. The Surveyor did not observe staff #1 washing her hands or applying hand sanitizer after delivering and setting up trays in each of these rooms. Staff #1 was not using hand sanitizer between residents although she was directly touching resident bedside tables, bed and personal items. Observation of these rooms revealed a hand sanitizer mounted on the wall of each room near the door. On 03-22-2021 at 12:57 PM, an interview with GNA staff #1 revealed that she received infection control and prevention training, but she was not aware that she had to perform hand hygiene in between passing meal trays…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of the clinical record and interviews with residents and facility staff, it was determined that the facility staff failed to follow physician orders. This finding was evident for 3 of 29 residents selected for review during this survey (#32, #61 & #73). The findings include: 1. On 06-17-19 at 9AM, interview with resident #32 revealed that the resident had not received their medication as ordered on 06-02-19 and 06-03-19. Resident #32 stated that he/she was not having blood sugar checked and not receiving insulin during that period. On 06-19-19, surveyor review of the physician's orders for June 2019, revealed that resident #32 had an order to have the blood glucose checked before meals and at bedtime. In addition, there were two orders for insulin. One order was for Humalog insulin to be injected subcutaneously (a type of injection, in which a short needle is used to inject a drug into the tissue layer between the skin and the muscle) per a sliding scale amount before meal times and at bedtime. The second order was for 15 units of Lantus insulin to be…

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

Based on surveyor observation and staff interview, it was determined that the facility staff failed to thaw potentially hazardous food in an appropriate manner to prevent the potential for development of foodborne illnesses. This finding was evident in the main kitchen which prepares meals for all residents within the facility. The findings include: 1.On 06-17-19 at 10:00AM, surveyor observed 5 bags of chicken breasts that were thawing in a sink at room temperature. Surveyor proceeded to the tray line to observe kitchen staff preparing trays. Random temperature checks of the pureed bread was 138 degrees and oatmeal was 156 degrees at the completion of the breakfast tray line service. On 06-17-19 at 8:25 AM, surveyor returned to the sink and again observed chicken breasts thawing at room temperature. The chicken breasts, which are considered potentially hazardous food, should be thawed: 1. In refrigerated units in drip proof containers in a manner that prevents cross contamination, 2. Under potable running water that is at or below 70 degrees Fahrenheit with sufficient force to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of clinical and administrative records and interviews with facility staff, it was determined that the facility failed to send a copy of the notice of transfer to a representative of the Office of the State Long-Term Care Ombudsman. This finding was evident for 5 of 6 (resident #44, #113, #13, #20 and #35) residents selected for hospitalization review. The findings include: 1. On 06-21-19 10:00 AM, record review revealed that resident #44 was transferred to an acute care hospital on [DATE] for emergency medical evaluation. There was no documented evidence that the facility sent a copy of the notice of transfer to a representative of the Office of the State Long-Term Care Ombudsman. On 06-21-19 at 10:25 AM, surveyor interview with Grand Heritage unit manager revealed that nursing staff was not responsible for notifying the Ombudsman of any resident transfers. On 06- 21-19 at 10:30 AM, during an interview with staff #3 and staff #5, it was discovered that nursing staff was responsible 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 surveyor observation and review of the clinical record, it was determined that the activity staff failed to develop a care plan to address a resident's participation in social activities. This finding was evident in 1 of 6 residents selected for review of the activities care area (#20). The findings include: On 06-17-19 during initial screening, it was noted that resident #20 had no activity calendar in his/her room. On 06-17-19 at 3:00 PM, further investigation revealed a care plan for participation in activities had not been developed for this resident. On 06-18-19, surveyor interview with the Activities Director confirmed that resident #20 had no care plan initiated for activities upon readmission to the facility.

Based on surveyor review of the clinical record, interviews with facility staff and resident interviews, it was determined that the facility staff failed to revise the plan of care to reflect the needs of the resident and failed to revise comprehensive care plans after each interdisciplinary team assessment. This finding was evident for 2 of 29 residents (#35 & #99) selected for review during the survey. The findings include: 1. On 04-17-19, resident #35 alleged that he/she was struck in the head by another resident. The resident was assessed to have a small abrasion on the nose and was transferred to an acute care setting for evaluation. Resident #35 was returned to the facility with a diagnosis of facial contusion, and head injury due to physical assault. There was no documented evidence found in the clinical record that the plan of care had been revised to reflect the facial contusion, the head injury or the physical assault. On 06-21-19 at 1:30 pm, interview with the Director of Nursing provided no additional information. 2. On 06-21-19, surveyor review of resident #99's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical record and resident and staff interviews, it was determined that facility staff failed to properly utilize outside resources as recommended by the admitting physician. This finding was evident for 1 of 29 (#95) residents selected for review during the survey. The findings include: On 06-19-19 at 3:05 PM, review of the clinical record revealed resident #95 was admitted to the facility on [DATE] after an acute care hospitalization with a physician order for a psychiatric consult. However, further review of the clinical record for resident #95 revealed no documented evidence that a psychiatric consult had been scheduled. On 06-19-19 at 3:10 PM, interview with the licensed Social Worker revealed that, once a physician order is placed for a psychiatric consult in a resident's clinical record, the nurse will notify the Social Services Department, whereby the residents' name is added to a log. In addition, the log is reviewed by the psychiatrist when he/she are in the facility.…

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