Maryland Masonic Homes LTD

Based on observation, interview, and record review it was determined the facility failed to take measures to ensure a resident was free from accident hazards. This was evident for 1 (Resident #20) out of 2 residents reviewed for accidents during the facility's recertification survey. The findings include: On 5/27/25 at 10:38AM the surveyor observed Resident #20 from the hallway to be laying on their back in their bed which was in a flat position and also in the highest position, with a hoyer sling situated under them and their foley catheter bag laying on top of their right thigh. No staff was observed by the surveyor to be present within the resident's room or within the hallway. On 5/27/25 at 10:40AM the surveyor conducted an interview of Resident #20 who reported to the surveyor that their nursing assistant had left to get something and they had been laying there for five minutes. Resident #20 stated to the surveyor: It makes me feel helpless. On 5/27/25 at 10:42AM the surveyor requested a dual observation with the resident's assigned nurse. On 5/27/25 at 10:43AM the surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility failed to ensure proper reconciliation of expired controlled drug medications during medication administration and drug record keeping for the resident. This was evident for 1 (Resident #33) out of 6 residents reviewed for medication storage during the facility's recertification survey. The findings include: During observation rounds and resident record review on [DATE] at 1:57PM with Licensed Practical Nurse (LPN) #6, the surveyor reviewed the narcotic count log book and the narcotic medications on-hand within the lock box where they are stored. The surveyor observed Resident #33's Oxycodone TAB 5mg medication card and noted an expiration date located on the back of the card, which revealed the medication was expired as of [DATE]. The surveyor then reviewed the controlled drug receipt/record/disposition form within the narcotic count log book which revealed that Oxycodone 5mg Tab was given to the resident on [DATE] by Registered Nurse (RN)…

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, record review, and interview it was determined that the facility failed to follow prescriber's orders and manufacturer's specifications regarding medication preparation during medication administration for the resident. This was evident for 1 (Resident #13) out of 4 residents observed for medication administration during the facility's recertification survey. The findings include: During observation rounds for medication administration on 5/28/25 at 8:56AM the surveyor observed Registered Nurse #5 prepare Resident #13's medications using a white eating utensil spoon not labeled with measurements to scoop 2 scoops out of a bulk Benefiber bottle, to mix in a measured cup prior to adding liquid. During surveyor review of Resident #13's medical record on 5/28/25 at 9:00AM the record revealed the following physician's medication order: Benefiber powder (Wheat Dextrin) Give 1 packet by mouth one time a day for diarrhea Dissolve contents in 8 ounces of liquid; Benefiber powder ADMINISTER 2 TEASPOONSFUL BY MOUTH ONE TIME A DAY FOR DIARRHEA DISSOLVE CONTENTS IN 8 OUNCES…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility failed to ensure safe and separate storage of food brought in by family or visitors for residents. This was evident for 1 out of 2 Central Supply Room refrigerators observed during the recertification survey. The findings include: During observation rounds the following was found: On 6/2/25 at 11:00AM with Unit Manager (UM) #11 within the Central Supply room located on Baltimore Hall #2, the surveyor observed 3 of 6 containers of smoked salmon cream cheese spread, with an expiration date of 5/18/25. On 6/2/25 at 11:02AM with UM #11 within the central supply room located on Baltimore hall #2, the surveyor observed 2 of 2 white soup containers of liquid with visitor label dated [DATE]. On 6/2/25 at 11:04AM with UM #11 within the central supply room located on Baltimore hall #2, the surveyor observed 2 of 2 containers of cottage cheese with fruit, with the expiration date: 4/7/25. On 6/2/25 at 11:06AM with UM #11 within the central supply room…

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

Based on facility document review and interview, it was determined that the facility administration failed to follow the guidelines for abuse investigation which included conducting complete and thorough investigations, identifying abuse and putting in appropriate interventions to prevent further occurrences of abuse. These failures placed all residents at risk for abuse. This was evident for 4 of 4 (#6, #7, #2 and #10) facility reported incidents reviewed completed by the previous facility Director of Nursing. The findings include: 1. Review on 10/17/24 at 11:55 AM of the FRI regarding Resident #6 an allegation of verbal abuse revealed that residents' family member reported to the (previous) facility DON, staff # 18, on 6/14/24 that staff were rude when delivering residents breakfast trays. The concern was further noted that staff would leave the breakfast trays in front of the resident and then would not assist the resident right away with eating. Record review at 12:30 PM on 10/17/24 revealed that Resident #6 was dependent on staff for meals and eating as noted in his/her care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff, it was determined that the facility staff failed to enhance a resident's dignity. This was evident during the review of a facility reported incident regarding activities of daily living care 2 of 30 (#6, R4). This failure placed residents at risk of their rights being violated and not upheld. The findings include: 1.) Review of the facility reported incident (FRI) on 10/17/24 at 11:55 AM regarding Resident #6 and an allegation of verbal abuse revealed that residents' family member reported to the (previous) facility Director of Nursing (DON) # 18 staff were rude when delivering residents breakfast trays. The concern was further clarified that staff would leave the breakfast trays in front of the resident and then would not assist the resident right away with eating. Record review at 12:30 PM on 10/17/24 revealed that Resident #6 was dependent on staff for meals and eating as noted in his/her care plan and in the daily nursing progress notes. Per…

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 documentation and interview with staff it was determine the facility staff failed to ensure that allegations involving abuse were reported to the Administrator of the facility and the State Agency no later than 2 hours after the allegation was made and results of all investigations were reported within 5 working days. This was evident in 3 of 26 (#6, #2 and #10) facility reported incidents reviewed during a complaint survey. The findings include: 1. Review of the facility reported incident (FRI) regarding Resident #6 and an allegation of verbal abuse on 10/17/24 at 11:55 AM revealed that residents' family member reported to the (previous) facility Director of Nursing (DON) #18 on 6/14/24 that staff were rude when delivering residents breakfast trays. The concern was further noted that staff would also leave the breakfast trays in front of the resident and then would not assist the resident right away with eating. On 6/20/24 a care plan meeting was held. That same family member, Resident #6's representative, asked the DON what the follow-up was to his…

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, it was determined that the facility staff failed to thoroughly investigate allegations related to potential abuse and injuries of unknown origin. This was evident during the review of 5 of 30 (#4, #6, #7, #10, #25 ) incidents requiring facility reports and investigations. The findings include: 1. Review of the FRI regarding Resident #6 and allegation of verbal abuse on 10/17/24 at 11:55 AM revealed that residents' family member reported to the (previous) facility Director of Nursing (DON) # 18 on 6/14/24 that staff were rude when delivering residents breakfast trays. The concern was further noted that staff would leave the breakfast trays in front of the resident and then would not assist the resident right away with eating. Record review at 12:30 PM on 10/17/24 revealed that Resident #6 was dependent on staff for meals and eating as noted in his/her care plan and in the daily nursing progress notes. On 6/20/24 a care plan meeting was held. That same family member, Resident #6's representative, asked the DON what 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 medical record review and interview with facility staff, it was determined that the facility staff failed to appropriately review a medication order and administer medication according to professional standards. This was evident for 1 of 3 facility reported incidents reviewed regarding medication management (Resident #1). The findings include: Review of the facility reported incident for Resident #1 on [DATE] at 11:30 AM revealed that Resident #1 was administered 10 x the ordered dose of Morphine. Further review of the incident report revealed that the medication order was taken as a verbal order on [DATE] at approximately 3pm by RN #7. The order was intended for a concentration of 20mg/ml of morphine to administer a dose of .25ml every 2 hours as needed for a dose of 5mg of Morphine. However, RN #7 transcribed the order as 2.5ml. When the medication arrived, the controlled drug receipt/record disposition form showed that the concentration of the Morphine was 20mg/ml. According to the medication…

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 clinical record review and staff interviews, it was determined that the facility staff failed to ensure adequate supervision while positioning a resident in bed during the provision of care. This deficient practice resulted in the Resident #17 falling out of bed. This was evident for 1 (17) of 1 resident reviewed for accidents. The findings include: On 10/17/24, a record review was conducted which revealed that Resident #17 had diagnoses which included myalgia, osteoarthritis, pain and quadriplegia. Quadriplegia is paralysis that affects all a person's limbs. The MDS (Minimum Data Set) is a screening tool that is utilized to ensure each resident's individual needs are identified. A review of the MDS assessment, with an assessment reference date of 07/7/2023, identified that to turn from side to side and position body when in bed, the resident was totally dependent on staff for the activity and required 2 staff persons to physically assist. According to facility notes dated 9/29/23 at 12:30 PM, 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 medical record review and interview, the facility failed to monitor a resident's weight loss and nutritional status. This was evident for 1 of 30 (resident #30) residents reviewed during a complaint survey. Findings includes: On 3/27/24, the State of Maryland's Office of Health Care Quality received a complaint which alleged the facility failed to monitor resident #30's status and well-being during his/her stay in the facility. Review of resident #30's medical record on 10/17/24 at 8:11 am revealed the resident was ordered to be weighed monthly. The resident's weight on 6/14/22 was 124 lbs. The resident's weight on 7/2/22 was 104 lbs. Review of the nutritional assessment on 8/4/22 revealed the assessment was done after the resident was transferred to a local hospital after a fall on 7/4/22 that caused a laceration to the resident's forehead. The resident's weight had increased to 108.4 lbs. after the hospital stay. The assessment also revealed that the resident was given a PEG tube, a feeding tube that used to provide nutrition to residents that are unable to eat or cannot…

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 of a facility reported incident and interview with facility staff, it was determined that the facility failed to address residents pain. This was evident for 2 of 5 (#1 and #17) residents reviewed for incidents of injuries with pain. The findings include: 1. Review of the facility reported incident (FRI) on 10/16/24 at 11:30 AM for Resident #1 revealed a noted change in condition identified by the RN on duty staff #5, that was sent to the on-call provider, MD, staff #21. RN #5 reported that Resident was exhibiting signs and symptoms of pain and discomfort, continually removing his/her oxygen and has episodes of agonal breathing .no longer eating or drinking. Is it possible to have an order for Morphine or some type of narcotic pain killer to keep him/her comfortable? This was sent on 8/7/24 at 11:31 AM under urgency -1 hour. At 11:42 AM on 8/7/24, MD staff #21, responded Please reach out to CRNP #7 as she is the first point of contact in E-medical. The concern and change in…

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

Based on medical record review of a facility reported incident and interview with facility staff, it was determined that the facility failed to ensure that a physician was responsive to the emergency needs of residents on a 24-hour basis. This was evident during the review of 1 of 5 (#1) incidents where the physician was contacted after hours. The findings include: Review of the facility reported incident (FRI) on 10/16/24 at 11:30 AM for Resident #1 revealed a noted change in condition identified by the RN on duty, staff #5, that was sent to the on-call provider, MD, staff #21. RN staff #5 reported that Resident was exhibiting signs and symptoms of pain and discomfort, continually removing his/her oxygen and has episodes of agonal breathing .no longer eating or drinking. Is it possible to have an order for Morphine or some type of narcotic pain killer to keep him/her comfortable? This was sent on 8/7/24 at 11:31 AM under urgency -1 hour. At 11:42 AM on 8/7/24, MD staff #21, responded Please reach out to staff CRNP #7 as she is the first point of contact in E-medical. 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.

Based on medical record review and interview, a facility provider failed to refer a resident's case to a dietitian when the resident required additional supplementation (resident #30). This was evident for 1 of 30 residents reviewed during a complaint survey. Findings includes: On 3/27/24, the State of Maryland's Office of Health Care Quality received a complaint which alleged the facility failed to monitor resident #30's status and well-being during his/her stay in the facility. Review of resident #30's medical record on 10/17/24 at 8:11am revealed the resident was ordered to be weighed monthly. The resident's weight on 6/14/22 was 124 lbs. The resident's weight on 7/2/22 was 104 lbs. Review of the nutritional assessment on 8/4/22 revealed the assessment was done as part of readmission protocols after the resident was readmitted to the facility after being transferred to a local hospital after a fall on 7/4/22. The resident's weight had increased to 108.4 lbs. after the hospital stay. The assessment also revealed that the resident was given a PEG tube, a feeding tube that used to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observation, and staff interview, it was determined that the facility failed to develop and implement comprehensive person centered care plans that were resident specific, with measurable objectives and goals. This was evident for 8 (#57, #25, #31, #54, #369, #9, #36, #26) of 35 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. 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) Review of Resident #57's medical record on 5/5/21at…

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

Based on observations of the facility's kitchen food services, and staff interview, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations. This was identified while observing the facility's dish washing machine in operation. The findings include. During the initial environmental kitchen food services inspection on 5/3/21, the Certified Dietary Manager (Staff # 12) in charge of the kitchen revealed that the facility was utilizing disposable dishware as the facility was currently in a COVID-19 outbreak. The trays that held the disposable dishware were the only items for washing in the dish washing machine. Observations were made, on 5/7/21 at 9:45 AM, of the cleaning of trays in the dish washing machine by 2 dietary staff (staff #23 and #24) who were operating the dish washer machine. Observations of the temperature gauges on top of the machine showed one gauge to register 130 degrees Fahrenheit (F) and the other gauge shown to be at 140 degrees F. Staff should ensure that dishwasher temperatures are…

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 records and interview with staff, it was determined the facility failed to revise and document an accurate up-to-date facility-wide assessment. This was evident during review of the sufficient and competent nurse staffing task of the annual survey. This had the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. A copy of the facility assessment was requested at the initiation of the survey on 5/3/21. The facility assessment was requested again on 5/11/21. Review of the facility assessment on 5/12/21, revealed the date of assessment or update was documented as 5/5/21. As of 5/5/21, there was a continuation of a Maryland state…

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

Based on observation, medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (#54, #71, #36) of 35 residents reviewed during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. 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) Observation was made on 5/3/21 at 2:29 PM, of Resident #54 lying in bed receiving oxygen 2 liters via nasal cannula. A nasal cannula is a small, flexible tube that contains two open prongs intended to sit just inside the nostrils. Review of Resident #54's medical record on 5/4/21 at 8:49 AM revealed a physician's order from 4/21/21 to 5/3/21 to titrate 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 observation, medical record review, and interviews, it was determined that the facility staff failed to meet professional standards by 1) failing to follow the 5 rights of medication administration by not confirming a resident's name prior to the administration of medications, 2) failing to offer water to a resident taking 8 medications, 3) documenting that a medication was administered when it was not observed to be administered, 4) documenting that a resident was receiving oxygen continuously when the resident was not using oxygen, 5) documenting that TED stockings were worn when they were not observed on the resident, 6) failing to follow physician's orders for blood pressure medications that had parameters for administration, and 7) documenting the administration of a pain medication that was not removed from the supply, and staff removal of a dose of narcotic pain medication from resident supply without documentation of the medication administration. This was found to be evident for 6 (#57, #49,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan as evidenced by: 1) failure to follow a physician order to obtain vital signs every shift for 7 days; 2) failure to ensure a heart rate was obtained and recorded when a medication with ordered parameters was administered; 3) failure to provide assistance with meals as indicated by the nursing assessment and included as an intervention in the care plan; 4) failure to administer pain medication as ordered for a resident with a broken hip on at least 13 occasions over a 26 day period; and 5) failure to have a system in place to ensure that weekly weights were obtained as ordered and that the registered dietitian addressed significant weight loss when it was identified and 6) failed to provide TED stockings as prescribed and then documented that the treatments were provided. This was found 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 medical record review and interview, it was determined that the facility failed to ensure that physicians reviewed the resident's total plan of care, completed, and signed orders during each visit; and ensure that the primary care physician's notes were placed in the resident's medical record in a timely manner This was found to be evident for 4 out of 25 residents (Resident #9, #26, #8, #22) reviewed during the investigative portion of the survey. The findings include: 1) On 5/10/21, review of Resident #9's medical record revealed that the resident was admitted in 2020 and whose diagnoses included but were not limited to arthritis, heart disease and dementia. The resident [NAME] dependent on g-tube feeding for all nutritional intake. Review of the medical record failed to reveal documentation to indicate the resident was currently receiving therapy services. a) On 5/10/21 at 11:56 AM, the Rehab Director (Staff #29) reported that the resident was receiving physical therapy services. Surveyor expressed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility records and interview with staff, it was determined that the facility failed to ensure that staff demonstrated competencies in skills and techniques necessary to care for residents' needs. All residents can be affected as competency skill sets should be based on resident care, safety and services delivered. The findings include: Competency in skills and techniques necessary to care for residents' needs includes, but is not limited to, competencies in areas such as; resident rights, person centered care, communication, basic nursing skills, basic restorative services, skin and wound care, medication management, pain management, Infection control, identification of changes in condition, and cultural competency. As required under F838, the facility's assessment must address/include an evaluation of staff competencies that are necessary to provide the level and types of care needed for the resident population. The facility failed to adequately address what competencies were required 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 medication administration observation, medical record and facility documentation review, and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 percent for 3 (#57, #49, #44) of 4 residents observed with 3 errors out of 27 medication administration opportunities which resulted in an error rate of 11.11% by 2 licensed practical nurses (LPN #3, LPN #4) and 1 certified medicine aide (CMA #5) that were observed during medication administration during an annual survey. The findings include: 1) Observation was made of the medication administration to Resident #57 on 5/5/21 at 7:58 AM by LPN #3. LPN #3 administered Olopatadine, 2 eye drops in each eye to Resident #57. Review of the physician's order revealed only 1 drop was to be given in each eye. 2) Observation was made of the medication administration to Resident #49 on 5/5/21at 8:25 AM by LPN #4. LPN #4 was observed dispensing medications from the blister packets into a medication cup. LPN #4 dispensed Preservision, Vitamin D3, Gabapentin, Carvedilol, and (2) 100 mg.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff, it was determined that the facility failed to ensure a resident was free of significant medication errors as evidenced by the nursing staff's 1) failure to hold a blood pressure medication when the blood pressure values were outside of the parameters to administer the medication and 2) failure to administer a blood pressure medication when the parameters indicated the medication should be administered. This was evident 2 (#369, #31) out of 5 residents reviewed for unnecessary medications during the annual survey. The findings include: Blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through the arteries. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps the blood out into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). 1) Review of the medical record 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 medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form and failed to ensure that geriatric nursing assistant (GNA) documentation was readily accessible. This was evident for 8 (#15, #25, #31, #57, #54, #169, #9, #22) of 35 residents reviewed during the annual survey. The findings include: A medical record is the official document 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. 1) On 5/10/21 at 8:00 AM, review of facility reported incident MD00159407 revealed that Resident #15 had a large discoloration to the left chest area of unknown origin that was found on 10/16/20. The facility did an investigation and the NP (nurse practitioner) ordered to monitor the bruising. Review of Resident #15's medical record failed to reveal documentation that the responsible party was made aware of the bruising. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined the facility failed to ensure an effective infection prevention and control program by 1) failing to follow infection prevention and control guidelines by not keeping the doors closed of isolated residents on droplet and contact precautions, 2) failing to ensure that staff utilized personal protective equipment (PPE) in a manner that met minimum standards and minimized risk for infectious spread and, 3) failing to ensure that signage was outside of each resident's room who was on isolation indicating all types of isolation the resident was on, and what PPE was required prior to entering the room. Failing to utilize proper infection control signage was identified for 2 (Resident #172, #56) of 35 residents reviewed during the annual survey. The interrelated, noncompliant practices within the facility's infection prevention and control program left all residents, staff, and visitors at increased risk for harm during a declared health pandemic and 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.

Based on medical record review and interview, it was determined that the facility failed to have a system in place to ensure residents' COVID test results were kept in the residents' medical records. This was found to be evident for 2 (Resident #26, #25) of 2 residents reviewed for COVID-19 during the annual survey, but was determined to be a facility wide practice. The findings include: 1) On 5/7/21, review of Resident #26's medical record revealed an order on 4/22/21 for a COVID test. Further review of the medical record failed to reveal the results of this test. On 5/7/21 at 2:04 PM, the Director of Nursing (DON) confirmed that the COVID test results were not presently kept in the residents' medical record. She went on to report that there was a portal to the lab where the results could be accessed, but confirmed that not all staff had access to this portal. She reported that she was currently working on linking the lab portal with [name of electronic health record system]. The concern regarding failure to ensure that COVID test results were kept in resident's medical record 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 medical record review and staff interview, it was determined that the facility staff failed to notify the physician of blood pressure readings outside of physician ordered parameters. This was evident for 2 (Resident #369, #31) of 5 residents reviewed for unnecessary medications during an annual survey. The findings include: Blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through the arteries. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps the blood out into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). 1) Review of Resident #369's April 2021 physician's orders on 5/5/21 at 10:40 AM revealed an order for Metoprolol Tartrate Tablet 25 mg., give 1 tablet by mouth 2 times a day for HTN (hypertension). Hold for BP (blood pressure) less than 110/60 or HR (heart rate) less than 60. The physician also ordered Hydrochlorothiazide 25 mg. every morning for edema (also treats high blood…

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

Based on medical record review and interview with the facility's staff, it was determined that the facility failed to provide notice to residents informing them that Medicare may deny payments for procedures or treatments and that residents may be personally responsible for full payment. This was evident for 2 of 3 residents reviewed for Beneficiary Protection Notification during the survey (Resident #4 and #65). The findings include: An Advance Beneficiary Notice (ABN) is a written notice from Medicare, given to residents before receiving certain items or services notifying beneficiaries that Medicare may deny payment for that specific procedure or treatment. An ABN gives residents the opportunity to accept or refuse the items or services and protects them from unexpected financial liability in cases where Medicare denies payment. 1. On 05/05/2021 at 2:43 PM, Resident # 4's Beneficiary Protection and Notification was conducted. This review revealed that Resident #4's last covered day for skilled nursing services was on 02/05/2021. There was no evidence in the resident's record 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.

Based on observation, interview, and documentation review, it was determined that facility staff failed to promote care for a resident in an environment that maintains or enhances each resident's dignity and privacy. This was evident for 2 (#54, #25) of 2 residents observed on the COVID unit during the annual survey. The findings include: Observation was made, on 5/3/21 at 2:34 PM on the COVID unit of, Resident #54 and Resident #25 lying in bed in the same room. The COVID unit consisted of rooms with residents that were on contact and droplet isolation precautions. There were no privacy curtains observed in the room. A second observation was made on 5/4/21 at 1:50 PM. There were no privacy curtains in the room. Staff #8 (geriatric nursing assistant) GNA and Staff #9 (LPN) were giving personal hygiene care to Resident #25 and Resident #54 without providing privacy to each of the residents. On 5/6/21 at 9:50 AM, an interview was conducted with Staff #15, the Director of EVS (Environmental Services). Staff #15 was asked if there was a specific reason why a privacy curtain would not 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, facility investigation documentation and interview, it was determined that the facility 1) failed to ensure that an injury of unknown origin was reported to the survey and certification agency and 2) failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was found to be evident for 1 out of three residents (Resident #169) reviewed for accidents and for 2 (#15, #120) of 7 residents reviewed for abuse during the annual survey. The findings include: 1) Resident #169, who was unable to provide information to staff due to dementia, was found on the floor with significant injuries on two separate occasions by staff. On the second occasion, the resident was found by the night time supervisor during routine rounds on the floor several feet away from their bed (despite the presence of a bed alarm). On 5/12/21, review of Resident #169's medical record revealed that the resident was admitted 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 review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate allegations of abuse. This was evident for 2 (#120, #121) of 7 residents reviewed for abuse. The findings include: 1) Review of facility reported incident MD00135677 for Resident #120 on 5/10/21 at 2:25 PM revealed the resident reported that a geriatric nursing assistant (GNA) came into Resident #120's room at 6:00 AM and asked Resident #120 if he/she was wet. Resident #120 stated that he/she was not wet, however the GNA proceeded to place his hand on Resident #120's brief. The facility determined that the GNA violated the resident's right to consent for care before it was given and terminated the GNA from the facility. On 5/10/21 at 2:45 PM, the Director of Nursing (DON) was asked if there was a documented investigation. The DON stated that the incident happened prior to her becoming the DON and there was nothing else in the file. The DON stated she would look to see if there was any other documentation. At that time, the employee's file 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 medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (#54) of 3 residents reviewed for hospitalization during the annual survey. The findings include. 1) Review of Resident #54's medical record on 5/4/21 at 8:41 AM revealed the resident had vomited, had chills, an elevated temperature and a change in mental status. The physician was notified and ordered for the resident to be sent to the hospital via 911. There was no documentation as to what interventions were put into place before the ambulance arrived, what the resident was told and if the resident understood where he/she was going and why. LPN #13 reviewed the electronic and paper medical record with the surveyor on 5/10/21 at 12:57 PM and confirmed that there was no documentation. The Director of Nursing was informed on 5/11/21 at 8:36 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews with staff and a resident, it was determined that the facility failed to ensure that an interdisciplinary team, which included the resident and or the residents representatives, contributed to the resident's comprehensive care plan as evidenced by the failure to conduct a quarterly care plan meeting. This was identified for 1 (#8) of 3 residents reviewed for nutrition. 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. Resident #8 was admitted to the facility on [DATE]. On 5/5/21, review of the first quarterly MDS (minimal data set) assessment dated [DATE], shown that resident #8 had a significant weight loss during the first 3 months of admission. (Excessive weight loss without prescribed weight loss program >5%within the past 30 days, >7.5% within the past 90 days.) Further review of the medical record on 5/10/21 did not reveal that the…

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

Based on observation, medical record review and interview, it was determined that the facility failed to provide activity services to meet the needs of the resident. This was found to be evident for one out of one resident (Resident #36) reviewed for activities during the investigative portion of the survey. The findings include: Review of Resident #36's medical record revealed that the resident was admitted to the facility in 2019. The resident was dependent on staff for assistance with transfers and requires assistance with locomotion. The most recent Brief Interview for Mental Status (BIMS) score was 14 out of 15, indicating the resident was cognitively intact. Review of the annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 11/4/2020, revealed that the resident participated in the assessment of Activity Preferences and indicated it was very important to have books, newspapers and magazines to read, listen to music he/she likes, keep up with news, go outside for fresh air and participate in religious services. The Minimum Data Set (MDS) is 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 medical record review and interview, it was determined that the facility failed to ensure that dressing changes were completed as ordered for an open area on the resident's coccyx (bony structure at bottom of spine). This was found to be evident for 1( #169) out of 25 residents reviewed during the investigative portion of the survey. The findings include: On 5/12/21, review of Resident #169's medical record revealed the resident was admitted to the facility in May of 2019 with diagnoses that included, but was not limited to dementia, high blood pressure, osteopenia (bone loss) and macular degeneration (eye disease that causes vision loss). Review of the progress notes revealed a nurse's note, with an effective date of 8/22/19, which revealed the resident was seen by the in house wound doctor for a consult on open area to coccyx area. Area observed 2 cm x 1.5 cm noted to be reddened and open, received order to cleanse area with Anasept pat dry apply med honey and 2 x 2 and cover with foam dressing qd [every day] and prn [as needed]. A corresponding physician order was found…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records, facility investigation documentation and interview, it was determined that the facility 1) failed to ensure unwitnessed falls were thoroughly investigated for 1 out of 3 residents (Resident #169) reviewed for accidents during the survey, and 2) failed to provide a physician ordered safety device for 1 of one out of the twenty five residents (Resident #8) reviewed during the investigative portion of the survey. The findings include: On 5/12/21, review of Resident #169's medical record revealed the resident was admitted to the facility in May of 2019 with diagnoses that included, but were not limited to dementia, high blood pressure, osteopenia (bone loss) and macular degeneration (eye disease that causes vision loss). Review of the admission nursing assessment, dated 5/1/2019, revealed the resident was able to ambulate with the use of an assistive device (ie walker) and was at a high risk for falls. Review of the nursing progress note, dated 5/10/19 at 10:38 AM, revealed 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 observation, medical record review and interview, it was determined the facility 1) failed to follow physician's orders for the administration of oxygen, 2) falsely documented that the resident was receiving oxygen when the resident was observed not receiving oxygen and 3) failed to develop and implement a person centered comprehensive care plan with resident centered goals for respiratory care to include oxygen therapy. This was evident for 1 (#57) of 4 residents reviewed for respiratory care during the annual survey. The findings include: Observation was made on 5/3/21 at 11:15 AM, of Resident #57 in his/her room lying in bed. An interview was conducted with Resident #57 at that time and a green oxygen tank was observed sitting upright against the wall under the television. Resident #57 was asked if he/she was using the oxygen tank and the reply was no and Resident #57 was not observed receiving oxygen therapy. A second observation was made of Resident #57 on 5/4/21 at 12:25 PM with another surveyor,…

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

Based on medical record review and interview, it was determined that the facility failed to administer pain medication as ordered for a resident with a broken hip on at least 13 occassions over a 26 day period. This was found to be evident for one out of the twenty five residents (Resident #169) reviewed during the investigative portion of the survey. The findings include: On 5/12/21, review of Resident #169's medical record revealed the resident was admitted to the facility in May of 2019 with diagnoses that included but were not limited to dementia, high blood pressure, osteopenia (bone loss) and macular degeneration (eye disease that causes vision loss). Further review of Resident #169's medical record revealed the resident sustained a fractured femur (broken hip) on 5/13/19 and was hospitalized for over a week. Review of the physician orders revealed the following order with a start date of 5/23/19: Hydrocodone-Acetaminophen Tablet 5-325 mg, give 0.5 tablet by mouth three times a day for pain. This order was in effect until it was discontinued on 6/17/19. As a narcotic,…

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 ensure that the interdisciplinary team had determined that the resident was safe to self administer medications prior to allowing the resident to keep inhalers for treatment of chronic obstructive pulmonary disease (COPD) and nasal spray for allergies at the bedside; failed to develop a care plan to address the resident's self administration of medications and failed to ensure that the physician order specified which medications were to be kept at the resident's bedside for self administration. This was found to be evident for 1 out of 6 residents (Resident #36) reviewed for unnecessary medications. The findings include: On 5/6/21, review of Resident #36's medical record revealed the resident had been admitted to the facility in 2019. The most recent Brief Interview for Mental Status (BIMS) score was 14 out of 15 indicating the resident was cognitively intact.The resident has a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the medical record revealed a physician's order, in place since…

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, staff interview, and facility documentation review, it was determined that facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 2 nursing units observed during an annual survey. The findings include: 1) Observation was made, on 5/4/21 at 2:44 PM, of an unlocked and unattended medication cart sitting in the hallway outside of room [ROOM NUMBER]. The surveyor opened the medication cart drawers and stood at the medication cart from 2:44 PM until 2:47 PM, while it was left unlocked and unattended. LPN # 7 walked up to the medication cart and stated, we thought we locked it. 2) Observation was made, on 5/11/21 at 2:05 PM, of an unlocked and unattended medication cart sitting in the hallway outside of room [ROOM NUMBER]. The medication cart was unattended from 2:05 PM until 2:08 PM when RN #34, an agency nurse, walked up from the nurse's station and stated, I must have forgot to lock it .The surveyor was able to open the drawers and observed 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 medical record review, diet slips, and staff interview, it was determined that a resident was receiving a therapeutic diet that was not prescribed by a physician. This was evident for 1 (resident #8) of 3 residents reviewed for nutrition. The findings include. Resident #8 was admitted to the facility in December of 2020. Review of the first quarterly MDS (minimal data set) assessment, dated 2/10/21, showed that resident #8 had a significant weight loss during the first 3 months of admission. (Excessive weight loss without prescribed weight loss program >5%within the past 30 days, >7.5% within the past 90 days.) Resident #8 was observed eating lunch on 5/7/21 at 12:10 PM. Resident #8 received a pureed diet that was divided into separate disposable containers. The portion sizes appeared to be small. Review of resident #8's meal/tray ticket indicated that the residents diet was pureed, NAS, small portions. The meal ticket also revealed/indicated Instructions: fluid restriction. Review of resident #8's electronic health record (EHR) did not reveal any orders for small portions…

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 interviews it was determined that the facility staff failed to provide a resident with the most dignified existence (Resident #42). This was evident for 1 of 30 residents selected for review during the survey process. The findings include: In an interview on 10/10/18 at 9:22 AM Resident #42 stated, the night shift nurse calls me Poppie. I don't really like it and have asked to be called by my name, but she still calls me that. Review of medical record revealed an activity of daily living care plan which stated that the Resident preferred to be called by his/her first name. The Administrator was made aware of this concern in an interview on 10/11/18 at 10:35 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility failed to notify a resident/resident representative in writing of a room change. This was evident for 1 (#38) of 30 residents reviewed during an annual re-certification survey. The findings include: Review of Resident #38's medical record on 10/12/18 revealed that Resident #38 was transferred to room [ROOM NUMBER] A on 09/21/18. In an interview with the facility social worker on 10/11/18 at 9:17 AM, the facility social worker stated that Resident #38 did not receive a written notice of a room change on 09/19/18 and confirmed Resident #38 was moved to his/her new room on 09/21/18. The facility Administrator and Director of Nurses were made aware of the findings at the exit conference on 10/12/18 at 3 PM.

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 resident and resident's representative were notified in writing of the resident's transfer and the rationale for the transfer to an acute care facility. This was evident for 1 of 30 (Resident #70) residents reviewed during the investigative portion of the survey. The finding includes: Review of the medical record for Resident #70 was conducted on 10/11/18 at 12:50 PM. Review of the nurse's notes written on 7/16/18 revealed that Resident #70 had a change in medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal documentation that the resident or the responsible party had been provided with a written notification of the transfer or the rationale for the transfer. Interview with social worker on 10/11/18 at 1:10 PM confirmed that the facility did not provide written notification of the hospital transfer or the rational. In an interview with on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 of 30 (Resident #42) residents reviewed during the survey process. The findings include: In an interview with Resident #42 and his/her spouse on 10/10/18 at 9:26 AM, they stated that Resident #42 had only had 1 shower since admission on [DATE]. Review of Resident #42's admission minimum data set (MDS) completed on 5/17/18 revealed that s/he was alert and oriented and required the assistance of 1-2 persons for activities of daily living to include bathing. The MDS is a federally-mandated assessment tool that helps a 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 received the care they need. Further review of…

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

Based on review of a medical record and staff interview, it was determined that the facility nursing staff failed to 1) obtain a dermatology consult for a resident, and 2) obtain weekly weights as ordered by the physician. This was evident for 2 (#36 and #8) of 30 residents reviewed during an annual re-certification survey. The findings include: 1) Review of Resident #36's medical record on 10/11/18 revealed a physician's order, dated 09/21/18, instructing the nursing staff to obtain a dermatology consult for Resident #36. Further review of Resident #36's medical record on 10/11/18 failed to reveal Resident #36 had been seen by a dermatologist. In an interview with the nursing unit manager for Resident #36 on 10/11/18 at 3:20 PM, the unit manager stated that the facility Dermatologist was in the facility on 10/09/18 but did not assess Resident #36. In an interview with the facility director of nursing (DON) on 10/11/18 at 3:30 PM, the facility DON stated that Resident #36's spouse was seen by the Dermatologist on 10/09/18. The DON stated that Resident #36 was seen by 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 medical record review and staff interview the facility staff failed to recognize and evaluate the nutrition needs of residents (Residents #13, #29, and #51). This was evident for 3 out of 31 resident reviewed during the investigation phase of the survey process. The findings include: 1. Review of Resident #13's medical record on 10/11/18 revealed the Resident was admitted to the facility on [DATE] and the facility staff developed a care plan for: At risk for weight loss/dehydration. On 9/25/18 the dietitian documented continue to monitor Resident's weights weekly. Review of the Resident's weights revealed a documented weight on 10/8/18 of 117 pounds. The previous documented weight for the Resident was on 10/4/18 for 153 pounds. Further review of the medical record revealed no re-weight of the Resident when there was a significant change in weight of 36 pounds or documented note that the facility staff recognized the weight change. Interview with the Director of Nursing on 10/12/18 at 9:50 AM confirmed…

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, resident and staff interview, the facility staff and pharmacy failed to provide medications as ordered by the physician (Resident #7). This was evident for 1 out of 30 residents reviewed during the investigation phase of the survey process. The findings include: During interview with Resident #7 on 10/10/18 at 9:35 AM the Resident stated the facility often runs out or doesn't have his/her medications, including Mobic and Synthroid. Mobic is a nonsteroidal anti-inflammatory drug used to treat pain or inflammation caused by arthritis. Synthroid is a medication that can treat hypothyroidism and can also treat an enlarged thyroid gland and thyroid cancer. Review of Resident #7's physician orders revealed on 9/17/18 at 2:35 PM the physician ordered Mobic 7.5 mg by mouth daily for pain. Review of the Resident's Medication Administration Record revealed the Mobic was not administered until 9/19/18, two days after it was ordered. Further review of the medical record revealed a nurse's note on 9/18/18 at 12:33 PM, Mobic is on the 2 PM run today per remedy.…

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

Based on medical record review and interview, the facility staff failed to obtain blood pressures for a medication with parameters as ordered by the physician for a resident (Resident #29). This was evident for 1 out of 30 residents reviewed during the investigation phase of the survey process. The findings include: Review of Resident # 29's medical record revealed on 8/24/18 the physician ordered: Lisinopril 10 milligrams (mgs) by mouth every day for hypertension, Hold for blood pressure less than 110/60. Lisinopril is a medication that lowers the blood pressure. Further review of the medical record revealed that the facility staff failed to document blood pressures with the administration of Lisinopril on the following dates in 2018: 8/29, 9/4, 9/6, 9/7, 9/8, 9/9, 9/10, 9/12, 9/14, 9/15, 9/16, 9/20, 9/21, 9/22, 9/23, 9/24, 9/25, 9/26, 9/27, 9/28, 9/29, 9/30, 10/3, 10/4, 10/5, 10/6, 10/7, 10/8 and 10/9/18. Interview with the Director of Nursing on 10/11/18 at 2:30 PM confirmed that the facility staff failed to document the blood pressure for a resident with medication parameters.

Based on observation, record review and staff interview it was determined that the facility staff failed to provide safe and sanitary conditions to prevent the development and transmission of disease and infection. This was evident for 1 (#51) of 30 residents reviewed during the survey process. The findings include: During the initial interview and observation with Resident #51 on 10/09/18 at 9:43 AM and again at 2:17 PM, the Resident's bathroom was observed with an opened box of gloves on the floor under the sink, a used glove on the floor, a urine collection bag, a urinal and a soiled fracture pan tucked behind or hanging from the bathroom hand rail. There was also a noticeable strong urine odor. Also observed were two tooth brushes not covered, one placed in a kidney basin with dried white streaks with a tube of toothpaste, the 2nd toothbrush was laying on the back of the sink uncovered with another tube of toothpaste. Follow up observation on 10/10/18 at 8:45 AM revealed the urine collection bag, a urinal and a soiled fracture pan tucked behind or hanging from the bathroom hand…

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 the facility failed to maintain the Resident call bell system in safe operating condition. This was evident during the initial tour of the facility and throughout the survey. The findings include: On 10/9/18 during the initial tour, room [ROOM NUMBER] was observed with call bell plate pulled away from the wall with wires visible. On 10/10/18, 10/11/18 and 10/12/18 room [ROOM NUMBER] was again observed with the call bell plate pulled away from the wall with wires visible. On 10/12/18 during medication pass the call bell wall plate in room [ROOM NUMBER] was observed pulled away from the wall with wires visible. The Administrator was made aware of this concern on 10/12/18 at 9:55 AM.