Lions Rehab Center

Based on observation, interviews and record reviews it was determined that the facility failed to review, update and revise Resident's care plans after Resident's changes in conditions. This finding was found to be evident in 2 (Resident #11 and #95) out of 13 Residents reviewed for care plan timing and revision. The findings include:Care plans are a written document that outlines a person's care needs and how they will be met. It's a key tool for health and social care professionals to ensure a Resident receives the right level of care. Care plan includes medical history, current treatments, and medications. Care plans should be reviewed regularly to monitor their effectiveness, and the Resident should be involved in the process. Additionally, care plans should be developed, revised and updated as necessary to reflect the Resident's condition by the interdisciplinary team. The care plan includes assessment, diagnoses, goals, interventions and outcomes. Care Plans are required to be developed within 7 days of completion of a Resident's admission comprehensive Minimum Data Set (MDS)…

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, record reviews, and interviews, it was determined that the facility failed to administer medications according to professional standards procedure. This was evident for 1 (Resident #69) out of 5 residents reviewed for medication administration. The findings included: Multi-dose insulin pens are handheld devices that contain a prefilled insulin cartridge for multiple injections combined with a needle. This pen allows users to dial specific dosages. A new needle is used for each dose given and the pen is designed for single-person use. The new needle is primed before every injection to remove air bubbles and ensure the needle allows the flow of insulin. Standard priming dose is 2 units of insulin. On 3/24/26 at 8:24 AM, the surveyor observed License Practical Nurse (LPN) #4 prepare insulin for Resident #69. The surveyor watched LPN 4 place the needle onto the top of the insulin pen and then dialed the insulin pen to 20 units. LPN #4 went into Resident #69's room to give the insulin to the Resident. After returning to the medication cart the surveyor asked LPN #4…

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

Based on record reviews and interviews it was determined that the facility failed to provide treatments according to a Resident's plan of care. This was found evident of 1 (Resident #96) out of 3 residents reviewed for wound care. The findings include: On 3/24/26 at 10:48 AM, the surveyor reviewed Resident #96's medical records. A review of Resident #96's December Treatment Administration Record revealed that on 12/10/25 an order was written that stated, apply skin guard ointment to {genital area} and coccyx every day and evening shift for skin healing. The order was documented as completed on the evening of 12/10/25 and morning and afternoon on 12/11/25. The order was discontinued on 12/11/25. A new order was written to start on 12/12/25 that stated apply skin guard to {genital area} every day and evening shift for wound healing. However the new order did not include the orders to apply the treatment to the coccyx. A new order for the coccyx wound was written to start on 12/17/25 and stated, to cleanse with wound cleaner, apply medi-honey to the wound bed and cover with a border…

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 monitor a Resident's hemodialysis access site. This finding was found to be evident in 1 (Resident #2) out of 1 Resident reviewed for dialysis.The findings include:Hemodialysis is a life-sustaining treatment for kidney failure that filters waste, toxins, and excess fluid from the blood using a machine and a dialyzer (artificial kidney). Typically performed three times a week for 3-5 hours, it reduces symptoms of kidney failure. Blood is removed from the body through a vascular access point (fistula, graft, or catheter). The surveyor conducted a record review of Resident #2's medical record on 3/25/2026 at 9:25 AM. Review of the medical record revealed that Resident #2 had a physician order for dialysis treatment every Tuesday, Thursday and Saturday. Further review of the physician orders revealed that there was no order for monitoring Resident 2's hemodialysis access site (right chest port). Additionally, Resident #2 did not have a comprehensive care plan for hemodialysis and emergency management.In…

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

Based on record review and interview, it was determined that the facility failed to complete a resident's behavior management documentation. This was evident for 1 (Resident #22) out of 10 residents evaluated for behavioral, mental, and/or emotional health care and services during the recertification survey. The findings include: Mental disorder and psychosocial adjustment difficulty refers to the development of emotional and/or behavioral symptoms in response to an identifiable stressor(s) that has not been the resident's typical response to stressors in the past or an inability to adjust to stressors as evidenced by chronic emotional and/or behavioral symptoms. (Adapted from Diagnostic and Statistical Manual of Mental Disorders - Fifth edition. 2013, American Psychiatric Association.).On 03/26/26 at 2:00PM, the surveyor conducted a record review. Resident #22 had diagnoses of major depressive disorder and anxiety. According to the resident's medication administration record, he/she was scheduled to take Mirtazapine 7.5 mg and Magnesium Oxide 400 mg. Their care plan and treatment…

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 staff interviews, it was determined that the facility failed to ensure medications were administered to a resident as ordered. This was evident for 1 (Resident #70) out 47 residents reviewed during the survey. The findings include: On 3/26/26 at 12:13 PM, the surveyor reviewed Resident #70's medical record. The review revealed that Resident #70 had an order changed on 3/14/25 for lorazepam (a benzodiazepine used to treat anxiety disorders and acute seizures) to be changed from every hour as needed to scheduled twice a day, due to an increase in behaviors. Depakote (an anticonvulsant and also used as a mood stabilizer) was also prescribed to be given twice a day for behaviors and agitation on that same day. Next the surveyor reviewed Resident #70's March 2026 Medication Administration Record (MAR). The review revealed that Resident #70's lorazepam was left blank, indicating the medication was not given, on the afternoon dose of 3/14/26 through the morning dose of 3/19/26, in which the medication was discontinued in the afternoon. However, the depakote…

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 properly store food in the refrigerator. This was evident during the initial kitchen tour. This had the potential to impact food prepared in the kitchen. The findings include:On 03/23/26 at 8:51 AM, the surveyor discovered multiple containers of food that were covered with punctured foil. On 03/23/26 at 8:52 AM, the surveyor interviewed the Dietary Manager regarding food storage requirements. The Dietary Manager expressed it was an error and immediately removed the containers from the refrigerator.On 03/23/26 at 3:01 PM, the administrator acknowledged the concern.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility, 1) failed to provide functioning hand sanitizers, and 2) failed to correctly identify residents requiring transmission based precautions and 3) failed to perform hand hygiene before direct contact with a resident. This was found to be evident for 5 (110, 111, 406, 407, and 409) out of 10 rooms reviewed for hand sanitizers and 1 (104) out of 7 rooms reviewed for correct transmission-based precaution signage, and 1 (Staff #18) out of 1 staff observed for hand hygiene during the recertification survey.The findings include: 1) On 03/23/2026 at 9:03 AM, the surveyor observed hand sanitizer not working in room [ROOM NUMBER], room [ROOM NUMBER] and in the hall outside the rooms 101, 111 and 112. On 03/24/2026 at 9:05 AM, the surveyor also found non working hand sanitizer in rooms [ROOM NUMBER]. When the surveyor asked Staff #7 about the process for replacing empty hand sanitizer, Staff #7 stated the facility did not yet possess the bags for the…

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

Based on observation and interview, it was determined that the facility failed to ensure that the resident's call system functioned properly. This was found to be evident for 2 residents (#32 and #100) out of 11 residents evaluated for call light access during the recertification survey. The findings include:On 03/23/2026 at 11:56 AM, Resident #100 told the surveyor, My call light is not working. GNA #13 investigated the concern and confirmed that Resident #100 and also Resident #32's call lights were not working. GNA #13 stated they would call maintenance. The Director of Nursing was in the hall and was notified of the concern. On 03/24/2026 at 7:56 AM, GNA #12 stated maintenance fixed Resident #100's call light immediately yesterday. The Maintenance Assistant stated that the call cords weren't functioning but but changing the cords fixed the issue. When the surveyor asked what backup measures the facility utilized, the Maintenance Assistant stated they gave bells to residents if they could not fix the call bell right away.On 03/24/2026 at 8:01 AM, the Administrator acknowledged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility failed to maintain a safe/functional/sanitary/comfortable environment for Residents and staff. This finding was found to be evident in 2 (Resident rooms [ROOM NUMBERS]) out of 15 Resident rooms and the Rehabilitation Department reviewed for safe, comfortable environment.The findings include:On 3/23/2026 at 11:00 AM the surveyor toured the Rehabilitation Department. The surveyor observed the screen cover to the speaker located in the ceiling to the entrance of the Rehabilitation Department. The screen cover was hanging loose from the ceiling and not intact to the ceiling. The surveyor conveyed to the Director of Rehabilitation (DOR) on 3/23/2026 at 11:05 AM that the screen cover was loose and hanging from the ceiling at the entrance of the therapy department. The DOR observed the screen cover and stated that she would notify maintenance.At 11:45 AM on 3/23/2026 the surveyor observed doors to Resident rooms [ROOM NUMBERS] that were marred,…

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 accurate dispensing and administration of medications. This was evident for 1 (Resident #5) of 1 resident reviewed for pain management.The findings include:On 10/27/25 at 10:32 AM, a review of the allegations related to complaint #2598971 indicated that Resident #5 was not getting the pain medication ordered for comfort care.A review of Resident #5's progress notes was conducted on 10/27/25 at 10:45 AM. A progress note with an effective date of 8/14/25 at 10:37 AM, indicated a verbal order from the physician to administer 5 ml of Morphine every 3 hours for pain and to discontinue all other medications. On 10/28/25 at 9:28 AM a review of Resident #5's narcotic count sheet was conducted with the Director of Nursing (DON). The review revealed that the morphine solution 10mg/5ml was delivered on 8/15/25. Further review of the narcotic count sheet revealed that the nursing staff had initially used the morphine solution with a stock dose of 10mg/5ml and pulled 0.25ml for each administration from…

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 residents are free from significant medication errors. This was evident for 1 (Resident #5) of 1 resident reviewed for pain management.The findings include:On 10/27/25 at 10:32 AM, a review of the allegations related to complaint #2598971 indicated that Resident #5 was in comfort care. However, the pain medication used was ineffective and the resident was complaining of pain and discomfort.A review of Resident #5's progress notes was conducted on 10/27/25 at 10:45 AM. A progress note with an effective date of 8/14/25 at 10:37 AM indicated that the resident was to receive 5 ml of Morphine every 3 hours for pain from a verbal order from the physician. The next progress note with an effective date of 8/14/25 at 10:54 AM indicated that the order for Morphine was checked and read back to the physician 3 times by the Registered Nurse (RN #3). The next progress note was created by RN #4 with an effective date of 8/14/25 at 10:31 PM, that indicated that the Morphine order was not delivered, and 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 notify resident's physician when medications were held. This was evident for 1 (R#62) of 3 residents reviewed for notification of medications not given during the complaint survey. The findings include: On 5/27/25 at 1:45 PM a record review of Resident #62's Medication Administration Record (MAR) for May 2025 revealed an order for metoprolol (a medication that lowers blood pressure) with the instruction to hold for a systolic blood pressure (SBP) [top number of blood pressure] of 110 or less, or for a heart rate (HR) of less than 60 beats per minute. The MAR entries on 5/03/25, 5/04/25, 5/15/25, 5/16/25, 5/21/25 indicated that the medication was held on those days due to either low SBP or low HR. Further review failed to reveal any documentation that the resident's physician was notified that the medication was held on those days. On 5/27/25 at 1:56 PM an interview was conducted with the Director of Nursing (DON) to review Resident #62's MAR for May 2025. She confirmed the finding that 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.

Based on record review and interview it was determined that the facility failed to complete thorough investigations of allegations of abuse. This was evident for 1 (#MD00217463) of 7 facility reported incidents reviewed during the complaint survey. The findings include: On 5/29/25 at 9:45 AM a review of the facility reported incident #MD00217463 revealed an allegation that staff verbally abused Resident #516 on 4/30/25. A review of the facility's investigation file revealed several typed resident interview statements. All of the resident statements lacked the name of the interviewer and the date the interview was conducted. The investigation file also contained staff interview statements from 2 Geriatric Nursing Assistants (GNA #16 & GNA #17). GNA #16's statement indicated that she was not assigned to the resident at that time, and GNA #17's statement did not indicate if she worked with the resident at that time. The file also lacked a list of staff who worked on the resident's unit that day, and lacked any evidence that abuse education was provided to staff after the incident. On…

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

Based on record review and interviews it was determined that the facility failed to maintain medical records in accordance with professional standards. This was evident for 1 (MD00215206) of 7 facility reported incidents investigated during the complaint survey. The findings include: A review of the facility reported incident (FRI) #MD00215206 revealed that Resident #509 had an unwitnessed fall on 2/26/25. On 2/27/25 a nursing assessment revealed that the resident's left wrist was swollen and discolored. An x-ray was ordered and done on 2/27/25 and showed that the resident's left wrist was fractured. A review of the facility's investigation file was conducted on 5/28/25 at 9:20 AM. The file contained two duplicate handwritten documents, dated 3/06/25, signed by the consultant orthopedic Physician Assistant (Staff #15). One form contained notations of a capital letter R within a circle to indicate that the resident's right wrist was affected. The other document contained notations of a capital letter L within a circle, to indicate that it was the resident's left wrist 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 record review and interviews, it was determined that the facility failed to ensure that residents received ordered medications or treatments. This was evident for three (Resident #36, #12, and #3) out of 29 residents reviewed for medical records. The findings include: On 5/28/2025 at approximately 11:00 a.m., the surveyor reviewed the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for Residents #36, #12, and #3. The surveyor found that the following physician-ordered medications and treatments were missed: Resident #36 On 5/4/25 (6:00 a.m. dose) - Acetaminophen, oral tablet 1000 mg, three times a day for chronic pain, was not administered. On 5/3/25 (5:00 p.m. dose) and 5/4/25 (6:00 a.m. dose) - Blood sugar checks with Humalog injection solution (100 units/mL, sliding scale), subcutaneously four times a day for diabetes management, were missed. On 5/16/25, 5/17/25, and 5/18/25 - All scheduled doses (6:00 a.m., 11:00 a.m., 4:30 p.m., and 10:00 p.m.) of blood sugar checks with Insulin Aspart FlexPen injector (100 units/mL, sliding scale),…

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, record reviews and interviews, it was determined that the facility failed to ensure that a resident's urine collection bag was secured off the floor. This was evident in 1 (Resident #502) of 3 residents reviewed for urinary catheters. The findings include: Resident #502 had been residing in the facility since early 2025. Medical records indicated that the resident was admitted with a foley catheter. A Foley catheter is a device that drains urine (pee) from your urinary bladder into a collection bag outside of your body when you can't pee on your own or for various medical reasons. Securing a urine collection bag is crucial to prevent leaks, reduce the risk of infection, and ensure proper catheter function, as well as prevent damage to the bladder neck or urethra. On 5/27/25 at 9:47 AM, Resident #502 was observed in bed sleeping with the urine collection bag laying on the floor. The Geriatric Nursing Assistant (GNA #8) who was assigned to the resident's unit confirmed the resident's name by pointing the resident out to the surveyor then left the area. Later 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 medical review and staff interview, it was determined that the facility failed to document the reasons for administering as-needed (PRN) pain medications, failed to document the pain assessment to include intensity of pain, location of pain, and description of pain, and failed to implement non-pharmacological interventions before administering pain medication to residents. This was evident for 2 (#24 and #64) of 3 residents reviewed for pain management. The findings include: A pain intensity scale is one way to measure pain. The pain scale helps track how well a treatment plan is working to manage pain. Most pain scales use numbers from 0 to 10. A score of 0 means no pain, and 10 means the worst pain one has ever known. On 5/27/25 at 10:30 AM a record review of the Pain Control Policy revealed that assessing a resident's pain should include the frequency, duration, intensity of the pain when a resident gets regularly scheduled and/or PRN analgesics. The physcisian should order Non-pharmacological Interventions (NPI). On 5/28/25 at 11:06 AM a record review of Resident #24'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 review and staff interview, it was determined that the facility failed to ensure a resident received their medications according to the attending physician's orders. This was evident for 1 (#518) out of 3 residents reviewed for medication regimen review (MRR). The findings include: A medical record review on 5/29/2025 at 10:43 AM showed that an MRR was completed by a pharmacist for Resident #518 on 3/21/25 with a recommendation to the resident's attending provider. The recommendation indicated that Resident #518 had been taking an antiulcer drug 40mg every day since 2023. It recommended a dose reduction to 20mg. A continued review revealed that Resident #518's attending provider responded to the recommendation on 3/28/25 with a new order to reduce the medication to 20mg daily. Further review of Resident #518's Medication Administration Record (MAR) from March 28 to May 30, 2025, revealed that the resident continued to receive the antiulcer medication at a total daily dosage of 60 mg, consisting of the 40 mg daily, and a newer dosage of 20 mg daily. In an interview on…

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

Based on record review, observation, and staff interview, it was determined that the facility failed to implement Enhanced Barrier Precautions (EBP) as part of the infection prevention and control program. This was evident for 2 (Resident #40 and Resident #503) of 3 residents reviewed for pressure ulcers. The findings include: Enhanced Barrier Precautions (EBP) are defined by the Centers for Disease Control and Prevention (CDC) as a targeted infection prevention intervention requiring gown and glove use for high-contact care activities in residents with wounds, indwelling medical devices, or colonization/infection with multidrug-resistant organisms (MDROs). High-contact care activities involve extensive, close physical contact between staff and the residents and are more likely to result in the transmission of infectious agents. These include but are not limited to dressing the resident, bathing/showering, transferring the resident, providing hygiene (e.g., assist with toileting, oral care), changing linens, providing wound care, providing device care or use (e.g., care of feeding…

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

Based on observations, interviews, and record review, it was determined that the facility failed to monitor temperatures for the dishwasher machine to ensure adequate sanitation, and ensure temperatures were checked for mechanical soft and pureed foods before serving. This was evident for 5 of 8 daily dish machine logs and 3 of 13 daily food temperature logs reviewed. The findings include: 1) On 1/8/25 during the initial entrance conference, the Director of Nursing (DON) reported that the facility was currently experiencing a GI (gastrointestinal) outbreak. A tour of the kitchen on 1/8/25 at 11:10 AM, revealed that the dish machine log had no entries since 1/3/25. At 11:15 AM, the surveyor reviewed the concern with the Nursing Home Administrator (NHA) and the DON that they were currently in a GI outbreak and that there was no indication that the dish machine temperatures had been checked for several days. During a follow up tour of the kitchen on 1/14/25, surveyor confirmed that the dishwasher provided heat sanitation of the dishes. After several runs through, the dishwasher…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments 1) were accurately documented and 2) accurately reflected a Resident's status. This was evident for 4 (#60, #24, #64, #75) out of 35 residents reviewed during the survey The findings include: The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility information necessary to develop a care plan, provide the appropriate care and services to the Resident, and modify the care plan based on the Resident's status. 1a) In an observation on 1/9/25 at 8:16 AM, Resident #60 was eating his/her breakfast and was noted to be edentulous (having no teeth). The Resident stated at that time that s/he wore complete dentures. On 1/13/25 at 4:18 PM, a review of Resident #60's medical record contained facility dental assessments dated 8/3/24 and 11/12/24. The assessments recorded that Resident #60 had no natural teeth. Continued review found a dental 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews, it was determined that the facility failed to ensure that a resident participated in the care plan process and failed to revise a resident's care plan. This was evident for one (#40) of eight residents reviewed for activities of daily living (ADL) and one (#269) of three residents reviewed for care planning during the survey. The findings include: 1) Resident #40 was admitted to the facility in late 2022. A review of the resident's most recent comprehensive assessment with a reference date of 12/20/24, was conducted on 1/9/25 at 11:33 AM. the review revealed Section GG (Functional Abilities), where the resident was coded according to the amount of assistance provided to complete several activities. These activities include: o Eating: Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. o…

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 interviews, it was determined that the facility failed to 1) provide residents with the amount of assistance needed during meals and 2) ensure that residents unable to carry out activities of daily living (ADL) were given incontinence care. This was evident for 5 (#469, #74, #270, #60, #22) of 8 residents reviewed for ADL during the recertification 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. 1a) A review of complaint #MD00193700 dated 6/23/23 revealed an allegation that Resident #469 required assistance with eating but was not helped by the staff to eat. The continued review contained an MDS assessment dated [DATE] for Resident #469. The MDS recorded that the Resident required extensive to total assistance from staff with all ADLs and extensive assistance with eating. Further 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 interviews, it was determined that the facility failed to document the reasons for administering as-needed (PRN) pain medications, failed to document pain assessment to include the location of the pain and type of pain, and failed to implement non-pharmacological interventions before administering pain medication to a Resident reporting pain. This was evident for 1 (#24) of 6 Residents reviewed for unnecessary medications and 2 ( #59, #64) of 3 residents reviewed for pain management. The findings include: 1) A review of Resident #24's medical record on 1/9/25 at 2:04 PM showed that the resident had been residing in the facility since August 2015 with diagnoses including chronic pain, Arthritis, neuropathy (pain from the nerves) and was able to communicate his/her needs. A pain scale is a numerical scale, usually 1-10, used to rate a person's severity of pain. A continued review of Resident 24's medication administration record for November 2024 to January 2025 showed that the resident had received pain medication on 11/7/24 for a pain level of 4,…

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

Based on observations and interviews, it was determined that the facility failed to ensure resident's urine collection bag was kept in a privacy bag to maintain dignity. This was evident for 2 (#419, #64) of 3 residents reviewed for urinary catheters. The findings include: 1) On 1/8/25 at 11:19 AM, Resident #419 's foley bag was observed on the floor from the hall without a privacy cover. The Resident was in bed. On 1/8/25 at 11:46 AM, Resident #419's foley bag was observed attached to the bed rail from the hall without a privacy cover. On 1/8/25 at 1:16 PM, Resident #419 was observed in bed eating lunch using a wheeled bedside table. The foley bag did not have a privacy cover. On 1/8/25 at 1:49 PM, it was observed that the bedside table, without a food tray, had been moved away from the Resident. The foley bag lay on the floor without a privacy cover. On 1/13/25 at 10:30 AM, Resident #419 was observed asleep in bed. The foley bag lay on the floor without a privacy cover. On 1/13/25 at 10:57 AM Resident #419 was observed awake in bed. The foley bag lay on the floor without a privacy…

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 interviews, it was determined that the facility failed to ensure that call devices were kept within reach of the resident. This was evident for 1 (Resident #40) in 24 residents reviewed during the survey. The findings include: Resident #40 had been residing in the facility since 2022. Two complaints related to MD00210880 and MD00211651 indicated concerns with the resident's call device being placed on the roommate's nightstand outside the resident's reach. 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. On 1/9/25 at 11:33 AM, a review of Resident #40's most recent MDS assessment with a reference date of 12/20/24 was conducted. The review revealed that Resident #40 was coded as dependent on staff for transfers and mobility and needed substantial/maximal assistance from staff for toileting hygiene. On 1/10/25 at 10:43 AM, Resident #40 was observed sleeping in his/her room with…

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

Based on interviews and record review, it was determined that the facility failed to provide residents with quarterly statements in writing of their personal funds account managed by the facility. This was evident for one Resident (#22), who was reviewed for personal funds during the survey. The findings included: In an interview on 1/8/25 at 11:18 AM, Resident #22 responded Yes to keeping money in the facility like a bank. Then, it was added that s/he had not received a written quarterly statement of the account for a year. During a subsequent interview on 1/10/25 at 11:45 AM, the Business office manager (BOM) reported that he hand-delivered quarterly statements to residents who could make their own decisions. He also noted that he discussed the statements with the residents' who signed them and returned them to him for his records. He added that he only made copies for residents who requested them. A review of Resident #22 medical record contained a document completed by the Resident's attending provider that indicated the Resident could make his/her own decisions. In an interview…

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 they informed residents of their right to formulate an advance directive. This was evident for one resident (#269) who was reviewed for advance directives during the survey. The findings include: A medical record review for Resident #269 on 1/8/25 at 1:00 PM showed that the resident was admitted to the facility in December 2024. The review contained a document completed by the resident's attending provider on 12/22/24 that indicated the resident could make his/her own decisions. An advance directive is a legal statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor because of illness or incapacity. The review failed to show that Resident #269 had an advanced directive or that the resident or his/her representative had been informed of his/her right to formulate an advanced directive. During an interview on 1/8/25 at 1:16 PM, the nurse manager, also…

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 staff interviews, and record reviews, it was determined that the facility failed to notify the physician when a medication was held several times for low systolic blood pressure (SBP). This was evident for 1 (Resident #44) of 6 residents reviewed for unnecessary medications. The findings include: The review of Resident #44's medical records on 1/15/25 at 3:38 PM revealed an order, with a start date of 12/27/22 for Metoprolol 50 mg to be given twice a day for Cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body); and to hold (not administer) if the pulse was less than 60 or the systolic blood pressure (top number of a blood pressure) was less than 100. On 1/15/25 at 4:06 PM record reviewed revealed that on several occasions when the metoprolol was held due to low parameters; that no documentation was found to indicate that the physician was made aware. Review of the April 2024 MAR revealed that the metoprolol was held due to low SBP or low heart rate (HR) on the following dates: 4/3 pm - HR was 54 4/6 pm - BP…

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 implement its abuse policy. This was evident for one ( #3) of two residents who alleged misappropriation of property and filed a grievance. The findings include: On 1/8/25 at 4:40 PM, during an interview with Resident #3, the resident stated that in December 2024, their items were stolen and they suspected a staff member. The resident reported the stolen items to the facility. On 1/9/25 at 11:20 AM, the Director of Nursing (DON) was asked to provide the facility's grievance log for 2024 and the facility's grievance policy. On 1/10/25 at 11:33 AM, a review of the December 2024 facility grievance log failed to show an entry of Resident #3's allegation. On 1/16/25 at 11:39 AM, during an interview with the DON, she stated that the Nursing Home Administrator (NHA) investigated Resident #3's allegation of stolen items. The DON also verbalized that it was the facility's policy that either the NHA or the DON reported any allegations of misappropriation of residents' property to the state agency. On 1/16/25…

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 report an incident of alleged misappropriation of resident's property to the Office of Health Care Quality.This was evident for 1 (Resident #3) of 2 residents who alleged misappropriation of property and filed a grievance. The findings include: The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's healthcare facilities and community-based programs. Allegations of misappropriation of property are to be reported to the Office of Healthcare Quality in a timely manner. On 1/8/25 at 4:40 PM, during an interview with Resident #3, the resident stated that in December 2024, their items were stolen and they suspected a staff member. The resident reported the stolen items to the facility. On 1/16/25 at 11:39 AM, in an interview with the Director of Nursing (DON), she stated that the Nursing Home Administrator (NHA) investigated Resident #3's allegation of stolen items. The DON also verbalized that, per 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 record review and staff interviews it was determined that the facility failed to ensure essential care upon admission. This was evident for 1 (Resident #71) out of 4 residents reviewed for neglect during the survey. The findings include: Diabetes is a condition when one's body cannot transport glucose, the useable energy for cellular life, out of the bloodstream and into the individual cells of the body. Diabetic management may require that the Diabetic person receives insulin to help transport the glucose out of the bloodstream and into the cells. On 1/13/25 at 1:40 PM, a record review of Resident #71 lab results dated 4/20/23 showed blood glucose was 361.0 mg/dL at 10:24 PM. On 1/13/25 at 2:04 PM, a record review of hospital discharge orders dated 4/20/23 at 11:34 AM, documented insulin orders as: Lantus (long-acting) 14 units subcutaneous at night daily, Lispro (short-acting) 4 units before lunch and 9 units before breakfast. On 1/13/25 at 2:07 PM, a record review of the Medication 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 record review and staff interviews, it was determined that the facility failed to provide a person-centered comprehensive care plan developed and implemented to meet residents' needs. This was evident for 1 (Resident #419) out of 3 residents who were reviewed for care planning during a survey. The findings include: An indwelling Foley catheter is a medical device used to treat urinary incontinence, the involuntary leakage of urine, that transports urine through a tube, from the bladder to an external bag. On 1/13/25 at 4:13 PM, a record review of the physician orders showed an order to maintain 16 French [indwelling] Foley catheter and [give] catheter care every shift. On 1/13/25 at 4:18 PM, a record review of the Treatment Administration Record (TAR) showed that foley care was being completed. On 1/13/25 at 4:41 PM, a record review of Resident #419's comprehensive Care plan failed to plan, develop and implement catheter care. On 1/16/25 at 11:40 AM, during an interview with the Director of Nursing (DON), she stated, I expect residents with an indwelling foley catheter 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 staff interviews, and record review, it was determined that the facility failed to follow the physician's orders for weights. This was evident for 1 (Resident #44 ) of 6 residents reviewed for unnecessary medications. The findings include: On 1/13/25 at 12:08 PM, during a review Resident #44's medical record revealed a diagnosis of congested heart failure (CHF). Review of the care plan revealed a plan for Potential for fluid volume imbalance related to CHF and included an intervention of daily weights as ordered. This intervention was most recently revised on 10/24/24. Review of the medical record revealed a fax coversheet that documented that the facility notified the physician on 10/21/24 that the resident was refusing daily weights, and asked Can we just do weekly weights on [him/her]? The physician had responded with a yes and her signature and the date on the return fax was 10/25/24. Further review of the medical record revealed there was an order for daily weights in effect from 4/29/24 until it was discontinued on 11/8/24. Further review of the medical record failed…

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 provide necessary treatment and services to promote healing of pressure ulcers. This was found to be evident for 1 (Resident #75) out of 4 residents reviewed for pressure ulcers during the survey. The findings include: Review of Resident #75 medical records on 1/16/25 revealed the resident was admitted to the facility on [DATE] after a hospitalization for surgical repair of a hip fracture. The resident ' s diagnosis included but not limited to diabetes, anemia, and high blood pressure. The hospital transfer summary also included documentation of a sacral decubitus (pressure) ulcer. The sacral area is located at the base of the spine. Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date [last date of assessment] of 7/23/24, revealed the resident required partial assist for rolling left to right and substantial assistance with moving from sitting to lying. This assessment also revealed…

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, records review and interviews, it was determined that the facility failed to ensure fall mats were in proper placement. This was evident for 1 (Resident #10) in 3 residents reviewed for accidents. The Findings include: Resident #10 had been residing in the facility since 2018. An interview with the Resident's responsible party on 1/9/25 at 9:31 AM indicated that the resident was a fall risk. On the same day at 10:02 AM, Resident #10 was observed in bed, no care was actively being provided. The fall mat was folded up on the floor, against the cabinet by the foot of the resident's bed. On 1/10/25 at 9 AM a review of Resident #10's care plan regarding potential for injury from falls had interventions that include to apply fall mats to the left side of the bed. On 1/10/15 at 10:36 AM, the resident's fall mat was observed folded up on the floor, against the cabinet by the foot of the resident's bed. The resident was in bed, no one else was in the room with the resident. A review of the most recent fall risk evaluation with a reference date of 12/30/24 was conducted…

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, interviews,and observations, it was determined that the facility failed to provide appropriate treatment and services for care of residents with indwelling catheter. This was evident for 2 (#64, #419) of 3 residents reviewed for urinary catheters. The findings include: 1) Resident #64 was admitted to the facility in early 2024. During the initial tour of the facility on 1/8/25 at 12:37 PM, the resident was observed in his/her room and the urine collection bag was lying directly on the floor. The Registered Nurse (RN #3) who was assigned to the unit where Resident #64 resided was interviewed on 1/8/25 at 12:39 AM. During the interview, the concern was discussed that the resident's urine collection bag was observed lying directly on the floor in the resident's room. RN #3 went in the resident's room, confirmed the finding and hung the urine collection bag on the resident's bed frame. An indwelling catheter, also known as a Foley catheter, is a thin, flexible tube that is inserted into the bladder to drain urine. The catheter is held in the bladder by 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 interviews, it was determined that the facility failed to ensure that a resident's care was overseen by a physician. This was evident for 1 (#24) of 6 residents reviewed for unnecessary medications. The findings include: A review of Resident #24's medical record showed that s/he had been living in the facility since 2015 and received antidiabetic and thyroid medications daily. The continued review contained Resident #24's attending provider's (provider #23) notes from January- December 2024. The notes referred to the resident's A1C and TSH blood work results from 2022 and 2023 (A1c is a blood test that measures the average blood glucose level over the past 2-3months and TSH- is a test that measures the level of thyroid-stimulating hormone in the blood). However, the review failed to show that A1C and TSH blood work were done in 2024 for Resident #24. Further review of attending provider #23's notes dated 6/27/24 contained a statement to do A1C blood work as ordered. Then, on July 7/23/24, the notes said to recheck A1C the following month. The notes for…

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

Based on medical record review and staff interviews, it was determined that the facility failed to ensure that physician's notes were complete, accurate, signed, and dated at each visit and part of the medical record. This was evident for 2 (#24, #44) of 35 residents reviewed during the survey. The findings include: 1) Record review on 1/9/25 at 11:00 AM showed that Resident #24 had been residing in the facility since 2015. A continued review lacked documentation of Resident #24's attending provider's (provider #23) visit notes from January to December 2024. The director of nursing (DON) was questioned at the time and stated that there were no attending provider visit notes in the facility's electronic medical record (EMR) for Resident #24. On 1/13/25 at 12:07 PM, the DON presented the attending provider's notes from January- December 2024 to the surveyor. The notes were not part of the medical record for Resident #24 at the time of the survey. Continued review revealed that Resident #24 had received visits from attending provider #23 on 1/3/24, 1/31/24, 2/28/24, 3/26/24, 4/29/24,…

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 nursing staff were competent with their skills set. This was evident for 2 Registered Nurses (RN #19 and RN #3) of 2 nursing staff evaluated for competency. The Findings include: Nursing competence is defined by the American Nurses Association as an expected level of performance that integrates knowledge, skills, abilities, and judgment. On 1/08/25 at 10:57 AM, a list of all employees was requested. On 1/09/25 at 2:50 PM as part of the staffing task for the recertification survey, the Director of Nursing (DON) was asked to provide competency evaluations for 2 randomly selected nurses. On 1/14/25 at 2:21 PM, staff documents were received and a review revealed: 1). RN #19 was hired in August 2024 and had no record of competency evaluation, 2). RN #3 was an agency staff hired in May 2023 and had no record of competency evaluation. On 1/15/25 at 3:53 PM, an interview with the DON was conducted. The DON was asked if the facility had any evidence of competency evaluations for RN #3 and RN #19. On…

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

Based on interview and record review, it was determined the facility did not have a Director of Nursing who worked on a full-time basis. This was evident during the recertification survey and had the potential to impact all residents, staff, and visitors. The findings include: On 1/14/25 at 9:40 AM, an interview with the Director of Nursing (DON) was conducted. The DON confirmed that she was the only Infection Preventionist (IP) nurse in addition to her role as the DON of the facility. She also explained that she knew the dual role created a concern with the lack of a full-time basis DON. The DON stated that the facility's administration was aware of this concern. On 1/16/25 at 2:03 PM, during another interview with the DON, she acknowledged that her dual role as the IP nurse and DON created a deficiency for a full-time DON at the facility.

Based on medical record review and interviews, it was determined that the facility failed to ensure that Irregularities identified by the pharmacist were reviewed and acted upon timely by the attending physician and failed to develop policies and procedures for the monthly Medication Regimen Review (MRR) to include time frames for the different steps in the process. This was evident for one (#24) of 6 Residents reviewed for unnecessary medications. The findings include: A medical record review on 1/9/25 at 2:04 PM showed Resident #24 had been residing in the facility since 2015 and received multiple drugs, including an antifungal cream, to the abdomen folds. The continued review contained monthly pharmacy review notes from January- December 2024. On 5/21/2024, the pharmacy recommendation stated, Resident continues Nystatin powder BID [twice daily] for MASD [moisture associated skin damage] to Abd. [abdominal] folds. Per the antibiotic stewardship program, it is recommended to use antifungals for the shortest duration possible. Please review if [he/she] can change to a barrier cream…

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 staff interviews, it was determined that the facility failed to keep residents' drug regimens free from unnecessary medications by failing to ensure residents received their medications according to the attending physician's orders. This was evident for 2 (#59, #44) of 6 residents reviewed for unnecessary medications. The finding include: 1) Resident #59 had been residing in the facility since early 2024. On 1/8/25 at 11:16 AM, the resident was observed in his/her room. The resident was lying in bed, appeared to be in discomfort, and when asked to conduct an interview, the resident declined and stated, I'm not feeling too good. Morphine is used to treat pain severe enough to require daily, around-the-clock, long-term opioid treatment and when other pain medicines did not work well enough or cannot be tolerated. Morphine belongs to the group of medicines called narcotic analgesics PRN is an abbreviation for the Latin phrase pro re nata, which means as the need arises. On 1/10/25 at 9:41 AM, a review of Resident #59's medication orders were conducted. 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 observations, interviews, and record review, it was determined that the facility failed to 1) accurately document the reconciliation of controlled medications and 2) store medications in accordance with professional standards by failing to discard expired medications, failing to date medications when opened, and failing to ensure that medications were not left at a resident's bedside. This was evident for 1 out of 2 narcotic record books reviewed and 1 (#26) out of 35 residents observed during the survey and 2 of 2 medication carts observed. The findings include: 1) On 1/8/25 at 11:25 AM, an observation on of a narcotic record book laying on the medication cart, in the 400-hallway was made. Observation revealed the nurse that reconciled that narcotic count at 7:00 AM also signed in the space reserved for the change of shift for 3:00 PM. On 1/8/25 at 11:27 AM, during a brief interview with Nurse (Staff #7), she reported that she did sign the narcotic transfer book in its designated line at 7:00 AM at 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 staff interviews and record review, it was determined that the facility failed to have a qualified dietary staff. This was evident for 1 of 1 Director of Food Services. The findings include: On 1/13/25 at 3:43 PM, an interview with the Director of Food Services (Staff #22) and the Regional Manager of Food Services (Staff #21) was conducted. When asked for their credentials for their current positions, Staff #22 stated that she was currently enrolled in school for her certification and she would provide the information for her school records. On 1/14/25 at 3:31 PM, the surveyor called to speak with the Clinical Dietitian, who began working remotely with the facility the last week of November 2024, and is currently employed with Nutrico. During the interview, the dietitian confirmed that she does interact with the kitchen staff for snacks, supplements and menus for the residents but that she does not manage or supervise the kitchen. On 1/17/25 at 12:08 PM, surveyor reviewed the concern with the Regional Manager of Food Services (Staff #21) that the Director of Food Services…

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 record review it was determined that the facility failed to comply with State regulations when the facility failed to 1) employ a qualified social worker, 2) monitor employee's relevant health status, 3) provide a minimum of 3 hours of bedside care per occupied bed per day, and 4) ensure the Quality Assurance committee contained the required members. These deficiencies were found during the recertification survey and had the potential to affect all residents, staff and visitors. The findings include: 1). The State of Maryland Code of Regulations at 10.07.02.30 B states that B. (S 1320, ' Staff Qualifications ' ) Social Work Staff Responsibility. (1) Social services responsibilities in the nursing home shall be assigned to a: (a) Licensed bachelor social worker; (b) Licensed graduate social worker; (c) Licensed certified social worker; or (d) Licensed certified social worker- clinical. (2) If the social worker is not a licensed certified social worker (LCSW) or a licensed certified social worker-clinical (LCSW-C), the nursing home shall arrange for an LCSW 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 observations, interviews and record review, it was determined that the facility failed to maintain complete, accurate and legible medical records. This was evident for 3 (#26, #36, #12) out of 35 residents reviewed during the survey. The findings include: On 1/8/25 at 11:00 AM, an observation of a plastic medicine cup with many pills sat on top of Resident #26's bedside table. On 1/8/25 at 11:10 AM, in an interview with Staff #7, a Licensed Practical Nurse (LPN) stated, that the resident takes them when s/he wants to. I can't make her/him take them. On 1/8/25 at 11:15 AM, the surveyor observed Staff #7 instructed the resident to take the medications that sat on the bedside table. On 1/8/25 at 11:25 AM, in a brief interview, Staff #7 reported that medications were documented as given when brought into the room. I don't know what time s/he takes the medications. On 1/13/25 at 5:18 PM, in an interview with the Director of Nursing (DON), she reported that the facility did not have a process to know when Resident #26 took the medications. She stated, There's no way of telling…

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: 1) ensure a glucometer was adequately disinfected between different resident uses in a manner that met minimum standards and minimized risk for the infectious spread of blood-borne pathogens, and 2) ensure that Infection Prevention Control Program (IPCP) policies and procedures were reviewed at least annually. This was evident for 1 Resident ( # 26), in a random observation during a recertification/complaint survey. The findings include: Blood glucose meters are portable devices that measure blood glucose levels and aid in diabetes self-management. Healthcare providers use these types of devices in a variety of clinical settings. Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place. 01/10/25 06:26 AM, Nurse Agency Staff #2 was observed measuring Resident #419's glucose levels utilizing a glucometer. On 1/10/25 at 6:32 AM, continued observation…

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 record review, it was determined that the facility failed to provide the 2024-2025 COVID-19 immunization to residents and staff. This was evident for 1) five residents (Resident #3, #22, #63, #64, #269) of five residents, and 2) four staff (Staff #3, #24, #25, and #26) of five staff records reviewed for COVID-19 immunization during the recertification survey. The findings include: 1a) On 1/8/25 at 12:01 PM, an interview with Resident #22 was conducted and he/she stated that he/she requested the 2024-2025 COVID-19 vaccine but had not received the vaccine. On 1/9/25 at 3:47 PM, a review of Resident #22's health record failed to show that the resident received or refused the 2024-2025 COVID-19 vaccine. 1b). On 1/8/25 at 4:49 PM, an interview with Resident #3 was conducted and he/she stated that he/she requested the 2024-2025 COVID-19 vaccine but had not received the vaccine. On 1/9/25 at 3:51 PM, a review of Resident #3's health record failed to show that the resident received or refused the 2024-2025 COVID-19 vaccine. On 1/9/25, at 4:27 PM, a review of 3 other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined that the facility failed to ensure that advance directives were discussed with residents and/or responsible representatives and orders for life sustaining treatment were voided when new orders were implemented. This was found to be evident for 3 (Resident #27, #46 and #136) out of 6 residents reviewed for advance directives. The findings include: 1) Review of Resident # 27's medical record revealed that the resident was admitted to the facility in [DATE]. The resident was deemed unable to make health care decisions by two physicians on [DATE]. On [DATE] at 3:00 PM, review of the resident's paper chart revealed two valid MOLST (Maryland Orders for Life-Sustaining Treatment) forms. The MOLST, dated [DATE], revealed orders for No CPR and indicated that it was not discussed with the resident, but rather a health care agent or gaurdian. The MOLST, dated [DATE], revealed orders to attempt CPR in the event of cardiac and/or pulmonary arrest and indicated…

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 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 4 (#3, #133, #19, and #7 ) of 4 residents reviewed for hospitalization. The findings include: 1) On 3/14/23 at 1:00 PM, a review of Resident #3's medical record revealed that, on 2/26/23, Resident #3 was transferred to the hospital emergency department following a change in his/her medical condition. On 2/26/23 at 6:34 PM in an SBAR (Situation, Background, Assessment, and Request) (a standard way to communicate medical information) note, the nurse documented that Resident #3 had a change in condition related to abdominal pain, constipation, or impaction; the primary care provider was notified and recommended that Resident #3 be transferred to the emergency room. On 2/26/23 at 7:21 PM, in a Nurse's Note, the nurse indicated that Resident #3's oxygen level was fluctuating…

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 failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 4 (#3, #133, #19, and #7 ) of 4 residents reviewed for hospitalization. The findings include: 1) On 3/14/23 at 1:00 PM, a review of Resident #3's medical record revealed, that on 2/26/23, Resident #3 was transferred to the hospital emergency department following a change in his/her medical condition. On 2/26/23 at 6:34 PM, in an SBAR (Situation, Background, Assessment, and Request) (a standard way to communicate medical information) note, the nurse documented Resident #3 had a change in condition related to abdominal pain, constipation, or impaction and the primary care provider was notified and recommended that Resident #3 be transferred to the emergency room. On 2/26/23 at 7:21 PM, in a Nurse's Note, the nurse indicated that Resident…

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

Based on medical record review and interview, it was determined that the facility failed to ensure the Minimum Data Set assessments accurately reflected the resident's status as evidenced by failure to assess that a resident was receiving dialysis, and incorrectly assessing the resident as having diabetes when there was no supporting evidence to indicate it was a current active diagnosis. This was found to be evident for 2 (Resident # 136 and #7) out of 46 residents reviewed during the survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 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 3/15/23, review of Resident # 136's medical record revealed that the resident was admitted to the facility in December 2022 with diagnoses that…

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

Based on medical record review and interview, it was determined that the facility failed to ensure the development of a comprehensive person centered care plan as evidenced by failure to develop a care plan to address a resident's needs related to receiving dialysis; failure to develop a care plan for 3 months to address the resident's needs related to a pressure ulcer. This was found to be evident for 3 ( #136, #51, and #21) out of ## residents reviewed during the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. MDS (Minimum Data Set) - is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1) On 3/15/23, review of Resident # 136's medical record revealed that the resident was admitted to the facility in December 2022 with diagnoses that included, but were not limited…

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

Based on medical record review and interview, it was determined that the facility failed to have 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 and failed to update care plans when there were changes in resident needs or preferences. This was found to be evident for 3 (Resident # 133, #7, and #46) out of 43 residents who had care area investigations completed during the survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 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 3/16/23 at 9:56 AM, a review of Resident #133's medical record revealed that Resident #133 resided in the facility since June 2020, until…

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 activities to meet the needs of the residents. This was found to be evident for 2 (#46, and #7) out of 5 residents reviewed for activities during the survey. The findings include: 1) Review of Resident #46's medical record revealed the resident has resided at the facility for more than a year. The resident was dependent on staff for bed mobility and had impaired cognitive status with confusion. On 3/6/23 at 1:36 PM, the resident was observed in bed, staff were in the room but not interacting with Resident #46 at the time of the observation. On 3/7/23 at 8:55 AM and at 11:04 AM, resident was observed in bed. No tv, music or other activity were observed at these times. The resident was not observed participating in or receiving visits from activity staff during the first two days of the survey. On 3/8/23, review of the resident's care plan revealed a plan with a focus of Resident spends the majority of time in/near [his/her] room and needs 1-1 visits. Goal: Resident will…

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 staffing information, complaints allegations, medical records and interviews, it was determined that the facility failed to ensure sufficient nurse staffing. This was found to be evident for 3 of 10 complaints reviewed. The findings include: Review of complaint MD00178267, received on 6/7/22, revealed the following: Staffing is bad at the facility, there are residents that are not getting the care that they need. The staff is working hard to assist the residents however there aren't nearly enough staff to assist them all. Review of complaint MD00187979, received 1/20/23, revealed the following: The majority of the time they are very understaffed . Residents are not being showered .there are times that residents are not changed properly There are residents with wounds that need [to be] packed are not being packed properly. Review of complaint MD00188640, received 2/6/23, revealed the following: The is also working with minimal staff. On 3/06/23 at 2:33 PM, Resident #58 stated that s/he would like a shower once in a while, however, there are not enough staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, it was determined that the facility 1) failed to ensure that nursing staff signed that the controlled drug count was completed at the change of shift as evidenced by missing signatures on the controlled drug count sheets, and pre-signing of the count sheets; 2) failed to account for all narcotics removed from supply as evidenced by documentation of borrowing narcotics and failure to ensure that two staff witnessed wasting of narcotics; 3) failed to ensure that medications were kept secure in the medication cart as evidenced by the observation of two syringes with insulin in them that were observed on top of an unattended medication cart located in a hallway that residents and visitors would be able to access; and 4) failure to ensure that a medication refrigerator was kept at an acceptable temperature. These observations were found to be evident on 3 out of 4 resident units. The findings include: 1) Narcotic pain medications are potent and effective 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 observation, record review, and interview, it was determined that facility staff failed to ensure that residents had the right to choose when to take a shower. This was evident for 2 (#21 and #19) of 21 residents reviewed for choices. 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 the resident's care planning activities. 1. On 3/16/23 at 5:49 AM, Resident #21 was heard requesting a shower from Geriatric Nursing Assistant (GNA) #38 and she replied that it was too early for a shower. Further observation revealed that GNA #38 was walking in the 200 hallway and looked in a few rooms and then sat down at the computer in the hallway. GNA #38 was interviewed at this time and she reported she was completing her documentation. A medical record review for Resident #21 on 3/17/23 at 8:04 AM revealed that Resident #21 was legally blind. A Minimum Data Set…

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 failed to ensure that nursing staff notified the physician that a pressure wound was continuing to worsen and develop possible signs of an infection. This was found for 1 (#51) of 5 residents reviewed for pressure ulcers. The findings include: On 3/21/23, review of Resident #51's medical record revealed the resident was originally admitted to the facility in 2020' Review of the progress notes revealed that, on 1/11/22, a stage 2 pressure ulcer was identified on the resident's coccyx. The physician was notified and treatment orders were implemented. The coccyx, or tailbone, is located at the base of the spine. Review of the Weekly Skin Measurement assessment, dated 1/11/22, revealed the stage 2 pressure ulcer was 2 cm in length and 1 cm in width with no depth, the wound bed was red with no exudate (drainage) or pain. A classification of Stage 2 for a pressure ulcer indicates partial-thickness skin loss with exposed dermis (second layer of skin) presenting as a shallow open ulcer. The wound bed is viable,…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that residents received the written Notice of Medicare Non-Coverage prior to the date the services were to end. This was found to be evident for one (Resident #132) out of three residents reviewed for beneficiary notification. The findings include: Review of Resident #132's medical record revealed the resident was admitted in November 2022 for rehabilitation following a hospitalization. On 3/10/23 at 2:01 PM, the Assistant Administrator confirmed that Resident #132 did go private pay before the actual discharge. On 3/10/23, review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review sheet completed by the facility revealed the resident's last covered day of Part A Service was 1/2/23 and the termination was determined by a facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. In the section of the review form for the facility to document if a SNF ABN (Advance Beneficiary Notice of Non-Coverage) or a NOMNC (Notice of…

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

Based on review of facility documents and staff interview, it was determined the facility 1) failed to report an allegation of an injury of unknown injury to the State Agency, the Office of Health Care Quality (OHCQ), immediately, but not later than 2 hours after the abuse allegation was made, and 2) failed to report the results of the investigation no later than 5 working days after the incident. This was evident for 2 (#134, #130) of 13 residents reviewed for abuse. The findings include: 1) On 3/17/22 at 10:00 AM, a review of facility reported incident MD00180828 revealed, that on 3/22/22 at 3:15 PM, Resident #134 reported to a nurse that a GNA (geriatric nursing assistant) had verbally abused him/her. On the self-report form, the facility documented that the date and time of the incident was 3/22/22 at night, and reported by the resident on 3/23/22 at 2:15 PM. The email confirmation of the facility's report to the state agency documented that the allegation of abuse was reported to the state agency on 3/24/22 at 8:06 AM. The facility failed to report the allegation of abuse…

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

Based on review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, including an injury of unknown injury. This was evident for 2 (#134, #130) of 13 residents reviewed for abuse. The findings include: 1) On 3/17/22 at 10:00 AM, a review of facility reported incident MD00180828 revealed, that on 3/22/22 at 3:15 PM, Resident #134 reported to someone that a GNA (geriatric nursing assistant) had verbally abused him/her. On the self-report form, the facility documented the date and time of the incident was 3/22/22 at night and reported by the resident on 3/23/22 at 2:15 PM. The facility's report did not identify who the resident reported the allegation of abuse to. The facility's report documented that Resident #134's mother was interviewed, however, review of the facility's investigations failed to identify who the resident's mother was, and there was no documentation of an interview or statement from the resident's mother in the documentation of the facility's investigation. 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 medical record review and staff interview, it was determined that the facility failed to document the information conveyed to a receiving acute care provider when a resident was transferred there emergently. This was evident for 2 (#3, #133) of 4 residents reviewed for hospitalization. The findings include: 1) On 3/14/23 at 1:00 PM, a review of Resident #3's medical record documented that, on 2/26/23, Resident #3 was transferred to the hospital emergency department following a change in his/her medical condition. On 2/26/23 at 6:34 PM in an SBAR (Situation, Background, Assessment, and Request) (a standard way to communicate medical information) note, the nurse documented Resident #3 had a change in condition related to abdominal pain, constipation, or impaction and that the primary care provider was notified and recommended that Resident #3 be transferred to the emergency room. On 2/26/23 at 7:21 PM, in a Nurse's Note, the nurse indicated that Resident #3's oxygen level was fluctuating 85-88% on 4 Liters of oxygen, and documented the resident had lower abdominal pain and no…

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

Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was evident for 2 (#3, #133) of 4 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 3/14/23 at 1:00 PM, a review of Resident #3's medical record documented that, on 2/26/23, Resident #3 was transferred to the hospital emergency department following a change in his/her medical condition. On 2/26/23 at 6:34 PM in an SBAR (Situation, Background, Assessment, and Request) (a standard way to communicate medical information) note, the nurse documented that Resident #3 had a change in condition related to abdominal pain, constipation, or impaction; the primary care provider was notified and recommended that Resident #3 be transferred to the emergency room. On 2/26/23 at 7:21 PM, in a Nurse's Note, the nurse indicated that Resident #3's oxygen level was fluctuating 85-88% on 4 Liters of oxygen and documented the resident had lower abdominal pain and no bowel…

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

Based on medical record review and interview, it was determined that the facility failed to ensure that the individual who completed a portion of the Minimum Data Set assessment signed and ceritified the accuracy of that portion of the assessment. This was found to be evident for 2 (Resident #136, and #7) out of 46 residents reviewed during the survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 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 3/15/23, review of Resident # 136's medical record revealed that the resident was admitted to the facility in December 2022 with diagnoses that include, but were not limited to, end stage renal disease. Review of the MDS with an Assessment Reference Date of 12/26/22, Section Z0400 Signature of…

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

Based on record review and interviews, the facility failed to complete a PASSAR during the original admission period for a resident. This was found to be true for 1 (Resident #38) of 3 residents reviewed for PASSARS during the investigation phase of the annual survey. The findings include: PASSAR=Preadmission Screening and Resident Review required by Medicaid certified nursing home facilities to evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID) or related conditions (RC) in order to prevent inappropriate admissions for long term care. During a review of the hard copy medical record on 03/07/23 at 1:30 PM, the surveyor failed to locate a copy of the original for Resident #38's PASSAR, dated 10/05/18. On 3/16/23 at approximately 2:00 PM, the surveyor interviewed the social services worker # 8 regarding the responsibility for the completion of the PASSAR when applicable during the initial admission process. The responsibility for initiating the form, completion of the form, and retention of the PASSAR form is the responsibility of the social…

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

Based on record review and staff interview, it was determined that the facility failed to ensure the safety of a cognitively impaired resident by failing to provide adequate supervision as evidenced by the resident was found on the floor 8 times and had 3 falls in a 20-day period. This was evident for 1 (#71) of 4 residents reviewed for falls. The findings include: 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. MDS (Minimum Data Set) - is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. BIMS (Brief Interview of Mental Status) - is a test used to get a quick snapshot of cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates…

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 staff assessed and developed a care plan to address a resident's needs related to dialysis; and failed to ensure staff completed pre and post dialysis assessments. This was found to be evident for 1 (Resident #136) out of 1 resident reviewed for dialysis. The findings include: On 3/15/23, review of Resident # 136's medical record revealed the resident was admitted to the facility in December 2022 with diagnoses that included, but were not limited to, end stage renal disease. The resident also had orders, in effect since 12/22/22, for dialysis Tuesday/Thursday/Saturday or as scheduled. Review of the Minimum Data Set (MDS) assessment with an Assessment Reference Date of 12/26/22, failed to reveal documentation to indicate the resident was receiving dialysis. The Section O Special Treatments, Procedures, and Programs, which includes areas to document if the resident received services in the past 14 days either while a resident, or if newly admitted while not a resident. This section…

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 record review, it was determined that the facility failed to ensure that alternatives to side rails were attempted prior to the initation of side rails. This was found to be evident for 3 (Resident #46, #27 and #7) out 3 residents reviewed for side rails. The findings include: 1) On 3/9/23, review of Resident #7's medical record revealed that the resident resided at the facility for more than a year. The resident had cognitive impairment as evidenced by a BIMS (Brief Interview for Mental Status ) score of 5 out of 15 in August 2022 and again in February 2023. The resident was deemed unable to make health care decisions by two physicians on 5/24/21. Further review of the medical record revealed a current order for the use of siderails, a care plan for potential risk for injury secondary to the use of side rails. A Consent for Use of Side Rails was signed by the resident and licensed practical nurse #9. The date next to Nurse #9's signature was 5/21/21. Review of the side rail assessment, with an observation date of 5/21/21, and a completion date on…

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

Based on review of employee files and interviews, it was determined that the facility failed to ensure that performance reviews were completed for nurse aides at least once every 12 months. This was found to be evident for 3 (Staff #30, #31 and #33) out of 3 nursing assistants reviewed for annual evaluation. The findings include: Review of nursing assistant #30's employee file on 3/16/23 revealed a hire date in October 2017. No documentation was found to indicate that an annual evaluation was completed during the last 12 months. Review of nursing assistant #31's employee file on 3/16/23 revealed a hire date in December 2019. No documentation was found to indicate that an annual evaluation was completed during the last 12 months. Review of nursing assistant #33's employee file on 3/20/23 revealed an original hire date in December 2018. No documentation was found to indicate that an annual evaluation was completed during the last 12 months. On 3/20/23 at noon, the Director of Nursing reported that she could locate an annual evaluation for Staff# 33 for 2022.

Based on review of employee files and interview, it was determined that the facility failed to ensure that staff received training related to caring for residents with behavioral health care needs. This was found to be evident for 3 (Staff #30, #31 and #18 ) out of 3 staff reviewed for training related to behavioral health. The findings include: Review of nursing assistant #30's employee file on 3/16/23 revealed a hire date in October 2017. No documentation was found to indicate that staff #30 received behavioral health training. Review of nursing assistant #31's employee file on 3/16/23 revealed a hire date in December 2019. No documentation was found to indicate that staff #31 received behavioral health training. Review of hospitality aid #18's employee file on 3/16/23 revealed a hire date in October 2022. No documentation of education was found in the employee file. This failure to have documentation of education for Staff# 18 was reviewed with the Director of Nursing on 3/16/23 at 4:50 PM. On 3/22/23 at 3:46 PM, surveyor informed the Regional Director of Clinical Operations that…

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

Based on medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to ensure that prescribed medications had adequate parameters in place to indicate when to administer as needed medications for pain; and failed to ensure documentation of the indication for use of an as needed narcotic pain medication. This was evident for 1 (Resident #3) of 4 residents reviewed for hospitalization and 1(Resident #7) out of 6 residents selected for unnecessary medication review . The findings include 1) A review of Resident #3's medical record was conducted on 3/14/23 at 1:00 PM. Review of Resident #3's physician orders revealed an order for 1) Tramadol (Opioid pain medication) 50 MG (milligrams) tablet, give one tablet by mouth every 8 hours as needed for pain, initiated on 3/8/23 and documented as given on 3/9/23 at 10:36 AM for pain level 6, and 2) a 3/8/23 order for Tylenol (Acetaminophen) (pain medication) 325 MG tablet, give two tablets by mouth every 6 hours as need for pain. There was no clear…

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, it was determined that the facility failed to ensure that an as needed psychotropic medication order was limited to 14 days. This was found to be evident for one (#8) out of three residents reveiwed for unnecessary medications. The findings include: On 6/16/23 at approximately 2:00 PM, review of Resident #8's medical record revealed an active order, originally written on 5/29/23, for Lorazepam 0.5 mg to be given by mouth every 8 hours as needed (PRN) for anxiety/aggitation. Review of the Medication Administration Record revealed a dose of the PRN Lorazepam was administered on 6/13/23 at 5:20 PM and again on 6/14/23 at 6:27 PM. Lorazepam is a benzodiazepine which are psychotropic medications. On 6/16/23 at 2:45 PM, surveyor reveiwed the concern with the Director of Nursing (DON) that the PRN Lorazepam order was in effect for more than 2 weeks. The DON acknowledged surveyor's concern. On 6/20/23, further review of the medical record revealed the 5/29/23 PRN order for the Lorazepam was discontinued on 6/16/23 at 4:46 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, it was determined that the facility failed to develop and implement infection control policies and procedures to ensure that laundry was processed in a way that prevents cross contamination and that, once placed on a linen cart the clean laundry remained covered and was not used to store personal items within the linens on the cart. This was evident for 1 of 1 laundry room and 1 of 4 linen closets on the nursing units. The findings include: On 3/17/23 at 8:49 AM, a review of the facility's policy titled, Departmental (Environmental Services) - Laundry and Linen revealed under section titled, Washing Linens and other Soiled Items #6 read to keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times. #7 read, clean linens will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measure designated to protect it from environmental contamination, such as covering clean linen carts. 1) 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 record review, review of policy, and staff interview, it was determined that the facility failed to have a process in place to ensure that the flu vaccine and pneumonia vaccine was offered to each resident and that the residents/resident representatives received education regarding the vaccines. This was evident for 3 (#46, #21, and #48) of 5 residents reviewed for flu vaccinations and 4 (#46, #58, and #21) of 5 residents reviewed for the pneumonia vaccinations. The findings include: 1. On 3/17/23 at 8:50 AM, a review of the facility's policy titled, Influenza (Flu) Vaccine revealed a policy statement that read, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives) . In the section titled, Policy Interpretation and Implementation under #1. Between October…

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, policy review, and staff interview, it was determined that the facility failed to develop and implement policies and procedures to ensure that their, 1) residents were offered the COVID 19 vaccination, resident and/or resident representatives were educated and that the education was documented in the resident's medical record and 2) staff were offered the COVID 19 vaccination, educated and that they maintained records of the education provided. This was evident for 5 (#46, #10, #58, #21, and #48) of 5 residents and 12 (#52, #5, #53, #54, #55, #19, #50, #57, #58, #22, #18, and #12) of 12 staff reviewed for COVID 19 vaccinations. The findings include: On 3/17/23 at 8:49 PM, a review of the facility's policies and procedures was conducted regarding how they would ensure that residents and staff would receive education regarding the risk and benefits of the COVID 19 vaccination and when supplies were available, offer their staff and residents the COVID 19 vaccinations as mandated. Facility staff were provided a list of polices and procedures for the survey team…

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

Based on record review and staff interview, it was determined that the facility failed to develop and implement policies and procedures to ensure that 100% of staff were fully vaccinated, had an approved exemption, or had a temporary delay to receive the vaccination and/or was not eligible for the required second dose. This was evidenced by a 93% vaccination rate with 8 (#5, #54, #55, #19, #50, #57, #58, and #18) of 109 staff had not been fully vaccinated, received an approved exemption, or had a temporary delay. The findings include: On 3/21/23 at 10:00 AM, a review of the facility's Policy, COVID 19 Vaccination Mandate and Exemption was conducted. The policy had a revision date of 1/1/22, but the facility failed to provide a date that the policy had been implemented. The policy read, It shall be the policy of [facility name] to meet the COVID-19 vaccine mandate guidelines as issued by the governor of [state] Department of Health. To follow was the Procedures section. In this section, the facility wrote that newly hired staff will be mandated to receive the vaccination and 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.