Hidden Waters Rehabilitation and Wellness Center

Based on observation, review of survey results binders, and interview, the facility failed to 1) have readily accessible the survey results and 2) have the results from the last survey available for review. This was found on entry into the building and of 1of 2 survey result binders. The findings include: 1) On 10/28/25 at 8:13 AM, the surveyor requested to review the survey results from the last survey from the front desk receptionist Staff #22. Staff #22 stated that the survey binder was normally kept at the front desk but she was not able to find the book. On 10/28/25 at 8:17 AM, the Director of Nursing (DON) brought the surveyor the surveyor result binder. The DON explained that the Regional Director of Clinical Operations was reviewing the book yesterday and did not return the book to its normal location behind the front reception desk. 2) On 10/28/25 at 8:18 AM, the surveyor reviewed the survey results binder. The results from the survey that was completed in December of 2024 were in the binder; however, the results from the survey completed in June of 2025 were not. 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 a review of survey results binders, and interviews, it was determined that the facility failed to protect the privacy of residents' information. This was found evident in 2 of 2 survey results binders. The findings included: On 10/28/25 at 8:17 AM, the Director of Nursing (DON) brought the surveyor the survey results binder that belonged in the front lobby. On 10/28/25 at 8:33 AM, the surveyor reviewed the survey results binder. The review revealed nine pages of residents' names along with their attending physicians, totaling 232 residents' names and physicians' names. On 10/28/25 at 8:42 AM, the surveyor interviewed the Director of Nursing (DON). During the interview, the DON confirmed that the list of residents and their physicians should not have been in the book because the survey results binders are available for anyone to review. The DON stated he had an additional survey results binder on one West. On 10/28/25 at 9:09 AM, the surveyor reviewed the binder from one West. The review revealed that the same nine pages with 232 residents' names along with their physicians…

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

Based on record review and interviews, the facility failed to have an appropriate reason to involuntarily discharge a resident and failed to permit that resident to remain in the facility, and not discharge, while the appeal for discharge was pending. This was found evident in 1 (Resident #21) out of 1 Residents reviewed for involuntary discharges. The findings included: On 11/3/25 at 8:54 AM, the surveyor reviewed intake #2657616 that was submitted to the Office of Health Care Quality (OHCQ). The intake alleged that the facility inappropriately discharged Resident #21. It further stated that Resident #21 had an appeal for his/her discharge and the reason for discharge (non-payment) was inaccurate. It further stated that the facility was aware an appeal was filed and an email had been sent to the social worker to inform the facility. On 11/3/25 at 10:54 AM, the surveyor requested Resident #21's appeal for involuntary discharge from the Director of Nursing (DON). On 11/3/25 at 11:15 AM, the surveyor reviewed Resident #21's discharge summary and noted that Resident #21 was discharged…

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

Based on medical record review and interview, the facility failed to make prompt efforts to resolve a resident's grievance and also failed to keep the resident appropriately apprised of the progress toward resolution. This was evident for 1 (#25) of 55 residents reviewed in a complaint survey. The findings include: Review of a complaint MD 00217656, sent to the Maryland's Office of Health Care Quality (OHCQ), on 5/22/25 at 8:00 AM revealed that the complaint was sent by the Ombudsman alleging that the facility failed to promptly resolve resident #25's grievance of reimbursement for a missing prosthetic leg. Review of resident #25's medical record on 5/22/25 at 8:30 AM revealed no evidence that the facility misplaced the resident's prosthetic leg. Interview with the Ombudsman on 5/22/25 at 12:15 PM revealed that resident #25's prosthetic leg was missing since 1/2025. The Ombudsman stated that the resident complained to the facility that his/her prosthetic leg was missing from his/her belongings since 1/2025. The resident received no updates on the location of the prosthetic leg 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 record review and staff interview; it was determined that the facility failed to protect their residents from verbal abuse from a facility staff member. This was evident for 1 (#46) of 55 residents reviewed during a complaint survey. The findings include: Review of facility reported incident (FRI) MD00217347 on 5/29/25 at 8:00 AM revealed the FRI alleged that Geriatric Nursing Assistant (GNA) #13 verbally abused Resident #46 while providing ADL care. Review of Resident #46's medical record on 5/29/25 at 8:30 AM revealed a care plan for psychosocial well-being. The intervention for this psychosocial well-being was listed as encouragement for communication. The Director of Nursing (DON) provided the surveyor with the facility investigation of the alleged verbal abuse incident. Review of the facility investigation on 5/29/25 at 10:00 AM revealed the incident occurred on 5/2/25. GNA #13 made comments about the number of bowel moments being made by resident #46. The facility investigation determined that the allegation of verbal abuse was unsubstantiated. The facility's…

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

Based on review of facility documents and staff interview it was determined the facility failed to report an allegation of abuse immediately but not later than 2 hours after an allegation was made. This was evident for 1 (#21) of 19 residents reviewed for abuse during a complaint survey. The findings include: On 5/22/25 at 1:09 PM, a review facility reported incident, MD00205036, which alleged that Resident #21 sustained a scratch to his/her face during an altercation with Resident #2, resulting in Resident #21 being transferred to the hospital emergency department for further evaluation. The facility's investigation documented the incident had occurred on 4/3/24 at 6:30 PM. The facility's investigation did not include documentation as to when the incident was sent to OHCQ or when the final report was sent. The above concern was discussed with the Director of Nurses (DON) on 5/22/25 at approximately 1:30 PM and the surveyor requested email confirmation of when facility report sent to state office. On 5/22/25 at 2:18 PM, the DON reported to the surveyor that email confirmations 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 medical record review and interview with facility staff and the review of a facility reported incident (FRI), it was determined that the facility staff failed to 1. thoroughly investigate an injury (bruising) of unknown origin and 2. failed to thoroughly investigate allegations of abuse. This was evident during the review of 2 of 19 facility reported incidents. Residents (#20 and #21) The findings include: 1. Review of the facility reported incident #MD208608 on 6/2/25 at 12:57 PM revealed a concern related to a new discoloration observed around Resident #20's right upper eye lid. Secondary to Resident #20's diagnosed intellectual disabilities s/he was unable to give a verifiable account of what happened to cause this newly identified injury. According to an electronic medical record review, Resident #20 is also diagnosed with muscle weakness and lack of coordination. Further review at this time of the facility investigation report revealed that the facility determined that the allegation of abuse was 'unsubstantiated' after reviewing all documents and witness statements. A…

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 that facility staff failed to notify a resident in writing of a pending discharge and failed to ensure that the discharge was documented in the medical record. This was evident for 1 (#27) of 1 resident reviewed for discharges. The findings include: On 5/21/25 at 1:10 PM a review of complaint #MD00213157 revealed the complainant alleged Resident #27 had not received appropriate notice of the facility's intent to discharge him/her. A medical record review for Resident #27 on 5/27/25 at 1:31 PM revealed in the progress notes that the resident was discharged from the facility, however, there was no written notice of discharge. In Addition, staff failed to document discussion with the resident regarding discharge planning, the resident's input regarding the discharge, and the reason for the discharge. On 5/22/25 at 9:46 AM an interview with Social Worker Designee Staff #23 confirmed she worked with Resident #27 regarding discharge planning. She reported she had discussions with the resident about discharge and the resident was not…

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

Based on record review and staff interview, it was determined that facility staff failed to develop resident-centered comprehensive care plans for their residents. This was evident for 3 (#8, #27, and #53) of 38 residents reviewed for complaints. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Elopement is defined as a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. 1) On 5/28/25 at 3:46 PM during a review of the facility report incident investigation file for incident #MD00206569 it was revealed that on 6/12/24, facility staff were unable to find Resident #8 and s/he was found the…

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

Based on observation during tour and interview with facility staff, it was determined that the facility staff failed to ensure that the facility stock medications and supplies were maintained in a secure fashion. This was found evident during one of the random tours completed during the complaint survey on 1 of 3 units. The findings include: During the tour of the facility on 5/28/25 around 10:20 AM of the back hall that connects 3 East and 3 West, fully accessible to residents, the survey team identified an open room filled with boxes and contractor equipment. Upon closer inspection and observation, inside the numerous unorganized boxes were multiple bags of bottles and random bottles laying in the boxes of the following medications: Vitamin D 1250 milligram (mg) capsules Aspirin 81 mg Deep Sea premium nasal Spray Ferrous Sulfate 325 mg supplement Zinc 50 mg Acetaminophen extra strength 500 mg Stress Formula high potency dietary supplement Cranberry Dietary supplement Melatonin 3mg supplement Iron Tablets 325 mg supplement, Elemental Ferrous 65mg Multiple cases of Jevity 1.0…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 1 (#47) of 17 facility reported incidents reviewed and 1 (#35) of 38 residents reviewed for complaints. The findings include: 1) A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. resident records. Resident #47 was admitted to the facility on [DATE]. Resident #47's closed record was reviewed on [DATE] which revealed a MOLST form was completed on [DATE] by CRNP#1. The front page of the MOLST form did not indicate what Resident #47's wishes for life sustaining care. (Full Code, No CPR) In an interview with CRNP#1 on [DATE] at 2 PM, CRNP#1 reviewed Resident #47's [DATE] MOLST form and stated that s/he did…

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, record review, and interview it was determined that the facility failed to 1) use their resources appropriately to ensure the safety of their residents when they lost their primary heat source in the winter and 2) ensure that their facility assessment included all populations of residents, and the resources needed in the case of an emergency. This was evident during the survey and had the potential to affect all residents. The findings include: The Center for Disease Control's (CDC) Preventing Hypothermia publication on 2/7/24 read that victims of hypothermia are often: older adults with inadequate heat. www.cdc.gov. 1) On 12/2/24 at 1:00 PM an observation in the lobby of the facility revealed it felt cold, and residents and staff were wearing coats, hats, and gloves. An observation on the 1st floor nursing unit on 12/2/24 at 3:45 PM revealed it was cold on the unit. There was large heating units located sporadically in the hallways. Residents were observed wearing coats, hats, gloves, 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 record review and interview it was determined that the facility failed to have a transfer agreement. This was evident during the complaint survey and had the potential to affect all residents. The findings include: On 12/5/24 the Nursing Home Administrator (NHA)was asked to provide a copy of their transfer agreement. On 12/5/24 at 2:44 PM a review of the documentation provided revealed they had not included the transfer agreement. On 12/6/24 at 8:16 AM an interview with the NHA, revealed she provided the agreements with facilities in the case of an evacuation. NHA was asked to bring the transfer agreement with local hospital(s) in the event a resident needed acute care services. The NHA reported on 12/6/24 at 11:05 AM, that she was unable to locate a transfer agreement and was contacting their corporate office to see if they had one on file. During the exit conference on 12/6/24 at 11:29 AM, Regional Nurse #1 reported the facility had a transfer agreement, however was unable to locate it.

Based on record review and interview, it was determined that the facility failed to address the specific resources needed for their resident population. This was evident 103 and of 233 residents. The findings include: The facility assessment is a tool for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services that residents require. On 12/4/24 at 11:50 AM, review of the most updated copy of the facility assessment provided by the Nursing Home Administrator (NHA) failed to reveal they had addressed the population of residents that had DC Medicaid (DC Medicaid is a healthcare program that pays for medical services for qualified people residing in DC. It helps pay for medical services for low-income and disabled people. These residents are unique in that they do not have Medicaid in the state (Maryland) in which they are temporarily residing and not all nursing homes accept this payer source). Therefore, they had not identified resources for them in the case of an emergency and they needed to be evacuated. 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 interviews and medical record reviews, it was determined that the facility failed to inform the residents responsible party of a new medical treatment plan. This deficient practice was evident during a complaint revisit. The findings include: The Resident #4 was admitted to [NAME] Healthcare Center on 01/28/25 with multiple diagnosis, including cognitive communication deficit, and dysphagia. A review of medical records on 02/06/25 revealed a physician's progress note from 02/05/25 documenting the resident history of dementia. On 02/06/25 at 10:22 AM, during an interview with Resident #4's responsible party (RP), they stated that during a visit on 02/5/25, a staff member asked if they had been notified of the resident's order for intravenous fluids due to abnormal labs. The RP responded that they had not been informed. The staff member then explained that a peripheral line were inserted, and intravenous fluid were administered to treat dehydration. The RP stated that no one had contacted them to inform…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined that the facility staff failed to ensure the facility is maintained in a safe and homelike environment. This was evident for 3 out of 3 floors. The findings include: 1. The bed for the resident in 334, bed C, was observed on 4/17/23 to have cushion that was falling apart and the wall behind the bed was scraped up. 2. The 3rd floor East wing shower room was observed on 4/17/23 at 9:16 AM. The shower room had two shower stalls. The left stall had a small trash can in the middle of the stall filled halfway with a brown liquid and a washcloth in it. Flying insects were observed flying around the trashcan. The stall on the right had a brown substance, possibly feces, on the floor near the drain. There was a beside commode with a broken lid (half of it is missing) in the right stall as well. The drain near the toilet stall had a brown substance on the drain grate and numerous flying insects were observed around it. The tub in the tub stall had several brown…

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 during an environmental tour, it was determined that the facility failed to maintain a safe, sanitary, comfortable, and functional environment for the residents, staff, and visitors. The findings include: On 4/17/23 at 10:30 Am, a tour and observation with the Maintenance Director of the facility revealed that there was evidence of unattended maintenance needs: 1. A tour with the Maintenance Director revealed that one of the two elevators was not functional, and it has been down for several months. 2. Upon entering the facility, a strong foul smell was in the air. The Maintenance Director revealed that the sewer injector frequently backs up due to facility staff and residents putting wash clothes, gloves, and other non-flushable items in the toilets. 3. In room [ROOM NUMBER]-C the television was unsecured on top of a dresser leading up against the wall for support. 4. A tour of the laundry room revealed the dryer room walls were found to be crumbling apart or paint was peeling off, for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, it was determined that the facility failed to have adequate ventilation in resident bathrooms. This was evident in 13 resident bathrooms observed on the 2nd floor, 2 [NAME] of the facility. The findings include: Observation of resident rooms/bathrooms on 4/17/2019 at 10:35 AM, with the Maintenance Director revealed that exhaust fans were not operational in all 13 bathrooms on 2 West. The bathrooms had a lingering smell of feces and urine due to the lack of airflow. An interview with the Maintenance Director on 4/21/23 at 10:30 AM revealed that the lack of airflow was caused by a broken exhaust motor on the roof. The exhaust motor has been broken since the start of employment in June 2022, and the Administrator was made aware by the Maintenance Director at that time verbally. A work order has been submitted to the Heating and Air Condition company. On 4/21/23 at 3 PM the Maintenance Director stated that he fixed the exhaust fans, and they are now working. On 4/25/23 at…

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, staff, and Resident Representative interview, it was determined that the facility failed to ensure that resident concerns were addressed in a timely manner. This was found to be true for 1 of 1 facility Concern Forms and 6 of 6 Resident Council Meeting Minutes reviewed during the survey. Findings include: An interview was conducted with the complainant to investigate complaint report #MD00184779 on 05/04/23 at 12:45pm. The complainant shared that the multiple written and verbal concerns regarding the care of Resident # 675, their room, and the condition of the facility's environment were unanswered. On 05/05/23, at 11:15 am, an interview with the Director of Social Services (DSS) (staff #11) revealed that he was responsible for reviewing complaint reports and distributing the concerns to the responsible facility management to be addressed. The DSS added the responsible supervisor or director would follow up with the concern and submit their actions. He stated that there was no electronic documentation related to grievances filed. When asked, the DSS stated he…

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 staff failed to document accurate assessments for Resident (#189, #125, #137, and #144) on the MDS. This was evident for 6 of 164 residents selected for review during the survey process. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Categories of MDS (Minimum Data Set) are Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning, and structural problems which include the assessment of a range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use, and Treatments and procedures. At the end of the MDS assessment, the interdisciplinary team…

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 interviews and record review it was determined that the facility failed to review and revise a Resident's care plan after an assessment. This was evident for 3 of 9 (Resident #215, #56, and #49) Residents reviewed for care planning on an annual and complaint survey. These finding include: Minimum Data Set (MDS): The MDS is part of the Resident Assessment Instrument. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1. On [DATE] at 12:57 PM, the surveyor reviewed Resident #215's medical records. The review revealed that Resident #215 was admitted to the facility in early 2023. It further revealed that Resident #215 had an admission MDS assessment done on [DATE] and a quarterly done on [DATE]. Further review of the medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. A review of Resident #209's clinical record revealed that the resident used a continuous positive airway pressure (CPAP) device prior to admission. There is no mention of the CPAP in the admission assessments. The resident was noted to have a diagnosis of sleep apnea. The most common treatment for sleep apnea is CPAP. A review of the resident's progress notes revealed numerous mentions that the resident has had trouble falling/staying asleep. A review of the monthly pharmacy reviews revealed that the pharmacist did not determine that there were any irregularities with the medicinal regimen. Further review of the clinical record revealed the resident has had numerous medications ordered and administered either for insomnia or for another diagnosis but with the thought it would help the resident to sleep. The medications were: Clonazepam 0.5 mg twice a day for anxiety from 11/21/22 to 1/1/23, Seroquel 25 mg three times a day for schizoaffective disorder from 12/23/22 to 1/1/23, Trileptal 300 mg twice a day for…

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

Based on observations, interviews and record review it was determined that the facility failed: 1) to have water easily assessable for residents to promote hydration (#56, #3 and #188) 2) The facility staff failed to notify the provider of a noted weight loss (#42). This was found evident of 3 of 5 reviewed residents reviewed for hydration and 1 of 10 residents reviewed for nutrition while on an annual and complaint survey. 1. On 4/17/23 at 1:03 PM, the surveyor observed Resident #56 without a bedside table or cup of water. 2. Further observation revealed Resident #56's roommate, Resident #3, had a bedside table but had no water cup at his/her bedside. On 4/17/23 at 1:05 PM, the surveyor interviewed Geriatric Nursing Assistant (GNA) in training Staff #71. During this interview Staff #71 stated that Resident 56's water cup was located by Resident #56's roommate's TV stand along with Resident #3's water cup. Staff #71 confirmed the cups were out of the reach of both Residents and stated she would wash the cups and bring both Resident's water. On 4/18/23 at 10:00 AM, the surveyor again…

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 pureed bread was of appropriate consistency for residents who require a puree diet. This was evident for 1 of 4 pureed meal items being served for lunch at the facility on 5/11/23. The findings include: On 5/11/23 at 11:23 AM, surveyors conducted temperature testing of foods prior to lunch service with Staff #63, Dietary District Manager, present. Pureed bread was observed being placed on the steam table and being served for residents who required a puree consistency diet. On 5/11/23 at 12:00 PM multiple surveyors sampled the facility test trays which included a puree consistency tray. Pureed bread was sampled and found to be very thick in consistency and difficult to swallow. Surveyors noted the pureed bread stuck to the roof of the mouth presenting concern for potential of resident food pocketing (food held in the mouth for a period of time without being swallowed). On 5/11/23 at 12:17 PM surveyors brought concern to the attention of Staff #63, who acknowledged the concern,…

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 of the facility's kitchen, review of kitchen records and interviews of dietary staff, it was determined that the facility 1.) failed to ensure the temperature of food items maintained an acceptable serving temperature and failed to ensure timely delivery of a meal, 2.) failed to ensure the dishwashing system was properly functioning and maintaining appropriate temperatures for rinsing and washing of dishes, and 3.) failed to ensure sanitary practices were followed in accordance with professional standards for food service safety. These deficient practices have the potential to affect all residents. The findings include: 1.) On 5/8/23 at 11:25 AM, surveyors conducted observations of the facility's kitchen. Surveyors observed and reviewed the temperature logs. The temperature log for 5/8/23 was reviewed first, revealing breakfast, lunch, and dinner temperatures had been recorded. The facility was currently preparing lunch at 11:25 AM. Surveyors brought the temperature log dated 5/8/23 to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on residents' bedroom observation it was determined that multiple occupancy bedrooms did not provide the minimum space per bed as required. The findings: The following triple bedrooms (3 beds per room) did not provide the minimum of 80 square feet per bed as required: 1. room [ROOM NUMBER] provided only 79.4 square feet per bed, which is a shortage of .6 square feet. 2. room [ROOM NUMBER] provided only 79.4 square feet per bed, which is a shortage of .6 square feet. 3. room [ROOM NUMBER] provided only 78.7 square feet per bed, which is a shortage of 1.23 square feet. 4. room [ROOM NUMBER] provided only 78.8 square feet per bed, which is a shortage of 1.13 square feet. 5. room [ROOM NUMBER] provided only 78.6 square feet per bed, which is a shortage of 1.13 square feet.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility staff failed to ensure that handrails were firmly secured to corridor walls. This was evident for 3 of 3 floors reviewed for secured handrails. The findings include: On 04/24/2023 at 11:20 AM, an observation on the first floor revealed that the handrail on the left side of the entrance to the resident rooms was missing the corner piece. The missing corner piece allowed for the metal within the handrail to be exposed. This finding was verified by Assistant Maintenance Director (staff #44). On 04/28/23 at 9:15 AM, an observation on the first floor revealed that in the dining room the long handrail on the left side of the entrance was not firmly secured to the wall. The entire length was noted to be loose and the last 3 brackets were pulled out from the wall exposing the anchors. On 04/28/2023 at 9:20 AM, an observation on the first floor revealed that the handrail on the left side of the entrance to the resident rooms continued to miss…

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 tours of the facility, observation, and staff interview it was determined that the facility staff failed to ensure they had a working pest control program. This was evident for all three floors of the facility. The findings are: 1. The 3rd floor East wing shower room was observed on 4/17/23 at 9:16 AM. The shower room had two shower stalls. The left stall had a small trash can in the middle of the stall filled halfway with a brown liquid and a washcloth in it. Flying insects were observed flying around the trashcan. The stall on the right had a brown substance, possibly feces, on the floor near the drain. The drain near the toilet stall had a brown substance on the drain grate and numerous flying insects were observed around it. 2. On 4/21/23 at 2:09 PM the 2nd floor west wing shower room was observed. There was a roach observed in the middle of the room. 3. room [ROOM NUMBER] was observed on 4/21/23 at 2:12 PM to have roaches that were in the middle of room that then ran under the B bed. 4. On 4/27/23…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews, it was determined the facility staff failed to include a resident's representative and/or guardian in the care of a resident (Resident #201, #657, #56) This was evident for 3 of 164 residents reviewed during an annual survey. The findings include: 1. Review of Resident #201's medical record on 4/24/23 revealed the Resident was admitted to the facility on [DATE] from the hospital with a diagnosis to include mild cognitive impairment. Review of the Resident's hospital record revealed the Resident was in the hospital from [DATE] until 3/24/23. During the hospitalization, the hospital filed a Petition for Appointment of Temporary Guardian on 2/9/23 and it was granted by the Court for the Resident to have an attorney for a guardian on 2/14/23. Review of the guardianship order revealed it stated the Resident is an incapacited person whom (1) no guardian is in place, (2) no other person appears to have authority to act under the circumstances, and (3) two certifications of…

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

Based on record review and staff interview it was determined that the facility staff failed to ensure that a resident deemed incapable of making decisions had a responsible party or a surrogate decision maker to act on their behalf (#167). This was evident for 1 out of 164 residents in the survey sample. The findings are: A review of Resident #167's clinical record revealed the resident had a social work history completed on 9/6/21. Section C of the assessment noted the resident to not be capable of decision making, did not request advance care planning information, and does not have a Power of Attorney, conservatorship or a court appointed guardian. The facility had the resident sign the Maryland Order for Life Sustaining Treatment (MOLST) form and a COVID vaccine declination form on 9/6/21. The resident signed the facility's Consent to Treat form on 9/7/21. The Social Work Director (Staff #11) was interviewed on 5/1/23 at 9:52 AM. He confirmed the resident is not capable of making decisions.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure that the residents had access to the call bell system and failed to ensure a resident's choice of bathing preferences were honored This was evident for 3 (#118, #203 and #209) out of 164 residents reviewed during an annual and complaint survey. The findings include: 1. On 04/17/23 at 08:30 AM, the surveyors observed Resident # 118's call bell placed on the light fixture above the head of the bed. On 04/18/23 at 09:30 AM, the surveyors observed Resident # 118's call bell on the floor next to the left side of the bed out of reach. On 04/19/23 at 09:00 AM, the surveyors observed the call bell on the floor next to the left side bed. During the interview conducted with Licensed Practical Nurse (LPN) # 2, the surveyors pointed out that Resident # 118's call bell was currently on the floor and shared their prior observations of the call bell not within reach. LPN # 2 placed the call bell within reach 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 observation and interview, it was determined that the facility staff failed to display the results of the annual recertification survey and plan of correction in a place readily accessible to residents, family members, and legal representatives. This was evident in the 1 of 1 survey results book posted in the facility. The findings include: Surveyor observation of the lobby from 4/17/23 through 4/19/23 revealed no evidence of the State inspection results in an open and readily accessible area for residents, staff, and visitors to review. A Sign was posted telling residents where the state survey results were located behind a set of double doors on the first-floor nursing unit. The sign was posted but the survey book was not accessible. On 4/21/23 at 12:55 PM, an interview with the Nursing Home Administrator confirmed the facility staff failed to place the results of survey inspections in a place easily accessible to any persons to be reviewed.

Based on record review and interview it was determined that the facility failed to offer to formulate an advanced directive. This was found evident in 2 (Resident #126 and #137) out of 13 Residents reviewed for advanced directives during the annual survey. The findings include: 1. A review of Resident #126's clinical record revealed that the resident did not have an Advanced Directive in their chart. Further review of the electronic health record revealed that the resident was not offered one to complete. The Director of Nursing (DON) was interviewed on 4/28/23 at 1:27 PM. The DON said he reviewed the resident's clinical record and confirmed that the resident did not have an Advanced Directive. He also confirmed that one was not offered to the resident. 2. A review of Resident #137's clinical record on 4/18/23 revealed that the resident did not have an Advanced Directive nor was the resident offered the opportunity to complete one. The DON was interviewed on 4/28/23 at 1:27 PM. He confirmed that the resident did not have an Advanced Directive and there is no evidence that one was…

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

Based on observation and medical record review, it was determined that the facility staff failed to protect the personal privacy and confidentiality of medical records. This was evident for 1 (2 West) of 5 nursing stations. The findings include: On 04/27/2023 at 10:38 AM, an observation was conducted on unit 2 West. Resident #167 was observed wandering into the unattended nursing station and then he/she proceeded to handle residents ' medical records which had been left on the desk by facility staff. Resident #167 handled the records for approximately 2 minutes before the Unit Manager (staff # 29) noticed and redirected him/her. On 04/27/2023 at 12:00 PM, a review of resident #167 ' s medical record revealed that he/she had a history of dementia and that the facility recognized that he/she was prone to wander.

Based on observation, medical record review, and interview of facility staff it was determined the facility failed to comprehensively and accurately assess the diagnoses of a resident. This was evident for 2 out of 164 (Resident #9 and #203) residents reviewed during an annual and complaint survey. The findings include: 1. On 4/24/23 at 10:59 AM upon review of Resident #49's medical record, a care plan was found to be in place to address Parkinson's disease. Further review of the resident's diagnoses list and medical records revealed no diagnosis of Parkinson's disease. On 5/2/23 at 9:50 AM during an interview with Staff #9, Director of MDS, the surveyor brought the concern to their attention, at which time they stated they would get back to the surveyor with clarification. On 5/2/23 at 10:13 AM, Staff #9 responded to the surveyor that Resident #49 does not have a Parkinson's diagnosis. 2. During an interview conducted on 04/17/23 at 11:51 AM, the surveyors asked Resident # 203 if he had difficulty with her/his vision. The resident responded yes, I am legally blind, but I don't…

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, interviews, and record reviews, it was determined that the facility failed to develop a comprehensive care plan for residents. This was found to be evident for 2 (# 203 and # 738) out of 9 residents reviewed for comprehensive care plans. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1. On 04/17/23 at 11:51 AM, during observation, Resident # 203 stated she/he was blind and not able to find the call bell. On 04/25/23 at 09:50 AM, the record review revealed that Resident # 203 was admitted on [DATE], the care plan was initiated on 3/21/2023, with no care plan for Blindness. 2. During an observation conducted on 4/17/2023 at 08:00, the surveyors observed oxygen via 2 liters via nasal cannula in use by Resident # 738. On 04/24/23 at 11:37 AM, during the medical record review for Resident # 738, the surveyors found a physician order for Oxygen at two liters via…

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 resident interview and clinical record review it was determined that the facility staff failed to maintain an activity program that meets a resident's needs (#126). This was evident for 1 out of 164 residents in the survey sample. The findings include: Resident #126 was interviewed on 4/18/23 at 9:02 AM. The Resident stated that the facility does not have group activities and they do not provide room to room activities either. The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A review of the resident's annual MDS completed on 2/5/23 Section F Preference for routine and activities revealed the resident said it is very important to have access to books, to have music, to have animals, access to the news, to do things with a group, to do activities, and to go outside. The…

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

Based on medical record review and interviews with facility staff it was determined that the facility failed to 1.) follow up and ensure ophthalmology services recommendations were obtained for Resident #125, and 2.) failed to make an ophthalmology appointment for Resident #49. This was evident for 2 of 9 residents reviewed for Sensory Communication during the annual survey. The findings include: 1. During the initial tour on 4/18/23 at 11:50 AM, Resident #49 voiced concern to the surveyor that they received no assistance to make an ophthalmology (vision) appointment. On 4/21/23 at 11:15 AM, medical records for Resident #49 were reviewed revealing the resident had an active medical order beginning on 3/7/22 for medical consults including ophthalmology. During an interview with Resident #49 on 4/21/23 at 12:56 PM, the resident verbalized that s/he used to wear glasses, needed a pair of glasses, did not currently have a pair, and had requested for facility staff to schedule a vision appointment. On 4/21/23 at 12:56 PM surveyor requested all vision consult records from 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, it was determined that the facility failed to provide appropriate oxygen therapy equipment. This was found to be evident for 1 (# 738) out of 1 resident observed on oxygen therapy. The findings include: During an observation [DATE] at 08:00 AM, the surveyors observed oxygen in use by Resident # 738. The humidifier bottle was dated [DATE] and not connected to the oxygen tubing. Resident # 738 stated that his nose was dry, and his oxygen concentrator wasn't working correctly. On [DATE] at 09:00 AM, the surveyors observed oxygen in use by Resident # 738, the oxygen tubing was not dated or connected to the humidifier bottle that was dated [DATE]. During an interview conducted on [DATE] at 11:00 AM, the DON confirmed Resident # 738's had an expired humidifier bottle that was not connected to the oxygen concentrator. The DON further stated the resident's oxygen concentrator was not equipped to connect to the humidifier bottle. He also showed the surveyors that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the resident record the facility failed to provide dialysis services for Resident # 487 on Wednesday 7/27/22 as ordered by the physician. This was evident for 1 out of 1 person reviewed for dialysis. The findings include: On 5/9/23 at 12:53 PM, Resident # 487's medical record was reviewed for dialysis. On Monday 7/25/22, the resident was admitted to the facility from a community hospital to receive dialysis and rehabilitation services. The medical record review indicated that the resident was ordered to receive dialysis on Monday, Wednesday, and Friday. There was no documentation in the record that stated that Resident #487 went to dialysis on Wednesday, as ordered, or why the resident did not go. The medical record noted that the resident went to dialysis treatment on Friday, 7/29/2022, as ordered by the physician but was only on the dialysis machine for 10 minutes when dialysis staff sent him back to the nursing department. The record revealed that the resident was too weak and lethargic…

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 interview with staff it was determined that the facility failed to ensure that the physician addressed a resident's significant weight loss. This was evident for 1 (#42) of 164 residents reviewed for weight loss. The findings include: On 2/28/23 at 9:30 AM, a review of Resident #42's medical record revealed, in a weight tracking system report, Resident #42's weight was documented as 137.4 ponds on 1/20/2023 and 152 pounds on 10/1/2022, which was a 10 % weight loss in 90 days. Further, the record review revealed the dietician documented in the medical record on 2/2/2023 that the resident had a 10% weight loss in 90 days and to continue with a regular diet double entrée, no other follow-up was noted by the dietician in the medical record. Continued review of the medical record failed to reveal that the physician and/or CRNP evaluated and addressed the resident's significant weight loss when it was identified. Progress notes were reviewed in the medical record on 4/18/23, 3/28/23, and 2/28/23, with no mention of a 10% weight loss for Resident…

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

Based on observation and interviews it was determined that the facility failed to post accurate, up-to-date, staffing information prior to the start of each shift. This was found evident on 2 of 2 random observations. The finding include: On 5/12/23 at 8:51 AM, the surveyor observed Staff #68 in the front lobby taking down the previous days staffing information and replacing it with the staffing information for 5/12/23. This was done well after the start of the day shift. On 5/12/23 at 11:16 AM, the surveyor conducted an interview with Staff #68. During the interview staff #68 stated he was responsible for posting the staffing information located in the lobby. He confirmed that if the staffing changes for any reason, he would reprint and post the updated staffing in the front lobby. He further stated he did not post staffing on the weekends but that the supervisors could post it. He stated that he and Human Resources Director are the two departments that print staffing reports and that he could print them ahead for the weekend. He stated the weekend supervisors would have to update…

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, interviews, and record review, it was determined that the facility failed to ensure that a resident medication was administered as ordered as evidenced by delayed administration of insulin. This was evident for 1 (# 226) out of 1 resident reviewed for sliding scale insulin coverage administration. The findings include: According to the CDC Diabetes is a chronic (long-lasting) health condition that affects how the body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. When you have diabetes your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. During an interview on 4/28/23 at 11:00 AM, The Licensed Practical Nurse (LPN) # 2 stated she obtains the residents blood glucose level once the resident began to consume their meal to ensure insulin administration safety. 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, interviews, and record reviews, it was determined that the facility failed to ensure medications were stored properly. This was evident for: 1) 2 out of 2 Storage Rooms and 2) 4 out of 5 Medication Carts inspected for proper storage. The findings include: 1. During an observation conducted with Licensed Practical Nurse (LPN) Supervisor # 29 on 04/26/23 at 08:40 AM, of the 2 [NAME] Medication Storage room, a plastic bag was found in the supply drawer that contained 3 blue top vacutainers that expired 1/30/2023. LPN Supervisor # 29 confirmed that the expiration date was 1/30/2023 and said she would remove the vacutainers and remind staff to check for expiration dates. According to the CDC Diabetes is a chronic (long-lasting) health condition that affects how the body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy.…

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 clinical record review it was determined that the facility staff failed to ensure residents received needed dental care (#42). This was evident for 1 out of the 10 residents reviewed for dental needs during and annual and complaint survey. The findings include: 1. Resident #42 was observed on 04/18/23 09:08 AM. Resident #42 had missing and broken teeth and was not wearing dentures. A review of the resident's clinical record revealed the resident has not had a routine dental consult since being admitted to the facility on [DATE]. On 04/28/23 at 10:20 AM the DON was made aware of the findings and after a thorough review could not find any dental consults on the chart or that one was ever completed since the resident's admission. The facility must assist residents in obtaining routine and 24-hour emergency dental care.

Based on observation and interviews it was determined that the facility failed to accurately follow dietary menus. This was found evident in 3 out of 10 (#96, #25 & #188) Residents reviewed for nutrition during an annual and complaint survey. The finding include: 1. On 4/17/23 at 8:57 AM, the surveyor conducted an interview with Resident #96. During the interview Resident #96 stated he/she did not get coffee, margarine, or eggs with his/her breakfast. On 7/17/23 at 9 AM, the surveyor observed Resident #96's meal ticket and breakfast tray. The ticket included coffee, margarine and eggs. There was no margarine container or coffee cup present on Resident #96. Resident #96 stated he/she did not get them. On 5/4/23 at 1:06 PM, the surveyor observed the meal pass on 2 West. The surveyor observed no beverages on any of the food trays. On 5/4/23 at 1:08 PM, the surveyor interviewed Minimum Data Set (MDS) coordinator Staff #73. Staff #73 stated they would call down to dietary and let them know they needed the beverage tray. She further stated that they deliver the beverages separately than…

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

Based on observation and interview with facility staff it was determined the facility failed to maintain cleanliness of the garbage and waste disposal area. The findings include: On 5/15/23 at 11:15 AM, surveyors accompanied Staff #63, Dietary District Manager to the waste disposal area. Upon exiting the kitchen, a pile of spilled trash containing food waste was observed laying on the floor against the wall on the inside of the facility as surveyors were headed toward the loading dock area. On 5/15/23 at 11:17 AM surveyors observed the area around the dumpster with various uncontained trash and debris on the ground including dirty disposable undergarments and torn medical gloves. A gated and locked area near the dumpster was observed containing various debris on the ground including a dirty cloth rag and a pile of large empty water containers. Additionally, surveyors observed an overturned shopping cart, a hospital bed frame laying on its side, and a large piece of wood that appeared to be a decaying pallet was present in the dumpster area. On 5/15/23 at 11:23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined that the facility failed to keep accurate medical records. This was evident in 1 of 164 (Resident #96, #672, #203, and #484) Resident's records reviewed during an annual and complaint survey. The findings include: The Medical Orders for Life-Sustaining Treatment (MOLST) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment options for a specific patient. 1. On [DATE] at 7:43 AM, the surveyor reviewed Resident #96's medical record. The review revealed Resident #96 was admitted to the facility in March of 2023 and had a Brief Interview for Medical Status (BIMS) score of 15, indicating Resident 96 was cognitively intact. Further review of the record revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form filled…

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 and observations it was determined that the facility failed to maintain adequate conditions of a bed. This was evident during 3 of 3 observations. Then findings include: On 4/17/23 at 9:20 AM, the surveyor interviewed Resident #96. During the interview Resident #96 stated his/her bed was broken when he/she was transferred to his/her current bed. Resident #96 stated the footboard made of particle board was broken along the entire side and that the facility staff tried to cover the broken side with tape and wound dressings. Resident #96 further described that the dressings and tape continued to fall off, so he/she requested that the footboard be taken off the end of the bed to prevent an injury. The surveyor observed that Resident #96 had no footboard at the end of the bed the he/she was currently occupying. The surveyor also observed the broken footboard up against the wall across from the bed. The footboard had jagged edges along the side that was broken. On 9/17/23 at 9:25 AM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #8. During the…

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

Based on observations and interviews it was determined that the facility failed to provide appropriate bedroom furniture for a resident. This was evident on 2 of 2 observations. The Findings include: On 4/17/2023 at 12:50 PM, the surveyor observed lunch delivered for Resident #56. The meal tray was placed on Resident #56's nightstand. The nightstand was out of reach from the bed. There was no bedside table for Resident #56. On 4/17/23 at 12:56 PM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #12. Staff #12 stated he was unaware Resident #56 did not have a bedside table but would get her one. On 4/17/23 at 1:04 PM, Staff #12 returned to Resident #56's room with a bedside table. On 4/18/2023 at 10 AM, the surveyor again observed Resident #56 without a bedside table. On 4/18/23 at 10:03 AM, the surveyor interviewed Activities Director Staff #42. During this interview Staff #42 stated she would get her a bedside table. On 4/27/23 at 8:11 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated he was aware of the need for more bedside tables and would…

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 Records and staff interview, it was determined that the facility staff failed to secure personal property for Resident #36 and Resident #232, while both residents were in the Hospital. This was evident for 2 out of 42 Residents investigated during the survey process. The Findings Include: 1.On 03/12/19 around 09:38 AM, Resident #32 was interviewed about the loss of personal property. Resident #32 uses a motorized wheelchair to ambulate on and off the unit. Upon return to the facility on 2/18/19, the facility was unable to locate the Resident's chair. During an interview with the Environmental Service Director (EVS) on 03/14/19 around 11:05 AM, the EVS explained the process for storing resident's belongings: when a resident goes out to the hospital, nursing bags up the Resident's property and generates a property form that goes with the property. Nursing then notifies EVS to pick up the Resident's property and store it. The property form is signed again when the property is reclaimed. The EVS went on to say that a motorized wheel chair must be stored by maintenance…

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

Based on medical record review and staff interview it was determined the facility failed to clarify an unclear order for blood pressure medication for Resident #184. This was evident for 1 of 42 residents investigated during the survey. The findings include: The medical record for Resident #184 was reviewed beginning on 3/12/19 at 1:26 PM. During the review a physician order was found which stated, Hydralazine HCL (Hydrocloride) 25 mg. Give 25 mg by mouth every 8 hours for HTN (hypertension/high blood pressure). Give for SBP (systolic blood pressure) greater than 150. It is a minimal standard of nursing practice for nurses to call the physician and ask for clarification when an order is unclear. This order is unclear because it reads as though the medication is to be given routinely on every shift, but then states to give when SBP is greater than 150 (which would mean give only as needed). A review of the Medication Administration Record (MAR) (which nurses sign after administering medications) revealed that some nurses were giving the medication no matter what the blood 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 medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that the residents or resident's representatives were notified in writing of reason residents are being transferred out of the facility to an acute care hospital. This was found to be evident for 3 out of 3 residents records reviewed for hospitalization involving Resident #238, R#161, and R#145 reviewed during the investigative portion of the survey process. The finding includes: 1) 0n 3/13/19 at 1:15 P.M. during hospitalization record review involving R#161 and R#238 revealed a nurse's transfer to hospital progress note written on 2/4/19 involving R #161 had an unplanned change in condition which the resident was transferred to acute care hospital for medical evaluation. On 3/13/19 at 2:00 P.M. during medical record review for R#238 revealed a nursing hospital transfer note written on 3/10/19 for unplanned change in condition involving R#238 which the resident was transferred out the facility to acute care hospital for further medical evaluation. 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 record review and interview with Director of Nursing , the facility failed to notify in writing to responsible party and resident on why resident was transferred to the hospital and the bed hold policy. This was evident for 2 out of 4 residents transferred to the hospital. The findings include: 1. Resident #198 was transferred to the hospital on 2/21/19 for blood in the urine. All paperwork was sent with the resident to the hospital. The resident and responsible party were not notified in writing of why the resident was transferred to the hospital or the bed hold policy. Of which the Director of Nursing and Administrator were made aware. 2. Resident # 172 was sent to the hospital for a dislodged gastrostomy tube. All paperwork was sent with the resident to the hospital. The responsible party and the resident did not receive in writing notification of why the resident was sent to the hospital or the bed hold policy. The Director of Nursing and Administrator were made aware.

Based on medical record review and interviews it was determined the facility failed to ensure a medical device was removed as recommended for Resident #154. This was evident for 1 of 42 residents reviewed during the survey. The findings include: In February 2019 an anonymous complaint was received regarding the care of Resident #154. Resident #154 has a form of cancer and receives treatments at an infusion center. One of the treatments given to Resident #154 is through a Neulasta Onpro device. Per https://www.drugs.com/mtm/neulasta-onpro-kit.html, The Neulasta Onpro Injector is a special device placed on the skin that delivers your Neulasta Onpro Kit dose at a specific time. Per https://www.neulasta.com/onpro, Neulasta is a prescription medicine used to help reduce the chance of infection due to a low white blood cell count, in people with certain types of cancer (non-myeloid), who receive anti-cancer medicines (chemotherapy) that can cause fever and low white blood cell count. On 3/12/19 beginning at 12:30 PM the medical record for Resident #154 was reviewed. According to the…

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

Based on record review, the facility failed to provide orders for catheter care. This was evident for 1 out of 1 records reviewed for urinary catheters. The findings include: A record review was conducted for Resident # 196 on 3/11/19 at 12:14 PM. Resident 196 was admitted to this facility in 1/2019. The resident has a history of end stage renal failure, obstructive and reflux uropathy. He is dependent on renal dialysis. He also has chronic kidney disease among other diagnosis. The resident has a suprapubic cath, secondary to gun shot. He is also a paraplegic. There are no physician orders on the chart for care of his suprapubic cath. There are no orders to clean the cath area, change tubing or foley bag and how often. The Unit Manager was informed. Also, the Administrator and Director of Nursing DON) were made aware.

Based on observation and staff interview, it was determined that the facility staff failed to label a medication when opened. This was evident for 1 out of 6 medication carts observed during the survey process. The findings include: On 03/14/19 around 01:03 PM, 6 medication carts were reviewed for labeling and expired medications. The carts reviewed were 2 on 2 West 2 on 1 [NAME] 1 on 3 [NAME] 1 on 3 East - On 3 east- 1 bottle of Kreppa solution (controls seizures) 100mg/ml for Resident #83, a 70-milliliter bottle was opened and not dated when opened. 1 bottle of Kreppa Solution 100 mg /ml for Resident #57, a 300-milliliter bottle was opened and not dated when opened. Without a date of opening there is no way to determine the expiration date.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident bedroom observation it was determined that all multiple occupancy bedrooms did not provide the minimum space per bed as required. The findings include: The following triple bedrooms (3 beds per room) did not provide the minimum of 80 square feet per bed as required: room [ROOM NUMBER] provided on 79.4 square feet per bed which is a shortage of .6 square feet. room [ROOM NUMBER] provided on 79.4 square feet per bed which is a shortage of .6 square feet. room [ROOM NUMBER] provided on 78.7 square feet per bed which is shortage of 1.23 square feet. room [ROOM NUMBER] provided only 78.87 square feet which is shortage off 1.13 square feet. room [ROOM NUMBER] provided on 78.68 square feet per bed which is shortage of 1.37 square feet. Cross-reference with S 1365 for bedrooms that did not meet State of Maryland space requirement. Adminstrator was informed during and prior to the survey exit.