Autumn Lake Healthcare At Crofton

Based on record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plan for residents This was evident for 1 resident (Resident #1) out of 2 residents reviewed for care plan during the facility's recertification survey.The findings include: Anemia is a medical condition characterized by a low red blood cell count or hemoglobin levels. Hemoglobin is an iron-rich protein in red blood cells that carries oxygen throughout the body.A care plan is an outline of nursing care showing all the residents' needs and the ways of meeting the needs. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the individual's specific needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care.On 09/23/2025 at 8:23 AM, review…

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

Number of residents sampled: Number of residents cited: Based on interviews and medical record reviews, it was determined that the facility staff failed to ensure the resident's primary health care representative was invited to care plan meetings. This deficient practice was evident for one (#13) resident reviewed for care plan timing and revision during the annual survey.The findings include:On 09/19/2025 at 9:12 AM, during a phone interview Resident #13's healthcare representative #1, they stated that the last care plan meeting they attended was in the previous year. On 09/19/2025 at 11:43 AM, a review of Resident #13 medical records revealed a social service progress note indicating that quarterly care plan invitations had been electronically sent to healthcare representative #2 on 01/08/25, 04/04/25, and 07/02/25.Further review of the medical records revealed that quarterly care plan meetings were conducted on 11/12/24, 02/11/25, 05/13/25, and 08/12/25. For each care plan meeting progress note, the Social Worker (SW #6) documented that healthcare representative #2 declined 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 interviews and record reviews, it was determined that the facility failed to provide and document activities in accordance with resident preferences. This was evident for 1 resident (Resident #102) out of 2 residents reviewed for activities during the facility's recertification survey. The findings include:On 09/23/2025 at 1:04 PM, during an interview with Resident #102 regarding his/her activities in the facility, the resident stated he/she did not participate in any activity. When asked about the type of activity he/she liked, Resident #102 stated that he/ she liked reading. When he/she was asked if the books were provided by the activity staff members, he/she stated his/her daughter brought them. At the time of the interview and observation, no books were present at the resident's bedside.On 09/23/2025 at 1:30 PM, review of Resident #102's care plan goal initiated on 06/27/2025 showed: Resident will choose a leisure pastime within my comfortable abilities through a combination of self-directed activities and scheduled group programs within 90 days.Interventions included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, it was determined that the facility failed to 1.) initiate treatment for a resident who reported a new clinical concern, 2.) ensure that a medication was available for a resident upon admission since the resident could not eat without the medication, 3.) follow physician orders for blood pressure (BP) measurements. This was evident for 3 resident (Resident #1, #196, and #176) out of 11 residents reviewed during the facility's recertification survey. The findings include: 1.) On 09/18/2025 at 11:54 AM, during an interview with Resident #1, the resident stated that he/she had crusts in the eyes which were also itchy, and that this concern had been reported to a nurse. On 09/22/2025 at 1:35 PM, during an interview with Licensed Practical Nurse (LPN #13), when asked if she was aware of the resident's complaint of itchy eyes with crusting, she stated that the resident had informed her on 09/18/2025 and she had told the attending physician (Staff #26). When asked about…

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 the facility staff failed to ensure that residents received respiratory care consistent with professional standards of practice. This was evident for 2 resident (Resident #107 and Resident #9) out of 4 residents reviewed for respiratory therapy during the facility's recertification survey.The findings include: 1. Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from the health care provider. Oxygen tubing is a medical-grade hose that connects an oxygen source (like a concentrator or tank) to an oxygen delivery device, such as a nasal cannula or mask. It is designed to be lightweight, flexible, and kink-resistant to ensure a steady and uninterrupted flow of oxygen for therapy. On 09/18/2025 at 8:50 AM, during the initial tour of the facility, Resident #102 was observed seated in a chair with oxygen administered via nasal cannula connected to oxygen tubing. The surveyor observed that the…

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

Based on record review and staff interviews, it was determined that the facility failed to prevent a significant medication error. This was evidenced in 1 (Resident #199) out of 6 residents reviewed for medications. The findings include: On 9/24/2025 at 10:45 AM, a review of Facility Reported Incident #311885 was conducted. The incident was in regard to an allegation of Employee to Resident abuse, where Staff #35 was alleged to have shoved incorrect medications into Resident #199's mouth despite the resident refusing the medication. 9/24/2025 at 11:20 AM, an interview with the Director of Nursing (DON) was conducted. When asked about the facility's outcome of incident #311885, the DON stated that the facility determined the medication error to be substantiated and the alleged abuse to be inconclusive. On 9/24/2025 at 11:29 AM, a review of Resident 199's progress notes was conducted. In the Provider notes from 2/28/2025 at 2:42 PM, the provider stated, The patient is being evaluated for a follow-up regarding a medication administration error. It was reported that the patient…

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 interviews, it was determined that the facility failed to ensure residents were educated on the benefits and risks of pneumococcal vaccine following a refusal. This was evident for 1 resident (Resident #40) out of 5 residents reviewed for immunizations.The findings include:A BIMS score is derived from the Brief Interview for Mental Status, a brief screening tool for assessing cognitive function in long-term care settings. A score between 0 and 15, where higher scores indicate better cognitive ability, helps facilities track cognitive changes. Scores are categorized: 0-7 is severe impairment, 8-12 is moderate impairment, and 13-15 is cognitively intact. The assessment evaluates temporal orientation and short-term recallOn 09/24/2025 at 10:01 AM, review of Resident #40's immunization record showed no documentation that education regarding the risks and benefits of the pneumococcal vaccine was provided following the resident's refusal.On 09/24/2025 at 10:12 AM, during an interview with the Infection Preventionist (IP), when asked about 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 record reviews and interviews, it was determined that the facility failed to ensure all direct care staff received effective communication training. This was evident for 1 (Staff #38) out of 5 staff reviewed for staff training. The findings include: On 09/23/2025 at 1:20 PM, review of Geriatric Nursing Assistant's (Staff #38) training failed to reveal that they completed effective communication training. On 09/23/2025 at 1:27 PM, the surveyor reviewed the concern with the Director of Nursing (DON) and she indicated that the expectation was that the agency provided training for agency staff. She further indicated she had no further training to provide for Staff #38. During the same interview, the DON indicated there was not a process in place to ensure that all required training was completed by agency staff, including effective communication training that was not on the list of educational trainings completed for Staff #38.

Based on record reviews and interviews, it was determined that the facility failed to ensure all staff received mandatory Quality Assurance and Performance Improvement (QAPI) training. This was evident for 1 (Staff #38) out of 5 staff reviewed for staff training. The findings include: Quality Assurance and Performance Improvement training informs staff of the elements and goals of the facility's QAPI program. On 09/23/2025 at 1:20 PM, review of Geriatric Nursing Assistant's (Staff #38) training failed to reveal that they completed QAPI training. On 09/23/2025 at 1:27 PM, the surveyor reviewed the concern with the Director of Nursing (DON) and she indicated that the expectation was that the agency provided training for agency staff. She further indicated she had no further training to provide for Staff #38. During the same interview, the DON indicated there was not a process in place to ensure that all required training was completed by agency staff, including the training that was not provided by the agency (including QAPI training).

Based on record reviews and interviews, it was determined that the facility failed to ensure staff received the required compliance and ethics training. This was evident for 1 (Staff #38) out of 5 staff reviewed for staff training. The findings include: On 09/23/2025 at 1:20 PM, review of Geriatric Nursing Assistant's (Staff #38) training failed to reveal that they completed compliance and ethics training. On 09/23/2025 at 1:27 PM, the surveyor reviewed the concern with the Director of Nursing (DON) and she indicated that the expectation was that the agency provided training for agency staff. She further indicated she had no further training to provide for Staff #38. During the same interview, The DON indicated there was not a process in place to ensure that all required training was completed by agency staff, including the training that was not provided by the agency (compliance and ethics training).

Based on observation, medical record review, and interviews it was determined the facility failed to document the interdisciplinary team assessed and deemed appropriate a resident to self-administer medication. This deficient practice was evidenced in 1 (#102) of 1 resident who was allowed to self-administer medication during the survey. The findings include: On 02/06/24 at 11:08 am during observation rounds the surveyor observed Resident #102 in his/her room sitting in a chair next to the bed. The bedside table was in front of the resident and the observed a bottle of medication on the bedside table. When asked about the medication, the resident verbalized taking the medication with meals. On 02/09/24 at 8:22 am the surveyor received a copy of thee Resident Self-Administration of Medication policy from Director of Nursing #2. A review of the policy revealed the policy indicated the interdisciplinary team's assessment of the resident's capacity to self-medicate be recorded on the Medication Self Administration Assessment in the resident's medical record. On 02/09/24 at 10:36 am 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 the facility failed to ensure the surety bond covered the financial assets of the residents who finances they manage. This deficient practice was discovered during the survey. The findings include: On 02/14/24 at 1:30 pm the surveyor received a copy of the resident funds balance which was over $50,000. Review of the facility's surety bond certificate revealed the certificate was effective 08/01/23 - 08/01/24. The Surety Bond's amount was $50,000, which was less than the required amount to secure the residents' funds. On 02/14/24 at 1:38 pm during an interview with Business Office Manager #37 the surveyor reported the surety bond did not cover the number of finances in the residents' accounts. Business Office Manager #37 verbalized the facility started managing more resident accounts and the amount exceeded the surety bond. In December 2023 they had the correct amount insured.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews it was determined that the facility staff failed to maintain the building in good repair and failed to maintain a comfortable homelike environment for residents. This deficient practice was evident in 3 resident rooms and 1 shower room discovered during the survey. The findings include: On 02/06/24 at 10:56 am during observation rounds while in room [ROOM NUMBER] the surveyor observed a hole in the wall above the electrical outlet behind bed B; the phone was on the floor behind the bedside table, a bottle of lotion was under the bed, waste was on the floor on the left side of the bed, and a used and unlabeled urinal rested on the upper left bed rail. Admissions Coordinator #12 confirmed the surveyor's findings. On 02/06/24 at 11:08 am while in room [ROOM NUMBER], the surveyor observed warping paint near the trim in the bathroom which was a shared bathroom with the residents in between room [ROOM NUMBER]. On 02/06/24 at 11:24 am during the continuation of observation rounds the…

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

Based on record review and interview it was determined the facility staff failed to notify the state agency of an alleged abuse case within the allotted 2-hour reporting window. This deficient practice was evidenced in 1 of 2 facility reported incident's reviewed during the survey. The findings include: On 02/18/24 at 5:37 pm a review of the facility's investigation of MD00202068 revealed that on 01/31/24 at 8:30 am it was reported to Administrator #1 and that a GNA threw a cup of lemonade in Resident #52's face. Further review of the self-report form submitted to the state agency revealed the alleged incident was reported to the state agency on 01/31/24 at 11:10 am, which was outside of the allotted 2-hour reporting window. On 02/18/24 at 7:09 pm a review of the facility's abuse policy revealed that on page 4 Section VII Reporting Abuse Section A 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies with specified timeframes. (a) Immediately, but not later than 2 hours after the allegation is made, if…

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, medical record review, and interview it was determined that the facility staff failed to (1) initiate a person-centered care plan in a timely manner for a resident who was receiving oxygen therapy and failed to (2) ensure a residents' care plan was implemented for a resident with complaints of pain. This deficient practice was evident in 1 (#309) of 2 residents observed with oxygen therapy and 1 (Resident #154) of 3 residents reviewed for pain management 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 they receive in a facility. (1) On 02/06/24 at 10:45 am during observation rounds the surveyor observed Resident #309 in bed with 3 liters of oxygen via nasal cannula being administered. On 02/09/24 at 10:05 am review of Resident #309's electronic medical record revealed the facility staff failed to initiate a person-centered care plan for oxygen therapy for Resident #309 until the day of the start of the survey on 02/06/24. The 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.

Based on interviews and record review, it was determined that the facility failed to develop a person-centered care plan that was reviewed, revised, and implemented timely by an interdisciplinary team composed of individuals who had knowledge of the resident and his/her medical and psychosocial needs. This was evident for 2 (Resident #413 and #409) out of 2 residents reviewed during the survey. The findings include: 1). An initial screening on 2/6/2024 at 10:55 AM, found that Resident #413 had his/her eyes closed and the arms were crossed tightly over the chest. During the interview, the resident stated, I know I am getting depressed, because now I have a stool bag attached to me everywhere I go. Observation, 2/09/24 at 10:58 AM, found Resident #413 semi-sleeping with the television on. Later, during an interview, the resident stated, No one talked to me about the stool bag yet, I want to go home but I do not know how to take care of the stool bag which makes me sad. I did tell the staff. Record review, on 2/9/24 at 11:43 AM, revealed that Resident #413 was admitted to 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.

Based on medical record review and interviews it was determined that the facility staff failed to ensure a dialysis resident had orders for the arteriovenous graft to be assessed according to nursing professional standards. This deficient practice was evident in 1 (#102) of 1 resident record reviewed for graft orders. The findings include: An (AV) graft is a type of access used for hemodialysis treatments. The graft is usually placed in the arm. Hemodialysis is a procedure where a machine with a special filter is used to clean the blood. A thrill is a vibration caused by blood flowing through the fistula and can be felt by placing the fingers on the site of the graft. A bruit is a whooshing sound heard when a stethoscope is placed over the av graft which indicates the graft is patent. On 02/06/24 at 11:08 am during observation rounds the surveyor observed Resident #102 with a dressing to the left upper arm. The resident verbalized receiving dialysis treatments. On 02/08/24 at 2:23 pm a review of Resident #102's medication administration record (MAR) and treatment administration…

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 failed to: (1) administer a medication timely as ordered by the physician for (Resident #215) (2) administer oxygen therapy according to the physician's order and failed to notify the assigned nurse of a resident's compromised respiratory status, and (3) follow rotation of injection sites for administration of insulin for (Resident #15). This was evident in 3 of 25 residents records reviewed for nursing staff following physician orders during the survey. The findings include: (1) The Pyxis is an automated medication dispensing system located inside the facility. Restless leg syndrome (RSL) is a condition characterized by a nearly irresistible urge to move the legs which may result in pain. RSL typically occurs while sitting or lying down. Review of Resident #215's record revealed the resident was admitted with diagnoses that included restless leg syndrome. The resident was cognitively impaired and was totally dependent on staff for care. Review of complaint MD00182723 and 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 resident medical record review, and staff interview it was determined the facility failed to ensure that a resident prescribed psychotropic drugs received gradual dose reductions in an effort to discontinue the medications. This was evident for 1 resident (#127) out of 7 residents reviewed during the survey. The findings include: Review of Resident #127's medical record on 02/15/2024 at 04:46 PM revealed that resident was prescribed Zoloft 100 mg daily by mouth for depression, Trazadone 50 mg daily by mouth for depression/sleep aid, and Buspirone 10 mg every eight hours by mouth for anxiety. There was no documentation in Resident #127's medical record that a gradual dose reduction attempt occurred for Resident (#127). Interview with Director of Nursing on 02/15/24 at 4:48 PM confirmed that there was no documentation in resident medical record that a gradual dose reduction attempt occurred for Resident (#127) for psychotropic medications. Interview with staff (#29) on 02/16/24 at 11:26 AM also confirmed that there was no documentation in resident medical record and stated…

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 the facility failed to ensure that injectable immunization diluents and/or vials had matching expiration dates. Additionally, the facility failed to comply with its medication storage policy and procedures. This was found to be true for 6 out 6 varicella injectables located in the medication refrigerator #2 located on unit # 3. Additionally, six vials of Hepatitis B were found expired in medication refrigerator #1 located on unit # 3. The findings include: On 02.14.24 at 10:56 AM the surveyor interviewed staff Registered Nurse (RN)# 38. The surveyor found the temperature in the medication storage refrigerator #1 had a temperature of 29 degrees Fahrenheit which did not meet the facility's policy standard temperature range of 36-46 degrees. Six vials of Hepatitis B vaccine were found with expired dates for use and were dated 12.07.23 and unopened in the medication refrigerator #1. At 11:06 AM on 02.14.24 the surveyor found six vials of varicella injectables with non-matching dates of expiration for use in refrigerator #2. The DON…

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 provide an updated and accurate facility assessment. This deficient practice was discovered during the survey The findings include: On 02/06/24 at 1:46 pm the surveyor received a copy of the facility assessment from Administrator #1. On 02/20/24 at 2:22 pm review of the facility assessment revealed the Facility Assessment was approved and reviewed and by the quality assurance committee on 08/11/23. The assessment was signed by Administrator #1. Further review of the facility assessment revealed the current Infection Preventionist was not added to the assessment. All the staff training/education and competencies were not added to the assessment. Also, the ethnic, cultural, and religious portion of the assessment did not indicate what services if any are offered by the facility. In the special care needs section it indicated dialysis services is offered by the facility. On 02/06/24 at 10:15 an Director of Nursing #2 verbalized they facility does not provide dialysis services directly. On 02/20/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical records review and interview and it was determined that the facility failed to document accurate and complete information in resident (#215's) clinical record. This occurred in 1 of 18 residents reviewed during the survey. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current, and complete documentation in the medical record is an essential component of quality resident care. 1. Review of Resident #215's medical record revealed a diagnosis that included Chronic Renal Failure, Restless leg syndrome, Chronic obstructive pulmonary disease, and Polyneuropathy (unspecified). According to the medical record the resident was cognitively impaired. Review of the medical record on 2/20/24 at 10am revealed a Clinical Change in Condition -Hospital Transfer that documented Resident #215 was transferred to the hospital on [DATE] for a Blood urea nitrogen (BUN) of 24 mg/dl (normal reference range is (6-20mg/dl), and a Creatinine of 5.99 mg/dl…

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 staff failed to maintain infection control practices for a resident with a foley catheter. This deficient practice was evidenced in 1(#145) of two residents assessed for urinary catheters during the survey. The findings include: On 02/06/24 at 9:00 am during observation rounds the surveyor observed the Resident #145's Foley drainage bag hanging from the right side of the bed, onto the floor. The assigned nurse, LPN #10 was made aware. LPN#10 verbalized the foley drainage bag was on the floor because the bed was in the lowest position. On 02/09/24 at 8:01 am during an interview with Director of Nursing #2, when asked about the expectations of the staff to maintain infection control precautions when a resident has a Foley, he/she stated, The Foley bag should be in a dignity bag on the bed, but not on the floor. If there is an order for the bed to be low and locked, the Foley bag needs to be adjusted.

Based on an interview with family member, who is the responsible party and the resident, the facility failed to honor the family whishes to change the bed linen of the resident in a timely manner. This was evident for 1 out of 1 resident (R#292) reviewed. Findings Include: On 3/19/19 at 12:58 PM an interview was conducted with Resident # 292's daughter who is also the Responsible Party (RP). the daughter stated that on 3/18/19 she noticed a large amount of blood and drainage coming from fracture site. She asked the nurse to come in and check the dressing and to change the bed linen as it was quite soiled. This occurred during the afternoon of 3/18/19. The resident's linen was not changed until after 6 PM that evening. On the day of the interview with the surveyor on 3/19/19 at 12:58 PM, Resident # 292's daughter again asked the Geriatric Nursing Assistant, staff #4, at 8 AM to change her mother's (Resident # 292) bed linen, as there was some body fluid stain on the sheet. The daughter said that the GNA said nothing to her and has not gone into the room since. On 3-19-19 at 1 P.M.…

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

Based on the medical record and staff interviews, the facility staff failed to provide required written notice for Resident #117, or the Resident's responsible party, of the bed hold policy during a transfer out of the facility. This was evident for 1 out of 1 residents investigated for hospitalization during the survey process. The findings include: On 03/25/19 around 01:42 PM, Resident #117's medical record was reviewed for a recent hospitalization. On 2/21/19 the resident was found unresponsive with a blood pressure (BP) reading of 64/44. The doctor ordered that the resident be sent out to the hospital. Review of the hospital transfer information in the resident's chart did not reveal that a bed hold policy was given to the resident prior to leaving the building. This policy educates the resident on whether a bed can be held during the resident's absence, and or if not, the possibility of having to privately pay to hold the resident's bed, until the resident returns.

Based on observation of medication storage room and medication carts on March 25,2019 the facility failed to date medications that were opened on station 3 front certified medication aid (CMA) medication cart. This was evident for 1 out of 8 medication carts looked at for compliance. The findings include: On 3/25/19 at 12:40 PM 4 medication storage rooms were checked for compliance and 8 medication carts. On station #3, The front CMA (Certified Medication Aid) cart had 4 residents who did not have the dates when the medication was opened: Resident # 10 was ordered erythromycin ointment for bilateral eyes for the diagnosis of Blipharistis. There was no date when the ointment was opened. Resident # 96 was ordered systane liquid opth. drops ordered for each eye for the diagnosis of glaucoma. There was no date indicating when the systane eye drops were opened. Resident # 47 was ordered Refresh eye drops, 1 drop in each eye 3 times per day. There was no date when the Refresh eye drops were opened. Resident # 67 was ordered Lantanoprost opth. 1 drop in each eye for the diagnosis of…

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

Based on observation it was determined that the facility staff failed to use proper hand washing techniques prior to and after administering medications. This practice was observed during 3 times out of 4 residents observed during the medication pass. The findings include: On 03/25/19 during an observation of the morning medication pass, this writer witnessed staff #1 wash their hands with soap, under running water. The staff then was observed turning the faucet off with wet hands and not with a paper towel. Staff then proceeded to dry their hands and proceed to administer medications to the next resident. This was witnessed on two occasions for staff #1 during the medication pass. During the same medication pass observation, staff #2 was witnessed on 1 occasion, turning off the faucet with bare hands after passing medications to a resident. Both staff persons were informed of their error. Hand washing is one of the most effective ways to prevent the spread of germs from one person to another. Using a wet clean hand to turn off the faucet instead of a dry paper towel, transfer 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.