Cumberland Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews, it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was evident for one (Resident #22) of two residents reviewed for positioning and mobility during the survey.The findings include: On 10/2/25 at 10:28 AM, Resident #22, a long-term resident of the facility, was observed lying in bed and reported doing well. On 10/2/25 at 1:53 PM, a review of occupational therapy notes provided by the Director of Therapy (Staff #19), for the certification period 7/9/24–8/7/24, did not indicate that Resident #22 had an upper extremity contracture. On 10/2/25 at 1:54 PM, a brief interview with the Director of Therapy (Staff #19), confirmed that Resident #22 did not have an upper extremity contracture. On 10/2/25 at 2:10 PM, a review of the annual MDS Section GG assessment, with a reference date of 8/15/25, revealed that the resident was coded as having a functional limitation in one upper extremity.…

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 provide quality of care for their residents. This was evident for one (Resident #125) of three residents reviewed for nutrition and one (Resident #3) out of five residents reviewed for unnecessary medication.The findings include: 1.A complaint was received by the State Agency (SA) on 8/25/25, alleging the facility was not allowing Resident #125 to have water by mouth. The complainant explained that due to the extensive facial surgery (due to a diagnosis of buccal cavity (mouth) cancer) the resident had, s/he often experienced dry mouth and had been drinking water in the hospital. The complainant reported that the facility was giving the resident 1 can (237 milliliters mL) of Glucerna when s/he had been getting 2 cans (480 mL) in the hospital. The complainant reported this was due to the extra calories and protein needed to allow the resident to heal. Furthermore, the complainant reported that family had attempted to explain this…

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, observation and interview it was determined that the facility failed to ensure that prior to installation of bed rails appropriate alternatives were attempted, that residents were assessed for the risk of entrapment, and that informed consent was obtained, and failed to ensure re-evaluation for the continued use of the bed rails. This was found to be evident for two (Resident #41 and #88) out of two residents reviewed for bed rail usage. The findings include:1) Resident #41 has resided at the facility for more than a year and has a diagnosis of dementia. On 10/01/25 at 12:46 PM resident was observed in bed asleep with quarter bed rails in the up position.On 10/07/25 at approximately 11:00 AM resident was observed in bed asleep with quarter bed rails in the up position.On 10/7/25 at approximately 12 noon review of the medical record revealed the resident was dependent on staff for bed mobility. Review of the current care plan addressing activities of daily living, revealed an intervention of Bilateral bedrails to promote independence and assist with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the physician failed to review the hospital records for a resident who was newly admitted to the facility to ensure continuity of care. This was evident for 1 (Resident #125) of 3 residents reviewed for nutrition. The findings include:On 10/8/25 at 1:33 PM a medical record for Resident #125 revealed a History and Physical dated 8/3/25 from the acute care hospital that was uploaded in the miscellaneous section of the electronic medical record. A review of the History and Physical (H&P) revealed in the Assessment/Plan section under the treatment for buccal cavity (mouth) cancer it was documented the resident had surgical intervention, the resident tolerated oral fluids but had aspiration precautions. Furthermore, it read to continue the tube feedings and medications via a gastric tube (g-tube is a tube that is directly inserted into the stomach). The resident was ordered 480 milliliters (mL) of Glucerna 1.5 at 9 am, 2 pm, and 7 pm. A review of the…

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

Based on medical record review and interview it was determined that the facility failed to ensure regularly scheduled medication was re-ordered and delivered in a timely manner; and failed to ensure staff accessed interim supply of medication when needed. This was found to be evident for one (Resident #3) out of five residents reviewed for unnecessary medications.The findings include: On 10/6/25 review of Resident #3's medical record revealed the resident had an order for Atorvastatin 20 mg at bedtime for hyperlipidemia (high cholesterol). This order had been in place since 8/12/25. Review of a pharmacy delivery manifest, signed by nurse #16, revealed 30 tablets of Atorvastatin 20 mg were delivered to the facility for Resident #3 on 8/12/25. On 10/6/25 review of the Medication Administration Record (MAR) revealed documentation that the resident received the Atorvastatin when due 8/12 through 9/15/25. This is 35 dosses that were documented by staff.On 10/6/25 review of the Medication Administration Record (MAR) and the progress notes revealed the Atorvastatin was not administered 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 interview, it was determined that the facility failed to ensure resident treatment carts were locked when unattended; ensure insulin pens were dated upon opening and discarded according to manufacturer guidelines; and ensure that insulin pens were stored in a manner that prevented potential cross-contamination. This was evident during two random observation of treatment carts; 1 of 3 medication carts and 2 out of 3 medication storage rooms observed during the annual recertification survey. The findings include: 1.On [DATE] at 6:20 AM, an observation was made on the first floor. A treatment cart was noted near the nursing station but not within direct view of staff. The cart was unlocked, and the surveyor was able to open one drawer without staff noticing. The surveyor alerted Nurse (Staff #20) to the unlocked cart. Nurse (Staff #20) stated the cart should have been locked. On [DATE] at 6:21 AM, a review of the cart contents with Nurse (Staff #20) revealed, but was not limited to, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility failed to have a system in place to ensure only one active version of a resident's orders for life-sustaining treatment was located in the medical record. This was found to be evident for one (Resident #3) out of four residents reviewed for advance directives.The findings include: Review of Resident #3's electronic medical record revealed, in the miscellaneous section, an upload of a current Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form that included orders to Attempt CPR. This order, also known as a full code, means if cardiac and/or pulmonary arrest occurs, attempt cardiopulmonary resuscitation (CPR); this includes any and all medical efforts that are indicated during arrest, including artificial ventilation and efforts to restore and/or stabilize cardiopulmonary function. This MOLST was dated [DATE].MOLST forms include orders for Emergency Medical Services (EMS) and other medical personnel regarding CPR. It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interview, it was determined that the facility failed to document that the resident either received the pneumococcal and influenza vaccine(s) or did not receive the vaccine(s) due to medical contraindications, previous vaccination, or refusal. This was evident for 1 (Resident #117) out 5 residents reviewed for immunizations during the survey.The findings include: On 10/6/25 at 12:20 PM a record review in the electronic health record (EHR) regarding Resident #117 vaccination records revealed that the resident was admitted on [DATE]. It lacked documentation of immunization of whether the resident did or did not receive the vaccines, contraindications, vaccine history or refusal. On 10/6/25 at 12:45 PM in an interview with the Nursing Home Administrator (NHA) and the Infection Preventionist (Nurse #15), indicated that the process for immunizing or verifying a new resident's vaccine status was usually done in 5 days. They were unable to produce documentation that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interview, it was determined that the facility failed to document that the resident either received the Covid vaccine or did not receive the vaccine due to medical contraindications, previous vaccination, or refusal. This was evident for 1 (Resident #117) out 5 residents reviewed for immunizations during the recertification survey.The findings include:On 10/6/25 at 12:20 PM a record review in the electronic health record (EHR) regarding Resident #117 vaccination records revealed that the resident was admitted on [DATE]. It lacked documentation of Covid immunization, of whether the resident did or did not receive the vaccine, contraindications, vaccine history or refusal. On 10/6/25 at 12:45 PM in an interview, the Nursing Home Administrator (NHA) and the Infection Preventionist (Nurse #15), indicated that the process for immunizing or verifying a new resident's vaccine status was usually done in 5 days. They were unable to produce documentation that Resident #117'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 medical record review and staff interview it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 4 (#87, #76, #73, and #80) ) of 5 residents reviewed for hospitalization. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure that each resident receives the care they need. 1a) On 9/13/23 at 10:45 AM, a review of Resident #87's medical record was conducted and revealed that Resident #87 was admitted to the facility in July 2023 following an acute hospitalization. On 7/30/23 at 4:00 AM, in an SBAR summary, the nurse documented that Resident #87 was noted to be breathing harder and faster, heart rate kept jumping and the resident's Oxygen saturation was low. The nurse indicated the primary care provider was made aware and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 5 (Resident #45, #74, #80, #52, and #56) of 45 residents reviewed during the survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure that each resident receives the care they need. Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing facilities for long-term care. The PASRR process requires all applicants to Medicaid-certified nursing facilities (NFs) to be given a preliminary assessment to determine whether they might have serious mental illness or intellectual disability. This is called a Level…

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 implement a person-centered care plan. This was evident of 3 (Resident #41, #74, and #58) of 45 residents reviewed during the survey. The findings include: 1) Resident #41 has been residing in the facility since 2017. The medical records stated that Resident #41 had No speech and was rarely/never understood for making him/herself understood or ability to understand others. On 9/8/23 at 1:01PM, Resident #41's care plan that was completed on 8/9/23 was reviewed and revealed that s/he was dependent on staff for activities, cognitive stimulation, and social interaction. One of the interventions included in this care plan included: Prefers activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as (Specify). The end of this intervention was left blank, and no evidence was found in the resident's medical record specifying which structured activity the facility planned to provide for the resident. On 9/12/23 at 10:07AM, the activities director (staff…

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

Based on record review and interview it was determined that the facility failed to have an effective system in place to ensure that interdisciplinary team care plan meetings were scheduled to review and revise care plans after each Minimum Data Set (MDS) assessment. This was evident for 3 (Resident #52, #56, and #70) out of 3 residents reviewed for care plan timing and revision. The findings include: Minimum Data Set (MDS)- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. 1) Resident #52 has been residing in the facility since 2019. During the initial pool process, the resident was asked if the facility conducted meetings that included him/her in the development of their care plan. On 9/07/23 at 9:15AM, the resident answered, I don't think so. On 9/11/23 at 9:52AM, a review of the resident's electronic medical records (EMR) revealed the last care plan meeting held for Resident #52 was 6/14/23 while the last MDS assessment had 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 review of pertinent documents and interviews, it was determined that the facility failed to document a grievance and investigate the loss of a hearing aid as reported by a resident's family. This was evident for 1 (Resident # 247) out of 8 Residents reviewed for abuse during a survey. The findings include: On 9/19/23 at 8:12 AM, review of # MD00165791 revealed an allegation that the facility failed to replace a resident's lost hearing aid. On 9/19/23 at 9:01 AM, the Social Service Director provided a facility policy titled, Policies and Standard Procedures; subject: Resident Loss or Damaged Hearing Aid/ Dentures. Review of the policy revealed that a grievance form would be filled out for all missing or broken hearing aids. Further review revealed that the facility would replace lost hearing aids if the investigation revealed the facility was negligent. On 9/19/23 at 11:34 AM, during an Interview with the Social Services Director, she reported that their procedure was to complete a grievance form when an item was reported missing. The investigation of the missing item and…

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

Based on pertinent document review and interviews, it was determined that the facility failed to develop a policy regarding the consent for sexual activity in residents with impaired cognition. This was evident for 1 (Resident # 16) out of 16 residents reviewed for abuse during a survey. The findings include: Capacity for consent to sexual activity is the ability to understand and process the information necessary to make an informed decision to participate in sexual activity. Determining capacity to consent is an important step in investigating an allegation of sexual abuse towards a resident with impaired cognition. Review of Resident #16's records revealed that the resident was a long-term resident at the facility. Review of Physician Certification Related to Medical Condition, decision making and treatment limitations, dated 12/24/18, revealed that Resident #16 was assessed by a physician to lack adequate decision-making capacity (including decisions about life-sustaining treatments). Resident #16' s family member was appointed as the power of attorney (POA) to assist 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 that the facility failed to report an allegation of abuse within the mandated time frame. This was evident for 2 (Resident #251, #248) out of 16 residents investigated for abuse. The findings include: 1) On 9/22/23 at 10:45 AM, a review of the facility reported incident MD00173990 revealed that an allegation of abuse was made by Resident #248 to the day shift nurse at 8:00 AM on 11/5/21. A review of the timeline included in the investigation documentation revealed this information was then conveyed to the then acting Director of Nursing (DON Staff #26). Further review of the timeline revealed that the initial report was sent to the state agency by the acting DON (staff #26) on 11/5/21 at 12 PM. This information was verified by the time stamped email sent by Staff #26 to the state agency. On 9/25/23 at 12:30 PM, surveyor discussed the concern with the Nursing Home Administrator (NHA) and she confirmed in this interview that for Resident #248, the facility failed to report the allegation of abuse within the mandated time frame.…

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 interview and review of facility reported incident (FRI) investigation documentation, it was determined the facility failed to thoroughly investigate an allegation of abuse. This was evident for 1 (MD00189938) of 4 facility reported incidents reviewed for resident-to-resident altercations. The findings include: On 9/11/23 at 11:47 AM, a review was conducted of the facility's investigation of the facility reported incident MD00189938 related to an altercation between Resident #45 and Resident #55. A facility self-report, dated 3/9/23 at 6:25 PM, revealed documentation that while Resident #45 was in his/her own room, Staff #36, Geriatric Nursing Assistant (GNA) witnessed Resident #45 go over to the bedside of Resident #55, his/her roommate at which time Resident #55 reached up and slapped Resident #45 hand. The facility's self-report documented that the altercation between Resident #45 and Resident #55 was witnessed by Staff #36, GNA, who then reported the incident to Staff #9, LPN. Review of the facility's investigative documents failed to reveal evidence that staff or…

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 document the information that was provided to the acute care facility to ensure a safe and effective transition of care when a resident was transferred there emergently. This was evident for 1 (#76) of 5 residents reviewed for hospitalization. The findings include: On 9/14/23 at 8:55 AM, a review of Resident #76's medical record was conducted. The medical record documented Resident #76 was admitted to the facility in mid July 2023. On 8/6/23 at 8:50 PM, in a nurse's note, the nurse documented that Resident #76 was found to be very lethargic, weak, elevated temperature, diaphoretic (sweating heavily), with an altered mental status. The resident was able to open eyes, respond to verbal stimuli and was not oriented and Resident #76's significant other wanted the resident sent to the hospital, 911 was called, and Resident #76 was transferred to the hospital. The nurse wrote that telehealth was notified, all documentation was sent to the hospital with 911 and report was called 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 interview and medical record review, it was determined that the facility staff failed to notify resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#73) of 5 residents reviewed for hospitalization during the annual survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure that each resident receives the care they need. On 9/07/23 at 10:51 AM, during an interview with Resident #73's Representative, she stated that Resident # 73 was hospitalized in April 2023. On 9/18/23 at 10:05 AM, a medical record review revealed that Resident #73 had severe cognitive impairment per a Minimum data set (MDS) assessment, dated 3/22/23. A continued record review showed a nurse's note, dated 4/27/23, which indicated that Resident # 73 continued to have hip pain after 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 interview and medical record review, it was determined the facility staff failed to notify the resident/resident representative in writing of the bed hold policy upon transfer to an acute care facility. This was evident for 1 (#73) of 5 residents reviewed for hospitalization during the annual survey. The findings include: On 9/07/23 at 10:51 AM, an interview with Resident # 73's Representative revealed that Resident # 73 was hospitalized in April 2023. On 9/18/23 at 10:05 AM, a medical record review for Resident #73 was conducted. The review revealed a nurse's note, dated 4/27/23 that indicated that Resident # 73 continued to have hip pain after a fall. An X-ray confirmed a possible fracture, and the attending physician gave an order for Resident # 73 to be transferred to the emergency room for evaluation and treatment. A continued medical record review for Resident #73 showed a nurse's note, dated 4/27/23, that stated, County Medical Ambulance Transport on site @ 2145 hours, resident transferred to ambulance stretcher with some c/o pain and secured for safe transport. Face…

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

Based on medical record review and resident and staff interview, it was determined the facility failed to provide a resident and/or a resident's representative with a summary of the baseline care plan that included a summary of the resident's medications. This was evident for 2 (#87, #76) of 5 residents reviewed for hospitalization. The findings include: A baseline care plan must be completed within 48 hours of a resident's admission to the facility and must include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the baseline care plan as well as a list of the resident's current medications must be given to each resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) On 9/12/23 at 12:01 PM, when asked who was responsible reviewing the baseline care plan and providing the resident and/or the resident's representative a copy of the care plan, along with a summary of the resident's medications,…

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, observation and interview, it was determined that the facility failed to provide an ongoing program to support the resident in their choice of activities. This was evident in 3 (Resident #45, #87, and #70) out of 4 residents reviewed for activities. 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. Minimum Data Set- The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. 1) On 9/6/23 at approximately 2:00 PM, Resident #45 was observed in his/her room, lying on the bed. At that time, no television or radio was noted to be on. On 9/7/23 at 12:27 PM, Resident #45 was observed wandering in his/her room. At that time, no television or radio was noted to be on. In addition, on 9/6/23, 9/7/23, 9/8/23 and 9/11/23, random observations of Resident #45 failed to reveal evidence that the resident…

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

Based on record review and interviews, it was determined that the facility failed to report a resident's vital signs that were not within normal limits (WNL) to the resident's physician. This was evident for 1 (Resident #255) out of 5 residents reviewed for neglect during a survey. The findings include: Review of medical records on 9/15/23 at 11:15 AM, revealed that Resident #255 was admitted to the facility following a hospital stay. His/her diagnoses included, but were not limited to, orthostatic hypotension, chronic kidney disease and a cerebral vascular incident (Stoke). Orthostatic hypotension is a condition in which your blood pressure suddenly drops when you stand from a seated or lying position. Hypotension means low blood pressure. Per CDC a normal blood pressure is generally accepted to be 120/80 mm/Hg. Review of records for Resident # 255 on 9/15/23, revealed a nursing progress note, dated 7/12/23 at 5:30 AM, that Resident had a fall. Further review revealed that, immediately following the fall, the resident had a low blood pressure reading of 88/69 mm/Hg. Continued…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that facility staff failed to manage a resident's pain effectively. This was evident for 1 (#249) of 5 residents reviewed for neglect. The findings include: A pain scale is from 0-10; 0 means no pain, and 10 means the worst pain. It is used to assess the level of pain a patient is experiencing for better treatment. Non-pharmacological pain management is an intervention without the use of medications On 9/14/23 at 9:13 AM, a review of complaint # MD 00178633 for Resident # 249 revealed that Resident had back pain, which was ineffectively managed by the facility staff. On 9/21/23 at 10:41 AM, during a medical record review, it was revealed that a care plan for pain was initiated on 7/23/21 for Resident # 249. The interventions on the care plan included but were not limited to administer non-pharmacological interventions (repositioning, diversion activities, snacks, fluids, ice/heat, muscle therapy relaxation techniques, imagery). A medical record 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.

Based on medical record review and staff Interview, it was determined that the facility failed to ensure that a physician reviewed the resident's total program of care at each visit. This was evident for 1 (#87) of 2 residents reviewed for pressure ulcers. The findings include: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone, or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as 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 that a registered nurse (RN) was providing services for at least 8 consecutive hours a day during a 24 hour period. This was evident for 1 out of the 14 days reviewed for RN scheduling. The findings include: On 9/15/23, review of the assignment sheets from August 24th to September 6th, failed to reveal documentation to indicate that a registered nurse was working in the facility starting on the night shift of 9/1/23 till the night shift of 9/2/23. On 9/15/23 at 2:20 PM, the workforce manager (staff #29) was interviewed about her process in scheduling of staff in the facility. Staff #29 reported that the facility currently had openings for 2 night shift nurses. The surveyor discussed the concern with Staff #29 that the review of the assignment sheets revealed that on 9/1/23, no RN was on duty for the night shift, and no RN was on duty for all shifts on 9/2/23. This review revealed a total of 32 consecutive hours of not having an RN on duty in the facility. Staff #29 acknowledged 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.

2) On 9/08/23 at 12:10 PM, a medical record review for Resident #74 revealed an attending physician's order written on 5/7/23 for antihypertensive medication at bedtime for high blood pressure. The physician's order stated to check blood pressure and hold the medication for systolic blood pressure (SBP) less than or equal to 110 mmHg (millimeters of mercury). Systolic blood pressure is the top blood pressure and refers to the amount of pressure in the arteries during the heart muscle contraction. A review of Resident #74's medication administration records from 5/7/23 to 9/5/23 showed that Resident #74's SBP were not monitored daily. A review of the vital signs section of the facility's medical record documented blood pressure for Resident # 74; however, the blood pressure was not taken every day, and there was no correlation between when the blood pressure was taken and when the medication was administered. On 9/12/23 at 10:13 AM, an interview was conducted with staff # 32, a Licensed Practical Nurse (LPN). During the interview, staff # 32 checked Resident #32's 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.

Based on observation and interview it was determined that the facility failed to ensure medications were kept in locked compartments. This was found to be evident on 1 (2nd floor unit) of 2 nursing units. The findings include: 1) On 9/15/23 at 2:44 PM surveyor observed on the desk level of the 2nd floor nursing station a plastic bag marked REFRIGERATE which contained Latanoprost opth. Solution (eye drops) for Resident #16. No staff were observed at the station at the time of the observation. A nurse was in the hall at a medication cart, but was not behind the desk. The Director of Nursing (DON) arrived at the nursing unit at approximately the same time as the observation, when surveyor pointed out the medication on the counter, the DON stated: What is this? The DON then indicated she would throw out the medication. On 9/20/23 at 3:15 PM, surveyor informed the DON of the medication storage concern related to the observation on Friday 9/15/23. DON acknowledged the concern. 2) On 9/13/23 at 7:54 AM, the surveyor observed that the treatment cart, labeled 2B, was unlocked. All doors 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, interview, and pertinent document review, it was determined that the facility failed to properly store food to prevent foodborne illness. This was evident in 1 Kitchen refrigerator out of 2, and 1 resident refreshment refrigerator out of 2, reviewed during a survey. The findings include: 0n 9/6/23 at 10:31 AM, an observation was made of refrigerator A in the facility kitchen. The surveyor was accompanied by the culinary supervisor (staff #21). The observation revealed 1 open container of mandarin oranges, 1 open container of chicken salad and 1 open container of egg salad. All items were without cover or date and time label. Staff # 21 was unable to state when the chicken salad or egg salad were made. Observation of the second-floor refreshment refrigerator on 09/13/23 at 07:00 AM, with nurse (staff # 3) revealed a refrigerator temperature log hanging on the wall behind the door. A closer observation of the temperature log revealed that the log was dated September 2023. It contained spaces for a daily AM temperature and PM temperature recordings, initials, and…

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

Based on record review and interviews, it was determined that the facility failed to maintain accurate medical records. This was evident for 1 (resident #16) out of 5 residents reviewed for unnecessary medications during a survey. The findings include: On 9/12/23, review of medical records for Resident #16 revealed that the resident received Psychogeriatric services from Nurse Practitioner (Staff #20), on 8/30/23. On 9/20/23 at 10:18 AM, the Nurse Practitioner (Staff #20) was interviewed regarding the care provided to resident #16 on 8/30/23. During the interview Staff #2O reported that she had not provided care to Resident #16 on 8/30/23. The Nurse practitioner reported that the document in Resident #16's medical record, on 8/30/23 was written by her, but it was for another resident's medical record, with a similar name. The document in Residents #16's medical record was a medical documentation for another resident that she had provided care to. On 9/21/23 at 9:15 AM, the Director of Nursing (DON) was interviewed, and the above concern was reviewed. The DON reported 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 medical record review and staff interview, it was determined that the facility failed to hire a qualified employee to provide social services for their residents. This was evident for 1 (Staff #7) of 1 staff reviewed in the Social Services Department. The findings include: During an interview with the Social Services Director Staff #7 on 9/20/23 at 8:03 AM, she reported that she had been hired in 2014 and she had been grandfathered in to provide social services to the residents. In addition, she stated she had a degree in human services. A review of Staff #7's employee file on 9/20/23, revealed she was hired as the Social Services Director in 2019 and per her application, she held an Associate Degree in human services. The regulation requires that the person hired to provide social services to residents should have a Bachelor's degree or higher. On 9/20/23 at approximately 2:30 PM, the Nursing Home Administrator (NHA) was asked to review the employee file and confirm whether or not Staff #7 had a Bachelor's degree in human services. An interview with the NHA on 9/21/23 at…

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

Based on record review and interview, it was determined that the facility failed to ensure that residents were offered the pneumococcal vaccine. This was evident in 1 (Resident #87) out of 5 residents reviewed for immunizations during the survey process. The findings include: Resident #87's medical record was reviewed on 9/15/23 at 11:01 AM and revealed the resident was admitted in July of 2023. Review of the resident's admission assessment revealed documentation that the resident had not received a pneumococcal vaccination. Further review of the record revealed no evidence of contraindication or that the vaccine was offered and that the resident had declined the vaccination. Contraindication is a medical term used for a specific situation or factor that makes a procedure or course of treatment inadvisable, because it may be harmful to a person. On 9/15/23 at 11:43 AM, the Infection preventionist nurse (IP/RN staff #14) was interviewed about her process when the facility admits a new resident. When the IP nurse (staff #14) was asked specifically about immunizations, she stated, When…

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

Based on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident, along with the reason for the transfer. This was evident for 6 (#95, 49, #46, #91, #20, #74) of 8 residents reviewed that were transferred to an acute care facility. The findings include: 1) Review of the medical record for Resident #95 on 2/5/19 revealed documentation that the resident was sent to an acute care facility on 10/12/18 for lethargy, and on 11/5/18 for abnormal laboratory results. There was no written documentation found in the medical record that the resident and/or resident representative was notified of the transfer in writing. 2) Review of the medical record for Resident #49 on 2/6/19 revealed documentation that the resident was sent to an acute care facility on 8/3/18 for chest pain, on 11/22/18 for a leg fracture, and on 12/27/18 for chest pain. There was no written documentation found in the medical record that the resident and/or resident representative was notified of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and review of medical records, it was determined that the facility failed to evaluate, and revise care plans as resident care needs became apparent or changed over time. This was evident for 10 (#46, #49, #91, #8, #53, #74, #3, #96, #59, #84) of 23 residents in the final sample. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) On [DATE] at 7:23 PM, Resident #46 stated, I have a problem with my nerves. It was difficult to interview the resident and the resident sat in the hallway in a wheelchair and yelled constantly for the nurse. Review of Resident #46's medical record on [DATE] revealed a care plan, has a behavior problem r/t yelling out. Resident indicates he/she feels down and depressed and feels tired. Resident at times has trouble concentrating on things and has trouble falling asleep. He/She has a diagnosis of depression, anxiety and schizoaffective…

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 interviews with the facility staff, it was determined the facility failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address deficiencies from a previous survey. This was evident during review of the Quality Assurance program. The findings include: Review of the Quality Assessment and Assurance (QAA) Program with Staff #7 on 2/1/19 at 5:45 PM, revealed that effective processes were not put in place regarding repeat deficiencies. The facility's action plans did not resolve quality deficiencies identified during the last recertification survey which concluded on 9/28/17 with a plan of correction compliance date of 11/12/17. The repeat deficiencies reviewed with staff #7 included areas of 1) Safe, clean, homelike environment, 2) accurate assessments, 3) care plan timing and revision, 4) quality of care, 5) posting of staffing, 6) free from unnecessary medications and 7) resident records.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation and staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, this was observed on both levels of the facility. The findings include: The following observations were made by multiple surveyors during initial observations of residents and the environment on 2/4/19 and 2/5/19. On 2/8/19 at 4:30 PM, an environmental tour was conducted with the nursing home administrator (NHA) and the director of nursing (DON) to review environmental concerns. Areas of concern included: room [ROOM NUMBER] - The laminate on the edge of the top of the dresser was missing and the particle board was exposed. The laminate on the over the bed tray table was missing from the top edge and around the corner of the table. The right side of the wheelchair was missing the vinyl edge mid-section. The paint on the ceiling in the shared bathroom 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 the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 5 (#95, #49, #46, #91, #20) of 8 residents reviewed for hospitalization. The findings include: 1) Review of the medical record for Resident #95 on 2/5/19 revealed documentation that the resident was sent to an acute care facility on 10/12/18 for lethargy, and on 11/5/18 for abnormal laboratory results. 2) Review of the medical record for Resident #49 on 2/6/19 revealed documentation that the resident was sent to an acute care facility on 8/3/18 for chest pain, on 11/22/18 for a leg fracture, and on 12/27/18 for chest pain. 3) Review of the medical record for Resident #46 on 2/7/19 revealed documentation that Resident #46 was sent to an acute care facility on 1/27/19. 4) Review of the medical record for Resident #91 on 2/8/19 revealed documentation that the resident was sent to an acute care facility on 5/28/18 due to a fall. 5) Review of the medical…

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 and staff interview, observation and medical record review, it was determined that the facility failed to develop and implement comprehensive person-centered care plans with measurable goals. This was evident for 8 (#91, #95, #46, #74, #3, #53, #56, #6 ) of 23 residents in the final sample. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) An interview was conducted with Resident #91, on 2/5/19 at 9:48 AM. Resident #91 stated, after I fell I lost my hearing. I would like to see an audiologist. A review of the medical record on 2/6/19 revealed an activities progress note, dated 10/20/18, which stated, resident's care plan meeting was held on 10/17/18 with resident present, resident spoke with social services concerning issues with new glasses and requesting an eye doctor appointment, as well as seeing ENT doctor for hearing loss in left ear. A plan of care note, dated 10/26/2018 at 12:39, documented, Resident indicated that she needed 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 staff interview, It was determined that the facility failed to ensure a resident's medication regimen was free from an unnecessary psychotropic medication by 1) failing to adequately monitor a resident for behavior, side effects or adverse consequences related to psychotropic medication use and 2) failing to ensure that a psychotropic medication prescribed as needed was limited to 14 days. This was evident for 3 (#59, #56, #84) of 6 residents reviewed for unnecessary medications. The findings include: 1) Resident #59's January 2019 and February 2019 MAR (medication administration record) was reviewed on 2/6/19. The MAR documented that Resident #59 received the psychotropic medications, Trazodone (antidepressant) by mouth every day for depression, Paroxetine (Paxil) (antidepressant) by mouth every day for depression, Klonopin (anxiolytic) by mouth twice a day for anxiety, and Seroquel (Quetiapine) (antipsychotic) by mouth every day for psychotic disorder. Review of Resident #59's January 2019 and February 2019 TAR (treatment administration record)…

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

Based on medical record review and staff interview, it was determined the facility failed to keep updated and accurate medical records. This was evident for 7 (#6, #51, #49, #91, #53, #13, #59) of 23 residents in the final sample. The findings include: 1) The facility failed to accurately document oxygen uses for resident #49. Observation was made on 2/5/19 at 10:17 AM of Resident #49 receiving oxygen (O2) at 3L/min. A second observation was made, on 2/6/19 at 4:02 PM, of Resident #49 sitting in a wheelchair with a portable oxygen tank sitting on the back of the wheelchair. The resident was receiving oxygen and the flow rate was set at 3L/min. Subsequent observations were made on 2/7/19 at 9:45 AM and 2:15 PM on 3L/min. Review of the February 2019 physician's orders documented that oxygen was ordered at 4L/min. The order was initially written on 8/9/18. Review of the February 2019 Treatment Administration Record (TAR) revealed that the nursing staff was signing off that 4L/min oxygen was being administered when the resident was observed to be receiving 3L/min on 3 days. In addition,…

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, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#17, #69) of 2 residents reviewed for Resident Assessment, 1 (#91) of 2 residents reviewed for communication/sensory, and for 1 (#59) of 6 residents reviewed for unnecessary medications. 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) Review of the medical record for Resident #17 on 2/5/19 revealed a psychiatry note, dated 11/1/18, which documented the diagnosis psychosis. Review of the MDS with an assessment reference date (ARD) of 11/3/18 failed to capture 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 resident and staff interview and medical record review, it was determined the facility failed to follow up with the resident to ensure that the resident received the services necessary to maintain adequate hearing. This was evident for 1 (#91) of 2 residents reviewed for communication/sensory. The findings include: On 2/5/19 at 9:48 AM, an interview was conducted with Resident #91. Resident #91 stated, I fell and after the fall my hearing has not been right since. The resident continued, I would like to see an audiologist. I asked them, but they just passed it on. A review of Resident #91's medical record on 2/6/19 revealed an activity's progress note, dated 10/20/18, which stated, Resident's care plan meeting was held on 10/17/18 with resident present, resident spoke with social services concerning issues with new glasses and requesting an eye doctor appointment as well as seeing ENT doctor of hearing loss in left ear. A second note, dated 10/26/18 at 12:39 PM, stated, Care plan meeting held on 10/17/2018. The note continued, Resident indicated she needed an appointment 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 review of the medical record and interview with facility staff, it was determined that the facility staff failed to provide services or treatment to increase or prevent further decrease in Range of Motion (ROM). This was evident for 1 (#74) of 2 residents reviewed for Position, Mobility. The findings include: Resident #74 was observed on 2/5/19 at 11:24 AM. The resident's left hand appeared to have a contracture (condition of fixed high resistance to passive stretch of a muscle). Staff #6 was interviewed at that time and confirmed that Resident #74 had contractures of his/her left hand and both legs. He/She also indicated that the resident had braces, but they were discontinued due to the resident's refusal and indicated that the resident received functional maintenance ROM exercises during care. Review of Resident #74's medical record revealed a current physician's order, written 1/16/19, for bilateral (left and right) palm protectors to be donned to Resident #74's upper extremities (hands) as patient is able to tolerate, as contracture management, every shift. 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 staff interview, it was determined that the facility staff failed to 1) ensure that oxygen was administered at the rate ordered by the physician, 2) failed to accurately document the resident's oxygen rate in the treatment record, 3) failed to assess a resident's breath sounds before and after a breathing treatment and failed to develop a resident centered care plan for a resident with a diagnosis of Asthma and receiving oxygen. This was evident for 1 (#59) of 6 residents reviewed for unnecessary medications, and for 1 (#49) of 2 residents reviewed for respiratory care. The findings include: 1) Resident #59 was observed utilizing oxygen via nasal cannula (n/c) tubing connected to an oxygen concentrator on 2/5/19 at 11:00 AM, on 2/6/19 at 4:18 PM, and 2/7/19 at 9:45 AM. On each of these observations the oxygen concentrator was set at 3.5 l/m (liters/minute). On 2/7/19, a review of Resident #59's TAR (treatment administration record) revealed an order for 02 (oxygen) at 2 L via n/c to maintain 02 saturation above 90% every shift that 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 a medical record review and staff interview, it was determined that a physician failed to fully evaluate a resident as related to facility acquired pressure ulcers. This is evident for 1 (#75) of 3 residents reviewed for pressure ulcers. The findings include: Review of Resident #75's medical record on 2/7/19 revealed this resident had acquired pressure ulcers while in the facility. On 11/3/18, a progress note was written related to the discovery of a stage II pressure ulcer to the resident's left buttock. The note indicated that the resident's attending physician was notified. The resident's attending physician had visited the resident on 11/14/18, 12/10/18, and 1/18/19. Review of the 3 handwritten physician notes did not reveal any documentation related to resident #73's facility acquired pressure ulcer. Review of the physician progress notes with the charge nurse (staff #14) on 2/7/19 at 2:30 PM, acknowledged that the 3 monthly physician notes do not assess or evaluate medical issues related to the resident's skin condition. Per nursing documentation in the resident'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.

3) A review of the medical record for Resident #13 on 2/6/19 noted the last physician's visit in the paper medical record was dated for 3/5/18. The last physician's visit in the electronic medical record was dated 9/11/18, with a documented average of 1 month between physician visit and upload to electronic medical record. There were no other physician's progress notes found in either the paper or electronic medical record. Upon request monthly physician visits notes going back to 4/8/2018 was received on 2/7/19 for review. Based on medical record review and staff interview, it was determined the physician failed to write, sign and date medical visit progress notes in resident medical records on the day the resident was seen. This was evident for 1 (#49) of 2 residents reviewed for respiratory care, 1 (#91) of 2 residents reviewed for communication/sensory, 1 (#13) of 2 residents reviewed for mood/behavior and 1 (#53) of 3 residents reviewed for Pressure Ulcer/Injury. The findings include: 1) A review of the medical record for Resident #49 on 2/6/19 noted the last physician's visit…

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.