Denton Nursing And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews it was determine that the facility failed to provide Residents with quality of care. This was found to be evident for 5 (Resident #88, #39, #41, #47 and #90) out of 18 Residents reviewed for quality of care during the recertification and complaint survey. The findings include: 1) On 03/11/2026 at 10:02 AM, this surveyor observed Licensed Practical Nurse (LPN) #4 administer medications to Resident #88. When administering medications, LPN #4 did not explain the medications to the resident or offer the opportunity for the resident to be informed. On 03/11/2026 at 10:58 AM, this surveyor observed LPN #4 administer medications to Resident #40. LPN #4 did not explain the medications or offer the resident the opportunity to be informed. On 03/13/2026 at 8:42 AM, this surveyor observed Registered Nurse (RN) #5 administer medications to Resident #39 in a shared room with Resident #41 present. RN #5 did not provide privacy during the medication administration, as the…

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

Based on observations, interviews and record reviews it was determined that facility failed to ensure a Resident was provided with supervision. This was found to be evident for 1 (Resident #1) out of 1 Resident reviewed for supervision during the recertification and complaint survey.The findings include: During a review of Resident #1's progress notes conducted on 03/11/26 at 9:15 AM, it was discovered that the Resident had multiple occasions where he/she displayed inappropriate sexual behavior. A Care Plan is a formalized, personalized, and actionable document developed by healthcare professionals in collaboration with patients and families to manage specific health conditions. It acts as a roadmap for care, outlining goals, necessary interventions, and timelines. These plans are constantly updated based on patient progress. During a review of the Resident #1's Care Plan conducted on 03/11/26 at 9:22 AM, it was discovered that the Resident had a Care Plan for inappropriate sexual behavior with an intervention for a 1 to 1 supervision. During an observation of Resident #1 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 interviews and record reviews it was determined that the facility failed to ensure that the individual designated as the Kitchen Manager was certified for food service management and safety. This had the potential to affect all residents. The findings include: During an interview with the Kitchen Manager on 3/10/2026 at 7:14 AM she reported she was the kitchen supervisor and managed the Kitchen. She advised she was not currently certified and did not currently hold a Certified Dietary Manager Certification (CDM). She reported she had completed her training and took the test in October; however, she needs to retake the test. She advised she's waiting for approval to retake the test. She advised the previous Kitchen Manager left about a year ago and she took over for him. She advised the facility does have a dietician that comes to the facility every Wednesday.During an interview with the Administrator on 3/10/2026 at 2:16 PM he reported the facility has a Dietician and she comes in every so often. He confirmed the Dietician was not full time. He advised he would check on 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 1) measures were in place to prevent and monitor the growth of Legionella and other opportunistic waterborne pathogens in the building water system. This deficiency has the potential to affect all residents who utilize the facility's water system and 2) staff perform appropriate hand hygiene. This was found to be evident for 1 Licensed Practical Nurse (LPN #4) of 2 LPNs observed for infection control during the recertification and complaint survey.The findings include: 1) Legionella (and other opportunistic waterborne pathogens) is bacteria that can grow in building water systems and cause illness when exposed to contaminated water. TELS is a web-based building management and maintenance software solution specifically designed for senior living and healthcare facilities. On 03/11/2026 at 2:55 PM, this surveyor conducted an interview with the Maintenance Director. When asked whether the facility has measures in place to prevent the growth of Legionella and other opportunistic waterborne…

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

Based on record review and interview, it was determined that the facility failed to provide influenza and/or pneumococcal immunizations as required or appropriate for residents. This was found to be evident for 4 (Resident #15, #47, #7, and #81) out of 5 Residents reviewed for influenza and pneumococcal immunizations during the Infection Control facility task conducted as part of the annual/complaint survey. The findings include:On 03/11/2026 at approximately 12:00 PM, this surveyor conducted a record review of residents' charts (Resident #15, Resident #5, Resident #47, Resident #7, and Resident #81) to determine influenza and pneumococcal vaccination status. The review showed no documentation that these vaccines were offered during the 2025-2026 season for the residents listed, with the exception of Resident #5, who was offered the influenza vaccine on 10/01/2025 and refused. Additionally, for Resident #7, admitted in February 2026, there was no documentation of vaccination status or that influenza or pneumococcal vaccines were addressed upon admission.On 03/11/2026 at 3:12 PM,…

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 complaint, reviews of a closed and active medical record, reviews of all pertinent administrative records, and staff interviews, it was determined that the facility failed to have a system in place to ensure clinical records were complete and accurately documented. This was found to be evident for 2 (Residents #8, #9) of 9 residents reviewed during the complaint survey.The findings include:Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication errors and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers…

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, interview, and medical record review, it was determined the facility failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed. This was evident for 1 (#13) of 14 residents reviewed during a complaint survey. The findings include: On 9/3/25 at 10:00 AM observation was made of Resident (R) #13 lying in bed. R #13 asked the surveyor to hand him/her the hair brush that was on the night stand. At that time observation was made of the call bell lying on the floor in front of the oxygen concentrator. R #13 was asked how he/she called the nurse. R #13 stated that the call bell was usually on the top of the bed, but [name] took it away from him/her because he/she was ringing it too much. At that time the surveyor showed Certified Medicine Aide (CMA) #23 the call bell that was lying on the floor. CMA #23 placed the call bell on the bed.Review of R #13's medical record revealed an ADL (activities of daily living)…

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, facility documentation and interviews, it was determined the facility staff failed to notify a physician promptly when a resident had a change of condition (Resident #12) and failed to notify a resident's representative when a resident had medication changes (Resident #6). This was evident for 2 of 14 residents reviewed during a complaint survey.The findings include:1.Review of Facility Reported Incident 295918 on 8/27/25 revealed the facility reported to the Office of Health Care Quality (OHCQ) that on 11/28/24 the facility staff reported to the Resident's nurse (Staff #34) that Resident #12 was declining, and Staff #34 failed to assess the Resident timely. Review of Resident #12's medical record on 8/27/25 revealed the Resident was admitted to the facility in 2015 had diagnosis to include traumatic brain injury, heart and renal failure. Further review of Resident #12's medical record revealed Staff #34's nurse's note on 11/28/24 at 12:04 PM that stated: patient noted as difficult to arouse, lethargic, plan of care ongoing. Further review of 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 review of facility reported incidents, record review, and interview, it was determined the facility failed to report an injury of unknown origin within 2 hours of becoming aware of the injury, to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (#1) 9 residents reviewed for 10 facility reported incidents during a complaint survey. The findings include: On 8/28/25 at 7:53 AM a review of facility reported incident 295995 was conducted and revealed on 4/6/25 at 5:38 PM a staff nurse was made aware of Resident #1 having a swollen, bruised left eye. Review of the facility's investigation revealed the resident had severe cognitive impairment and was unable to say what happened to his/her eye. Review of the email confirmation revealed the initial self-report was sent to OHCQ on 4/7/25 at 7:57 AM, which was not within 2 hours of being informed of a bruised and swollen eye that Resident #1 obtained while residing on the Memory Care Unit.On 9/3/25 at 10:55 AM an interview was conducted with the interim Director of Nursing (DON) and the Assistant…

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 incidents, documents, and staff interview, it was determined the facility failed to provide documentation that allegations of misappropriation of property were thoroughly investigated. This was evident for 1 (#2) of 9 residents reviewed for facility reported incidents during a complaint survey. The findings include: On 9/2/25 at 11:52 AM a review of facility reported incident 295797 was conducted and revealed Resident #2 alleged that on 12/17/24 between 10:00 AM and 1:00 PM someone entered the resident's room and stole money, a gift card, and 10 gift certificates. Review of the facility's investigation revealed written statements from (3) geriatric nursing assistants (GNA), (1) from the previous Director of Nursing (DON), and (3) other staff in leadership positions. The facility failed to obtain interviews or statements from any of the nurses that were working, staff from previous shifts, housekeeping staff, maintenance staff, or dietary staff that would have had access to the resident's room. On 9/4/25 at 11:08 AM an interview was conducted 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 medical record review and interview, it was determined that the facility staff failed to have quarterly care plan meetings for residents (Resident #9). This was evident for 1 of 14 residents reviewed during a complaint survey. The findings include:Once the facility staff completes an in-depth assessment (MDS) of a resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan are accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. Review of Resident #9's medical record on 8/27/25 revealed the Resident was admitted to the facility in November 2022. Further review of Resident #9's medical record…

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

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 follow physician ordered blood pressure and heart rate parameters for administering a blood pressure medication. This was evident for 1 (#6) of 13 residents reviewed during a complaint survey. The findings include: On 8/28/25 at 11:50 AM a review of Resident (R) #6's medical record was conducted. R #6 was admitted to the facility in August 2023 with diagnoses that included but were not limited to non-rheumatic aortic (valve) stenosis, hyperlipidemia, dementia, hypertension, atrial fibrillation, and heart disease. Review of R #6's physician's orders revealed the order for Metoprolol Tartrate 100 mg. two times per day related to hypertension (high blood pressure) and atrial fibrillation. Atrial fibrillation (AFib) is a heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly. The physician's order stated to hold for b/p (blood pressure) less than 110/65 and HR (heart rate) less than…

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

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #5). This was evident for 1 of 14 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Review of Resident #5's medical record on 8/27/25 revealed the Resident was admitted to the facility in 2018 with a diagnosis to include cerebral infarction (stroke) and hemiplegia affecting left nondominant side. Hemiplegia is the total paralysis or severe loss of strength on one side of the body, affecting the arm, leg, and sometimes the face. It results from damage to the brain, often caused by stroke, brain tumors, or trauma. Review of Complaint 295996 on 8/27/25 revealed Resident #5 had lost…

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 correct and monitor quality deficiencies identified on the previous survey. This was evident for 3 out of 19 deficiencies reviewed in the revisit survey. The findings include: On 11/13/2025 at 2:30 PM, A review of the survey teams findings revealed that the facility did not follow their plan of correction for 3 deficiencies (F610, F842, and S1320). Of these 3 deficiencies, S1320 was found to still be in noncompliance.On 11/14/2025 at 8:06 AM, the Director of Nursing (DON) stated that the facility's Quality Assurance (QA) contact person was the Administrator.On 11/14/2025 at 8:45 AM, an interview with Administrator was conducted. When asked how often they hold QA meetings, the administrator stated every month. When asked if there was a QA meeting after the facility received the deficiencies from the Office of Health Care Quality, they stated that they did meet. When asked if the QA team/committee discussed the citations and progress of the plan of correction, the administrator stated not really…

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, staff and resident interviews, record reviews, and facility policy review, the facility failed to ensure sufficient staffing was scheduled to meet the needs of the 81 residents in the facility. Five residents (Resident (R) 55, R48, R15, R44, and R48) and staff members, Geriatric Nurse Aide (GNA 11, GNA4, GNA9, GNA6, GNA3, GNA8, GNA5, GNA7, and GNA10), Registered Nurse (RN1), the Administrator, the Director of Nursing (DON), and the Regional Director of Labor Management voiced concerns regarding sufficient staffing, and the facility exhibited multiple failures related to a lack of sufficient staffing throughout the survey. Findings include: 1. Failure to Ensure that Residents Reviewed for Activities of Daily Living (ADL) Care Cross-reference F677: ADL Care Provided for Dependent Residents. The facility failed to ensure that R15 reviewed for ADLs received the necessary services to maintain appropriate grooming. 2. Failure to Ensure that Residents Reviewed for Weight Loss had Weekly Weights Cross-reference F658: Quality of Care. The facility failed to ensure 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 interviews and personnel files review, the facility failed to ensure a performance review was completed for five of five Geriatric Nurse Aides (GNA)5, GNA7, GNA13, GNA4, GNA 14) once every 12 months. The failure to ensure annual performance reviews were completed had the potential to impact all 80 residents in the facility related to safety, person-centered environment, and the number of adverse events or other resident complications. Findings include: Review of five GNAs' personnel files revealed: GNA5 with a start date of 11/01/22; GNA7 with a start date of 02/15/22; GNA13 with a start date of 03/27/23; GNA4 with a start date of 11/01/22; and GNA14 with a start date of 09/14/21, revealed they had not received an annual performance review in the past 12 months. During an interview on 11/01/24 at 3:27 PM, the Human Resources (HR) Director said GNA annual performance reviews were not being completed because of nurse leadership turnover. During an interview on 11/01/24 at 4:59 PM, the Administrator, and the Director of Nursing (DON) both confirmed that annual GNA evaluations…

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, document review and observations, the facility failed to ensure food was served at a palatable and appetizing temperature for two of two meal tray observations. This deficient practice had the potential to affect the meal consumption for all 80 of 80 residents who consumed food prepared from the facility's kitchen. Findings include: During the initial screening on 10/29/24 several residents made comments regarding the taste and temperature of the food provided by the facility. During an interview on 10/29/24 12:53 PM, Resident (R) 339 stated that the food was not good at the facility and that the eggs for breakfast were not appetizing. Review of R339's electronic medical record (EMR) revealed R339's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/18/24 with a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicated R339's cognition was intact. During an interview on 10/29/24 at 2:10 PM, R336 stated he will get a piece of hard meat and half-baked toast. Review of R336's EMR revealed the admission MDS with an ARD 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 observations, interviews, document review, policy review and review of the Federal and Drug Administration (FDA) Food Code, the facility failed to ensure food was served and prepared under sanitary conditions. The facility failed to ensure floors, baseboards, walls, appliances, hood vent and ice machine were kept clean and in good working condition. The facility also failed to ensure dietary staff adhered to sanitary requirements related to hair restraints. The deficient practice has the potential to affect 80 of 80 residents who received meals prepared in the facility kitchen. Findings include: Observation during the initial kitchen tour on 10/29/24 at 09:20AM, revealed the ice machine compressor was on top of the ice chest. The seam at the base of the compressor was covered with a white powdery substance. This substance could also be observed on the floor. Observation of the floor around the ice machine revealed trash, debris, a powdery white substance, and spider webs. The ice scoop was in a holder that was covered with a lid and attached to the ice chest. Inside of the…

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

Based on observations, interviews, document review, and policy review, the facility failed to ensure garbage and refuse was properly disposed of in that the facility did not ensure dumpsters were maintained in a sanitary condition. This deficient practice had the potential to affect all residents in the facility, Findings include: During the initial kitchen tour with the Dietary Manager (DM) on 10/29/42 at 9:20AM, observation of the garbage and refuse area revealed three separate green dumpsters, on a pad of grass. In the grass, at the front and sides of the dumpsters were multiple disposable gloves. At the rear of the dumpsters was a clear plastic trash bag that had a hole and contained disposable gloves, napkins and food wrappers Interview at this time, the DM was asked who was responsible for maintaining the garbage and refuse area. The DM stated that it was a housekeeping task but added that the dietary staff will pick up around the dumpster if they find trash on the ground. The DM provided a cleaning schedule for the dietary staff, and it did not indicate that they had any…

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, record review and facility policy review, the facility failed to wear the appropriate PPE when providing catheter care for one of one resident (Resident (R) 65) observed during catheter care out of a total sample of 31 residents. In addition, the facility failed to ensure that one resident (R65) had personal protective equipment (PPE) readily available to use during catheter care that was on enhanced barrier precautions (EBP) and failed to ensure that staff used EBP for two of three residents (R11, and R33) during care. This failure has the potential to place R65, R11 and R33 at risk for infection to the urinary tract. In addition, the facility failed to have a water management program. This failure has the potential to place all 80 residents residing in the facility at risk for Legionella. Findings include: Review of the facility's policy titled, Personal Protective Equipment (PPE), dated 01/31/24, indicated, .4. Indications/considerations for PPE use: a. Gloves: .ii. Perform…

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, personnel files review and policy review, the facility failed to ensure 12 hours of required in-service training for five of 5 Geriatric Nurse Aides (GNA)5, GNA7, GNA13, GNA4, GNA14) was provided to ensure continuing competencies. The failure to ensure an effective training program was in place had the potential to impact 80 residents in the facility related to safety, person-centered environment, and the number of adverse events or other resident complications. Findings include: Review of the facility's policy titled, Required Training, Certification and Continuing Education of Nurse Aides dated 09/16/24 revealed, The facility will provide at least 12 hours of in-service training annually, based on the employment date, not calendar year. Review of five GNA personnel folders revealed: GNA5 with a start date of 11/01/22; GNA7 with a start date of 02/15/22; GNA13 with a start date of 03/27/23; GNA4 with a start date of 11/01/22; and GNA14 with a start date of 09/14/21, revealed they had not completed their 12 hours of required in-service training to ensure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of complaints, observation of resident rooms and equipment, and resident and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident on 3 of 4 nursing units observed. The findings include: On 10/30/24 at 8:30 AM a review of complaint MD00201981 alleged that there was black mold in the rooms on the 400 wing. On 10/30/24 at 9:00 AM an environmental tour was conducted, and the following was observed: Room: 401/403 bathroom: Observed in the shared bathroom on the wall was a 1 ft. by 4-inch hole in the wall where the plaster was busted through to the wood studs. Room: 407 - (A) bed: the over the bed light on the wall was rusted from top to bottom. (B) bed area on back wall by the head of the bed was a 3 ft. by 2 ft. area of spackle that was not painted. The Resident stated it has been that way for a least 8 months. The trim on the wall under the television area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's investigations, medical record reviews, interviews, and policy review, the facility failed to fully implement their abuse policy for an allegation of physical abuse and verbal abuse and misappropriation of property three of five residents (Resident (R) 233, R11, and R232) reviewed for abuse out of a total sample of 31 residents. This failure to fully implement the abuse policy, including timely and thorough investigations and and timely reporting, increased the risk of continued abuse to residents. Findings include: Review of the facility policy, Abuse Neglect and Exploitation, dated 02/02/24, revealed abuse means the willful infliction of injury . intimidation . with resulting physical harm, pain, or mental anguish which can include staff to resident abuse and certain resident to resident altercations . instances of abuse of all residents . cause mental anguish . It includes verbal abuse . and mental abuse . alleged violation is a situation or occurrence that is observed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's investigations, medical record reviews, interviews, and policy review, the facility failed to investigate allegations of physical abuse, verbal abuse, and misappropriation of property timely and thoroughly for 4 of 31 residents (Resident (R) 233, R11, R232, and R65) reviewed for abuse. The findings include: 1. Review of the Facility Reported Incident (FRI) MD00201316 revealed R233 reported an allegation of physical and verbal abuse to Registered Nurse (RN)1 that Geriatric Nursing Assistant (GNA)15 was rough during care and threatened him if you touch your diaper you will regret it for the rest of your life and if I come back in the morning you better not have messed with your diaper. Review of the electronic medical record (EMR) Face Sheet revealed R233 was admitted to the facility on [DATE] status post stroke. Review of the EMR Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15…

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, record review, and facility policy review, the facility failed to ensure that two of five residents (Resident (R) 14 and R65) were treated with dignity and respect, out of a total sample of 31 residents. This failure has the potential to negatively affect all residents residing in the facility by affecting a resident's psychosocial well-being. Findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 02/02/24 indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and is in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident's rights .When interacting with a resident, pay attention to the resident as an individual .Maintain…

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, the facility failed to allow one of one resident (Resident (R) 15) reviewed from a sample of 31 residents for self-determination to make their own choice on the size of incontinent briefs to wear. This failure has the potential to affect R15 and other residents residing at the facility by not allowing the residents to make choices about aspects that affect their daily lives. Findings include: Review of R15's admission Record, under the Profile tab in the electronic medical record (EMR) indicated, R15 was re-admitted to the facility on [DATE] with a diagnosis of morbid obesity. During an interview with R15 on 10/29/24 at 1:00 PM, she said that she needs bigger incontinent briefs because the size she has now is rubbing her skin and they are painful to wear. During the interview, R15 was observed wearing a white incontinent brief which appeared to be too little and tight around her waist and thigh area. She said that she can not sit up with this size of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to notify a resident's responsible party (RP) when a new treatment was started for a pressure ulcer. This was evident for 1 (#65) of 4 residents reviewed for pressure ulcers. The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). On 10/29/24 at 11:34 AM a review was conducted of Resident #65'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure one of 31 sample residents (Resident (R) 4) reviewed for Resident Council grievances was promptly resolved. Specifically, the facility failed to ensure a grievance voiced by R4 during a resident council meeting on 09/24/24 was investigated, resolved, and followed up by staff. This failure had the potential to cause further grievances to be unresolved for residents throughout the facility. Findings include: Review of the facility's policy titled, Resident Council Meetings, dated 02/06/24 and provided by the facility revealed, The facility will make prompt efforts to resolve grievances. 1. Review of R4's admission Record, located under the Profile tab of the Electronic Medical Record (EMR), revealed R4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia, and major depression. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/08/24…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the facility's policy, the facility failed to protect the resident's right to be free from physical abuse for one of six residents (Resident (R) 39) reviewed for abuse out of a total sample of 31. Findings include: Review of the facility's policy titled, Compliant with Reporting Allegations of Abuse/Neglect/Exploitation, with an implementation date of 02/20/24, revealed, the purpose of . assuring the facility is doing all that is within its control to prevent occurrences [of abuse] . The policy recorded that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include . certain resident to resident altercations. Review of R39's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic hepatitis, alcoholic cirrhosis of the liver, anxiety disorder, panic disorder, and dementia. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility's investigations, medical record reviews, interviews, and policy review, the facility failed to timely report allegations of physical abuse and verbal abuse for 5 (Resident (R) 233, R32, R28, R65, R62) of 31 residents reviewed for abuse. This failure increased the risk of continued abuse to these residents. Findings include: Review of the facility policy, Abuse Neglect and Exploitation, dated 02/02/24, revealed . abuse means the willful infliction of injury . intimidation . with resulting physical harm, pain, or mental anguish which can include staff to resident abuse and certain resident to resident altercations . instances of abuse of all residents . cause mental anguish . It includes verbal abuse . and mental abuse . alleged violation is a situation or occurrence that is observed or reported by staff, resident, or others but has not yet been investigated . mental abuse includes, but is not limited to . threats of punishment . physical abuse includes, but is not limited to hitting,…

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, interview, review of the Resident Assessment Instrument (RAI manual and policy review, the facility failed to ensure one resident (Resident (R) 75) out of 31 sampled Minimum Data Set (MDS) assessments was transmitted in a timely manner. Findings include: Review of R75's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and died in the facility on [DATE]. Review of R2's MDS with Assessment Reference Date (ARD) of [DATE] revealed the Death in Facility MDS was completed timely. Further review revealed this assessment was transmitted on [DATE] and should have been transmitted by [DATE] During an interview on [DATE] at 08:20AM, the MDS Coordinator (MDSC)confirmed that the facility sends their assessments to their corporate offices, and they transmit the assessments in batches. She added that she does not know when they submitted the assessment, but that she sent it to them immediately. Review of Center for Medicare and Medicaid Services (CMS)…

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, the facility failed to develop a written care plan with interventions and goals for the use and discontinuation of an indwelling urinary catheter for one of one resident (Resident (R)11) reviewed for urinary catheters out of a sample of 31 residents. This failure resulted in R11 having an indwelling urinary catheter in place for seven months without a written comprehensive plan to discontinue the use of the urinary catheter. Findings include: A policy for care plan development was requested but not provided by the exit of the survey. Review of the electronic medical record (EMR) Face Sheet revealed R11 was admitted to the facility on [DATE]. Review of the EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R11 was cognitively intact. During an interview and observation on 10/29/24 at 10:30 AM, R11 was observed to have a urinary catheter…

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, interviews, hospice contract review, and facility policy reviews, the facility failed to ensure that one out of one resident (Resident (R) 32) reviewed for hospice had a care plan to include hospice out of a sample size of 31 residents. In addition, the facility failed to ensure that all necessary interdisciplinary team (IDT) members and outside resources were invited to participate in one of one resident (R32) care conferences, out of a sample size of 31 residents. Also, facility staff failed to have quarterly care plan meetings for residents (Resident #19, #45 and #65). This was evident for 3 of 33 residents reviewed during an annual survey. These failures had the potential to affect resident care. Findings include: Review of the facility's policy titled, Care Plan Revisions Upon Status Change, dated 02/13/24, indicated, .The comprehensive care plan will be reviewed, and revised as necessary .The Minimum Data Set (MDS) Coordinator and the IDT [Interdisciplinary Team] will discuss 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 interview, the facility failed to ensure that one of one resident (Resident (R) 3) reviewed for weight loss had weekly weights completed as ordered by the physician, out of a total sample of 31 residents. This had the potential to have increased weight loss for R3. Findings include: Review of R3's admission Record, under the Profile tab in the electronic medical record (EMR) indicated R3 was re-admitted to the facility on [DATE] with a diagnosis of dysphagia. Review of R3's Order Summary Report, dated 10/31/24, located under the Orders tab in the EMR indicated, .Weekly weights .for four weeks, start date of 10/14/24. Review of Weights and Vitals, located under the tab Weights in the EMR indicated:, 10/11/24: 115, 09/15/24: 128.6, 08/05/24: 124.6, 07/02/24: 121.8, 06/27/24: 125, and 05/31/24: 120.3. There was no documentation that R3 was weighed on 10/14/24 and/or 10/21/24. Review of Registered Dietitian (RD) Note-Nutrition/Dietary Note, dated 10/11/24, found under tab Notes in 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, record review and facility policy review, the facility failed to ensure that two of two residents (Resident (R) 15, and R33) reviewed out of 33 sampled residents, for activities of daily living (ADL) received the necessary services to maintain appropriate grooming. This failure has the potential to affect R15 and other residents residing at the facility's highest practicable physical, mental, and psychosocial well-being by not providing necessary ADL care to dependent residents. Findings include: Review of the facility's policy titled, Activities of Daily Living, dated 02/02/24, indicated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices . Care and services will be provided for the following activities of daily living: bathing .A resident who is unable to carry out ADL's will receive the necessary services to maintain good .grooming. Review of R15's admission Record, under the Profile tab in the electronic…

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 provide timely treatment/services to prevent/heal pressures ulcers. This was evident for 1 (#65) of 4 residents reviewed for pressure ulcers. The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). On 10/29/24 at 11:34 AM a review was conducted of Resident #65's medical record which 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and policy review, the facility failed to ensure that the designated smoking area was safe for one of one resident (Resident (R) 29) reviewed for smoking. R29 was the only smoker in the facility. Specifically, the facility failed to ensure there was an accessible metal container with a self-closing cover where the ashtrays could be emptied, that did not contain trash and there was no protective cover over the smoking area to protect R29 from rain and snow. Findings include: Review of the facility policy titled, Resident Smoking dated 02/11/24 revealed, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking .Smoking is prohibited in all areas except the designated smoking areas .Safety measures for the designated smoking are will included, but not limited to: Protection from weather conditions, accessible metal containers with self-closing covers into which ashtrays…

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, the facility failed to attempt a voiding trial and to discontinue an indwelling urinary catheter after multiple urinary tract infections for one of one resident (Resident (R)11) reviewed for urinary catheters out of a total sample of 31 residents. This failure increased the risk of continued urinary tract infections and antibiotic usage. Findings include: A policy for urinary catheter use was requested but not provided by the time of exit of the survey. 1. Review of the electronic medical record (EMR) Face Sheet revealed R11 was admitted to the facility on [DATE]. Review of the EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R11 was cognitively intact. During an interview and observation on 10/29/24 at 10:30 AM, R11 was observed to have an indwelling urinary catheter collection bag attached to her bed frame. R11 stated she was not sure…

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

Based on facility provided staffing documentation and interview, the facility failed to have a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days week. This was evident for 4 of 56 days reviewed during an annual survey. The findings include: Review of numerous complaints regarding low staffing from residents, staff and families during the annual survey, on 10/31/24 the Surveyor reviewed the following days for RN (Registered Nurse) coverage: 12/5/23-12/11/23, 12/29/23, 12/30/23, 1/24/24-1/30/24, 3/13-24/24, and 10/1/24-10/29/24. The following days did not have a RN as required on the staffing sheets provided by the Regional Director of Labor Management: 1/26/24 no RN coverage 1/28/24 no RN coverage 10/5/24 no RN coverage 10/20/24 no RN coverage Interview with the Regional Director of Labor Management on 11/1/24 at 8:40 AM confirmed the dates the facility failed to have a RN 8 consecutive hours a day.

Based on interview, record review and policy review, the facility failed to ensure medication regimens was free from unnecessary medications. The facility failed to ensure an as needed (PRN) psychotropics were not prescribed beyond 14 days without documented rational, for one (Resident (R)17) of five residents reviewed for unnecessary medications. Findings include: Review of R17's electronic medical record (EMR), revealed R17's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/18/24, indicated the resident has a Brief Interview for Mental Status (BIMS) of 10 out of 15 which indicated R17's cognition was moderately impaired. The EMR also revealed diagnosis of anxiety disorder. Review of R17's Care plan in the EMR under the Care Plan tab revealed a focus related to R17's use of psychotropic medications initiated 12/27/23. The goal indicated be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date.…

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, the facility failed to obtain a urology consult timely to assess the continued need for an indwelling urinary catheter for one of one resident (Resident (R)11) reviewed for indwelling urinary catheters out of a total sample of 31 residents. This failure resulted in the continued use of an indwelling urinary catheter without an appropriate indication for the catheter. Findings include: A policy for outside consultations was requested but not provided by the survey exit. Review of the electronic medical record (EMR) Face Sheet revealed R11 was admitted to the facility on [DATE]. Review of the EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/13/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R11 was cognitively intact. During an interview and observation on 10/29/24 at 10:30 AM, R11 was observed to have an indwelling urinary catheter collection bag attached to her bed frame. R11 stated she…

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 the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #19, #45 and #62). This was evident for 3 of 33 residents reviewed during an annual survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Review of Resident #19's medical record on 10/29/24 revealed the resident was admitted to the facility on [DATE]. On 10/30/24, Social Services Assistant was asked for evidence of care plan meetings for the last year. Social Services Assistant brought in evidence of care plan meetings in September 2023, November 2023, March 2024 and July 2024 on paper. Further review of Resident #19's medical record on 10/30/24…

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 observation, interviews, document review and record review, the facility failed to ensure a resident's bed was inspected and maintained for one (Resident (R) 2) of 31 residents in the sample. Findings include: During an observation and interview on 10/30/24 at 10:25AM, R2 stated her bed was broken, A physical check of the electric bed revealed that the headboard and footboard were not securely attached to the bed. This resulted in a gap of approximately three to five inches between the mattress and the headboard and the footboard. Review of R2's electronic medical record (EMR), annual Minimum Data Set (MDS)' with an Assessment Reference Date (ARD) of 08/16/24, has a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated the resident's cognition was intact. The Regional Director of Maintenance (RDM) was advised of this concern during an interview on 10/30/24 at 10:30AM. He confirmed that the loose headboard and footboard were a safety hazard. He added that the expectation was that residents' equipment was checked in accordance with 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 observation and facility staff interview, it was determined the facility staff failed to serve and assist residents with meals on a dementia unit in a dignified manner (Resident #29, #32, #33, #34, #35, #36, #38). This was evident for 7 of 17 residents observed during a complaint survey. The findings include: The Surveyor observed 3 meals on the locked dementia unit due to multiple resident family members concerns that the residents on that unit are not being fed or assisted in their meals. Observation on 8/28/23 at 12:20 PM of lunch being served on the locked dementia unit revealed 17 residents in the dining room with 4 staff handing out lunch trays. At 12:30 PM Resident #37 took the milk off of Resident #36's tray. At that time Staff #30 took the milk away from Resident #37. Staff #30 failed to replace Resident #36's milk and the Resident was left with nothing to drink for the entire lunch meal. Also on 8/28/23 at 12:30 PM Staff #22 was observed standing while feeding Resident #35 and Staff #33 was observed standing while feeding Resident #29. Also on 8/28/23 at 12:40 PM…

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

Based on facility investigation review, interview, and policy review, it was determined that the facility failed to implement the abuse policy by failing to do thorough investigations of alleged abuse, neglect, injury of unknown origin, and misappropriation of resident property. This was evident for 5 (#3, #15, #4, #14, #12) of 16 residents reviewed for abuse, neglect, injury of unknown origin, and misappropriation of resident property. The findings include: 1) On 8/22/23 at 1:05 PM a review of facility reported incident MD00173027 was conducted and revealed Resident #3 complained of left upper arm to shoulder pain. Resident #3 alleged he/she had been fixing a recliner and a tall man assisted the resident off the floor by grabbing the arm and the resident has had pain since. Review of the facility's investigation was incomplete as it did not have a statement from all staff that had worked with the resident during and before the alleged incident. 2) On 8/23/23 at 8:40 AM a review of facility reported incident MD00186361 was conducted and revealed Resident #15 was noted with bruising…

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 documentation review and interview it was determined the facility failed to report allegations of abuse, neglect, or an injury of unknown origin within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) and failed to submit a final report within 5 business days. This was evident for 3 (#15, #4, #12) of 11 residents reviewed for abuse during a complaint survey. The findings include: 1) On 8/23/23 at 8:40 AM a review of facility reported incident MD00186361 was conducted and revealed Resident #15 was noted with bruising to the right inner ankle and an x-ray which was suspicious for a nondisplaced fracture. A 11/30/22 at 8:59 AM nursing note documented that the GNA (geriatric nursing assistant) noted a bruise to the resident's right inner ankle while providing AM care. The right inner ankle had a, 12 cm x 11 cm x 0 cm yellow/greenish bruise. Right ankle is swollen and painful to touch. Radiology results that were reported on 12/1/22 at 6:34 AM reported a possible nondisplaced fracture. Review of the Comprehensive and Extended Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, neglect, and misappropriation of resident property. This was evident for 6 (#3, #15, #4, #14, #12, #24) of 16 residents reviewed for abuse, neglect, and misappropriation of property. The findings include: 1) On 8/22/23 at 1:05 PM a review of facility reported incident MD00173027 was conducted and revealed Resident #3 complained of left upper arm to shoulder pain. Resident #3 alleged he/she had been fixing a recliner and a tall man assisted the resident off the floor by grabbing the arm and the resident has had pain since. Review of the facility's investigation was incomplete as it did not have a statement from all staff that had worked with the resident during and before the alleged incident. On 8/23/23 at 9:40 AM the Director of Nursing (DON) stated that she only started in June 2023 and was not here at the time and that was all that was in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to hold care plan meetings to include the interdisciplinary team, resident and resident's representative for residents. (Resident #2, #8, #17, #19, #27 and #29). This was evident for 6 out of 41 residents reviewed during a complaint survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident. Care plan meetings are held each quarter and as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a complaint, medical record review and interview, it was determined the facility failed to ensure residents received medications and treatment in accordance with professional standards of practice (Resident #2, #10, #26, #30 and #31) This was evident for 5 of 41 residents reviewed during a complaint survey. The findings include: 1) On 8/24/23 at 8:34 AM complaint #MD00186966 was reviewed and revealed Resident #10 was admitted to the facility on [DATE] at approximately 5:00 PM. The complaint alleged that Resident #10 did not receive his/her scheduled blood pressure medication and pain medication until the next evening. Review of Resident #10's medical record on 8/24/23 at 8:34 AM revealed a discharge summary from the acute care facility which documented Resident #10 was to receive Tylenol 1,000 mg. every 6 hours every day for pain. The summary also documented the medication Diltiazem 120 mg. was to be given twice per day. Diltiazem is prescribed for chest pain and hypertension (high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to failed to follow up on a resident with weight loss to determine cause and need for additional interventions (Resident #18, #29 and #30). This was evident for 3 of 41 residents reviewed during a complaint survey. The findings include: 1. Review of Resident #18's medical record on 8/28/23 revealed the Resident was admitted to the facility on [DATE] with diagnosis to include dysphagia. Dysphagia is the difficulty swallowing of foods and liquids. Review of Resident's weights revealed the Resident weighed 129.6 on 4/23/20 and 115.2 on 7/29/20 for a 14.4 pound weight loss or 11%. Review of Resident's quarterly nutrition assessments revealed the Resident was assessed by the Dietitian on 4/20/20. Further review of Resident #18's medical record revealed the Resident was not assessed quarterly by the Dietitian in July or October 2020 following a weight loss. Interview with the Director of Nursing on 8/28/23 at 2:30 PM confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined physician progress notes were not in the resident medical records the day the resident was seen (Resident #7, #9, #17) and the physician failed to review the resident's total program of care (Resident #18 and #29). This was evident for 5 of 41 residents reviewed during a complaint survey. The findings include: 1) On 8/25/23 at 8:35 AM a medical record review was conducted for Resident #7. Review of physician/nurse practitioner (NP) progress notes revealed the notes were not signed and in the medical record at the time of the visit. The 7/21/21, 7/22/21, 7/30/21, 8/4/21, and 8/11/21 progress notes were not signed and put into the electronic record until 9/13/21. The 8/3/21 note was signed and put into the electronic record on 9/12/21, the 8/19/21 note was put in on 8/23/21, the 8/24/21 note was put in on 8/31/21, the 9/29/21 note was put in on 9/8/21 and the 9/14/21 note was put in on 9/29/21. 2) On 8/28/23 at 7:33 AM a medical record review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to notify the resident's responsible party (RP) and physician timely when a resident had a change of condition (Resident #31). This was evident for 1 of 41 residents reviewed during a complaint survey. The findings include: Review of Resident #31's medical record on 8/28/23 revealed the Resident was admitted to the facility on [DATE] and the Resident has diagnosis to include peripheral vascular disease (PVD). PVD is a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs. Further review of the Resident's medical record revealed on 2/3/23 the Nurse Practitioner (Staff #38) assessed the Resident's right foot and documented the Resident had a dressing around his/her right foot. During interview with the Resident's RP on 8/29/23 at 3:00 PM, the RP stated he/she visited the Resident almost daily and noted the Resident had a dressing on his/her right foot for a few days prior to 2/3/23 and asked 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 staff interview it was determined the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident on 2 of 5 nursing units observed during a complaint survey. The findings include: On 8/30/23 at 10:10 AM observation was made of Resident #39 sitting in a wheelchair in the bedroom. The vinyl on the left wheelchair armrest was torn along the entire length of the outside edge which exposed the underneath yellow padding. The vinyl on the right armrest was also torn in a couple of areas which also exposed the underneath padding. Observation was made of Resident #20's wheelchair. The front of the right armrest was missing vinyl and the underneath padding approximately 1 inch in width and length. Observation was made of Resident #12's wheelchair. The vinyl on the right armrest was torn halfway through the top of the armrest with the underneath padding exposed. This concern was cited on the complaint survey that ended on 2/24/23. The plan of correction (POC) documented that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff (Resident #24). This was evident for 1 of 11 residents reviewed for abuse during a complaint survey. The findings include: Review on 8/23/23 of a facility reported incident that occurred on 7/14/23 revealed Staff #23 (Licensed practical nurse) witnessed Staff #39 (geriatric nursing assistant) tell Resident #24 (expletive language) you. Review of Resident #24's medical record on 8/23/23 revealed the Resident was admitted to the facility on [DATE] and is alert and oriented. During interview with Resident #24 on 8/24/23 at 10:20 AM, Resident #24 stated on the evening of 7/14/23 he/she had asked Staff #39 if she could put the him/her back to bed. Resident #24 reported every time he/she asked Staff #39 they would tell the Resident they were busy and would have to do it later. Resident #24 then stated the last time he/she asked Staff #39 to put him/her to bed…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 (#5, #9, #11) of 41 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 8/23/23 at 11:48 AM a review of Resident #5's medical record was reviewed and revealed several behavioral notes. On 1/23/23 at 15:38 (3:38 PM) a note documented, Resident was very rude and disrespectful when this nurse attempted to give [him/her] medication. I went into [his/her] room the 2nd time to pop the pills out of the pack in front of [him/her] and [he/she] started…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident medical records and interview with staff, it was determined that the facility failed to develop a care plan for residents receiving oxygen therapy and for a resident that was to be discharged to the community. This was evident for 3 (#11, #8, #16) of 41 residents reviewed during a complaint 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. 1) On 8/24/23 at 9:43 AM Resident #11's medical record was reviewed and revealed the vital sign section of the electronic medical record that documented oxygen use with oxygen saturation levels that began as early as 8/13/21 up to 3/9/22. Review of Resident #11's care plans failed to produce a respiratory care plan. On 8/30/23 at 3:34 PM the Director of Nursing (DON) confirmed there was no care plan. The DON stated that they have had issues with care plans and that was something they would be working on. 2) On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #18 and #27). This is evident for 2 of 41 residents reviewed during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National Pressure Ulcer…

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, the facility staff failed to follow up and obtain a motorized wheelchair for a resident in a timely manner (Resident #19). This was evident for 1 of 41 residents reviewed during a complaint survey. The findings include: Review of Resident #19's medical record on 8/22/23 revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include quadriplegia. Quadriplegia is a form of paralysis that affects all four limbs. During interview with Resident #19 on 8/22/23 at 8:30 AM, Resident #19 stated he/she has been waiting on the facility to get his/her motorized wheelchair ordered. During interview with the Administrator on 8/25/23 at 12:55 PM, the Administrator stated the wheelchair has been approved and the facility is in the process of getting. At that time the Administrator brought the Surveyor a copy of the invoice and it was noted the date on the invoice is 5/24/23. During interview with the Administrator on 8/29/23 at 4:30 PM, the Administrator…

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 1) ensure that a resident who was placed on oxygen had a physician's order for oxygen along with the amount of oxygen to be administered and 2) ensure that an order for CPAP/BIPAP and oxygen had complete orders. This was evident for 2 (#11, #8) of 41 residents reviewed during a complaint survey. The findings include: 1) On 8/24/23 at 9:43 AM Resident #11's medical record was reviewed and revealed the vital sign section of the electronic medical record that documented oxygen use with oxygen saturation levels that began as early as 8/13/21 up to 3/9/22. Review of physician's orders for Resident #11 failed to produce an order for oxygen. Review of Resident #11's Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to produce documentation that the resident was receiving oxygen. The Director of Nursing (DON) stated on 8/30/23 at 3:34 PM that there was no order for the oxygen and nowhere to…

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

Based on observation, staff interview, and documentation review, it was determined that facility staff failed to keep medication carts locked when unattended. This was evident for 1 of 5 nursing units observed. The findings include: On 8/30/23 at 10:12 AM observation was made of an unlocked and unattended medication cart in the 500-nursing unit next to the nurse's station. The 500-nursing unit was the dementia unit. There were no staff near the medication cart and there were 4 residents sitting in the day room and there was 1 resident walking the hallway. The surveyor was able to open the top drawer of the medication cart which contained a plastic 30 ml. medication cup containing 1 blue pill, 1 brown pill, 1 green pill, 1 white round pill, and 1 oval white pill. The other drawers of the medication cart contained resident prescription medications, supplements, and miscellaneous items. The surveyor stood at the medication cart between 1 to 2 minutes before Registered Nurse (RN) #28 walked up to the cart. RN #28 was complaining about the falls and the surveyor asked her if she realized…

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

Based on facility record review and interview, it was determined the facility failed to have a full time licensed Nursing Home Administrator (NHA) authorized by the State of Maryland from 1/29/23 until 5/15/23. This is being cited as past noncompliance since the facility has had a licensed administrator in place since 5/15/23 and was verified by the Surveyor on 8/24/23. The findings include: During interview of the Administrator on 8/24/23 at 8:30 AM, the Administrator stated she was a licensed NHA in Virginia when she began working at the facility in November 2022 and had applied for a provisional nursing home administrator license in October 2022. The NHA stated her Regional NHA (Staff #10) was covering as the licensed NHA for the facility and had 4 buildings he was overseeing until 5/15/23 when she received her license. The NHA provided documentation on 8/24/23 from the Maryland State Board of Long-Term Care Administrators a provisional nursing home administrator license with an effective date of 10/31/22 until 1/29/23. On 8/24/23 at 8:43 AM the NHA stated she took the licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a facility reported incident, medical record review, and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #2 and #13) This was evident for 2 of 41 residents reviewed during a complaint survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 8/25/23 at 11:15 AM a review of facility reported incident MD00189149 documented Resident #13 had an injury of unknown origin that was reported to the facility on 2/15/23 from an acute care facility. According to the incident, Resident #13 was transferred to the acute care facility emergently on 2/15/23 at 7:15 PM. The facility's investigation revealed written statements…

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

Based on facility documentation and interview, the facility failed to have an Infection Preventionist (IP) onsite. Failure to have an Infection Preventioinist has the potential to affect all the residents in the facility. The findings include: An Infection Preventioinist is responsible for assessing, developing, implementing, monitoring the facility's Infection Prevention and Control Program to prevent and control infections. During interview with the Director of Nursing (DON) on 8/23/23 at 8:05 AM, the DON stated the Assistant Director of Nursing (ADON) was serving as the IP for the facility. The DON at that time stated the ADON is not certified as an IP and has only completed 13 of the 23 modules in the CDC (Centers for Disease Control and Prevention) IP training course. On 8/25/23 the ADON presented evidence to the Surveyor she has completed all the CDC IP training modules as of 8/24/23. At that time the ADON stated she began working at the facility in June 2023. Interview with the DON on 8/31/23 at 11:30 AM confirmed the facility failed to have an IP onsite until 8/24/23.

Based on medical record review, interview and observation, it was determined the facility staff failed to promote care for residents in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality by labeling a resident as feeder on the July 2019 order summary sheet. This was evident for 1 of 4 residents (Resident #42) reviewed for dignity during the annual survey. The findings included: On 7/25/19 a review of the medical record for Resident #42 revealed the following order 1-1 feeder for meals every day and evening shift for feeding. The term feeder Feeder is an undignified label meaning a resident is incapable of eating by themselves and is dependent on the nursing staff to feed them. Interview with the Director of Nursing on 7/25/19 at 9:00 AM confirmed that Resident #42 was labeled on the order summary sheet as a feeder.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview it was determined the facility staff failed to honor residents' right to form advanced directives concerning life sustaining treatments. This was evident for 3 of 4 residents (Resident #25, #52 and #54) selected for review of advanced directives. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a resident's wishes about medical treatments. 1.) Resident #25 who was admitted [DATE] with a diagnosis of dementia and had a care planning meeting on 3/29/19 with the facility staff and his/her health care agent. During the meeting Social Worker #16 noted the MOLST and Advanced Directive was not on the paper or electronic medical record. The health care agent reported they had one at home and would send to the facility. On 7/25/19 at review of Resident #25's paper…

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

Based on medical record review and interview with the facility staff, it was determined that the facility failed to provide timely notification to a resident or representative (RP) regarding notification and explanation of their rights regarding a pending discharge from Medicare covered services. This was evident in 3 of 3 residents (Resident #128, #129 and #66), reviewed regarding liability notices. The findings include: Notification to residents regarding the end of their Medicare coverage is required to be minimally 48 hours prior to the scheduled effective date that coverage will end, therefore, affording them an opportunity to appeal the decision or to prepare for discharge. In addition, a specific form is required to be used for the notification of the non-coverage of Medicare services. On 7/25/19 at 11:54 AM the Administrator presented the survey team with 3 beneficiary notices for Resident #128, #129 and #66 for review. Upon presentation he reported that none of notices were presented to the respective residents timely for multiple reasons. He further stated that the current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and observation of residents rooms during a tour of the facility on the 300 hundred wing revealed residents' rooms were not being maintained at comfortable temperatures between 71° to 81° Fahrenheit. This was observed in 4 resident rooms. The findings include: During an initial tour of the facility resident rooms on the 300 wing on 7/23/19 at 10:12 AM the following rooms were observed to be below the accepted range of 71 to 81 degrees. The rooms were observed to have a wall unit with an adjustable thermostat for heating and cooling inside the unit that can be adjusted by staff or residents. room [ROOM NUMBER] unit thermostat was set on 64, but the surveyor's thermometer read air temperature at 67 degrees. room [ROOM NUMBER] unit thermostat was set on 66, but the surveyor's thermometer read air temperature at 67 degrees. Observation of Resident #6 revealed the resident to be shivering in the room and covers pulled up to his/her chin. room [ROOM NUMBER] unit thermostat was set on 64 degrees,…

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

Based on observation, medical record review and interview with facility staff it was determined that the facility failed to have a system in place to identify and assess the side rails on the residents' beds. This was evident on the observation of 3 of 3 beds (Resident #52, #26 and #57) were side rails were covering the length of the bed that could not be lowered by the residents. The findings include: 1.) Surveyor attempted to interview Resident #52 on 7/22/19 at 9:39 AM. S/he was noted in bed with bilateral side rails up. The side rails were positioned in the middle of the bed and larger than the quarter and assist rails that were observed on the beds of other residents. Resident #52 was observed up against the right-side rail and holding on to it. S/he was unable to complete the interview screening questions or verbalize if s/he was able to lower the side rail. A second tour of the room on 7/24/19 at 10:18 AM revealed Resident #52 in bed. Staff #4 was present and confirmed the half side rails. A review Resident #52's medical record on 7/24/19 at 10:19 AM failed to reveal any…

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 administrative documentation, medical record review, and staff interview it was determined the facility failed to report an allegation of neglect to the state survey and certification agency in a timely manner. This was found to be evident for 1 out of 1 resident (Resident #228) reviewed during the investigative stage of the survey. The findings include Review of incident MD00129060 on 7/24/19 revealed an allegation of neglect involving Resident #228. Review of the investigative documentation revealed that on 7/14/18 the resident alleged he/she was left on the floor for about an hour by nursing staff. Further review revealed that the staff allegedly told other staff to leave the resident on the floor. Further review of the facility report revealed that Office of Health Care Quality (OHCQ) received the report of suspected neglect on 7/16/18 2 days after the alleged incident. During interview with the Director of Nursing (DON) on 7/24/19, the surveyor asked for the exact date that it was reported to the state survey agency and after reviewing the investigation she reported…

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

Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure the resident, or their responsible party 1.) was notified in writing of the reason a resident's was transferred to the hospital (Resident #69); and 2.) received written notification of a transfer to the hospital, including appeal rights and ombudsman contact information (Resident #45). This was found to be evident for 2 out of 2 residents reviewed for hospitalization during the investigation stage of the survey. The findings include: On 6/6/19, Resident #69 was sent to the hospital for elevated temperature and blood pressure and not wanting to take food or fluids. On 7/25/19 at 10:50 AM during an interview with the Director of Nursing (DON) it was revealed that as of July 2019 the facility had not sent the residents or their representative a written notice of the reason for the transfer to the hospital. The Director of Nursing (DON) verbalized understanding of the deficient practice. 2. On 7/25/19 a review of Resident # 45's medical records 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 medical record review and interview with facility staff, it was determined that the facility staff failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) form was completed correctly on readmission to the facility. This was evident during the review of 1 of 1 resident (Resident #51) reviewed for PASARR screening. The findings include: Preadmission Screening and Resident Review is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Everyone who applies for admission to a nursing facility must be screened for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions. Review of the medical record for Resident #51 on 7/23/19 at 12:41 PM revealed a completed PASARR form dated 10/16/17. Further review of the medical record for Resident #51 revealed in the hospital discharge record for 10/16/17, discharge diagnosis including cerebral palsy. In addition, certifications of incapacity were issued according to the…

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

Based on medical record review and interview with facility staff, it was determined that the facility failed to develop person-centered individualized comprehensive care plan as evidenced by failure to develop a care plan to address: 1.) three residents identified as having restraints (Resident #52, #25 and #57); 2.) activities (Resident #45). This was evident during the review of 4 of 25 residents during the investigative portion of the survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is valuable in preventing avoidable declines in functioning or functional levels. It must reflect immediate steps for assuring outcomes which improve the resident's status and progress. 1a.) Surveyor observed Resident #52 on 7/22/19 at 9:39. Bilateral side rails were noted in the up position in the middle of the bed and larger than the quarter and assist rails that were observed on the beds of other residents. A review Resident #52's medical record on 7/24/19 at 10:19 AM failed to reveal any documentation of the presence of the side rails…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff, it was determined that the facility failed to revise care plans related to: 1.) a resident's repeated falls; 2.) a resident's visual needs; 3.) pain management and 4.) care plan updates hospitalization. This was evident during the review of 4 of 25 residents (Resident #52, #57, #70, and #43) reviewed during the investigative portion of the survey. The findings include: 1.) Review of the medical record for Resident #52 on 7/22/19 at 12:53 PM revealed a change in condition note on 6/29/19. Further review of Resident #52's medical record revealed diagnoses including; cognitive impairment, degenerative joint disease and dysphasia requiring feeding via a gastrostomy tube. The Director of Nursing (DON) was asked on 7/23/19 for any further falls and investigations related to falls for Resident #52 for the past 6 months. It was noted on 7/26/19 at 9:46 AM that Resident #52 had 2 falls occurring on 6/13/19 and 6/29/19. A review of the care plan failed 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 observations of residents, review of medical records and staff interview it was determined that the facility staff failed to ensure residents are provided with activities that meet the resident's needs based on their assessment. This was evident for 1 out of 6 residents (Resident #45) reviewed for activity during the investigation stage of the survey The findings include: On 7/24/19 a review of Resident #45's medical records revealed the resident had been admitted to the facility in March 2019 for rehabilitation and with diagnoses that included high blood pressure, history of falling and stroke. Further review of the medical records revealed that the resident has a daughter who was very involved in the resident's care. A review of the resident's admission preference and activity assessment revealed the assessments had all dashes indicating it was not completed. Review of the instructions for completing the assessment revealed if resident is unable to complete, attempt to complete interview with family member or significant other. Review of the resident's Individual 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 with facility staff, it was determined that the facility attending physician failed to: 1.) document procedural treatments rendered to a resident and 2.) document an updated and complete assessment of a resident's medication for 11 months. This was evident during the review of 2 of 25 residents (Resident #52 and #70) reviewed during the investigative portion of the survey. The findings include: 1.) Review of the medical record for Resident #52 on 7/22/19 at 9:36 AM revealed treatment orders for a wound. Further review of the resident's medical record revealed weekly notes from LPN #1 or the Assistant Director of Nursing, both with certifications in wound care regarding the wound changes and needs for wound management. Further review of Resident #52's medical record revealed a wound debridement on 3/22/19. Debridement is the removal of unhealthy tissue from a wound to promote healing. It can be done by surgical, chemical, mechanical, or autolytic (using your body's own processes). A physician note from 3/22/19 noted that in plan sacral…

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

Based on observation, medical record review and staff interview it was determined the facility staff failed to only administer ordered medications. This was evident for 1 of 6 residents (Resident #5) observed during the medication administration task during the annual survey. The findings included: On 7/25/19 at 7:50 AM during medication administration observation LPN #11 crushed Resident #5's medications. She then poured a water cup full of MedPass 2.0. When questioned she said Resident #5 is on nectar consistency liquids due to a swallowing problem and the MedPass 2.0 is the same consistency so she uses it for Resident #5 to swallow his/her medications since she doesn't have any liquid thicker on her cart. Liquid thickener just thickens liquids like water or juice and does not add calories or nutritional supplements. LPN #11 then administered the crushed medications and had Resident #5 swallow the cup of MedPass 2.0. MedPass 2.0 is a fortified nutritional shake used to supplement calories and protein to enable weight maintenance or weight gain. MedPass 2.0 requires a physician…

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 staff interview , it was determined that the facility had not properly labeled and dated leftover food that was in the refrigerator. This was true of 1 out 2 observations made in the kitchen's walk-in refrigerator. This deficient practice can impact all residents and the facility's infection control practices. Findings include: On 7/25/19 at 10:12 AM a tour of the kitchen was conducted with the Dietary Manager #7. The following items were not dated when the package/container was opened: 1. A box that contained fresh tomatoes. 2. Raw Carrots that were in a 50 lb. bag 3. Raw onions that were in a 50 lb. bag 4. Box of butter blocks Review of the facility food service policy on 7/25/19 revealed that items shall be labeled and dated when put into use. Interview with Dietary Manger #7 on 7/25/19 at 11:44 AM confirmed the facility's policy.

Based on observation and staff interview it was determined the facility staff failed to clean hands between residents during medication pass observation. This was evident for 4 of 6 residents observed during the medication pass task. The findings include: On 7/22/19 during medication pass observation with LPN #11 she passed medications to 4 residents. After completing the medication pass she exited the rooms never washed or used hand sanitizer to her hands. LPN #11 then continued on to the next resident. The facility's administering medications policy states staff shall follow established facility infection control procedures(e.g., handwashing, antiseptic technique, gloves, isolation precautions,etc) for the administration of medications, as applicable. This finding of LPN #11 not cleaning hands was confirmed with the Director of Nursing on 7/24/19 at 1:00 PM.

Based on observation, resident and staff interview and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program. This was evident on 3 out of 4 nursing units and has the ability to impact all residents, staff and visitors in the facility. Findings include: Review of facility pest control reports on 7/25/19 at 9:46 AM revealed the Insect Light trap was not working on the 200 wing on 5/22/19, 6/5/19, 6/19/19, 7/11/19, and 7/17/19 per the pest control contractor for the facility. Observation on an initial tour of the facility revealed flies and small black bugs that were observed coming from under the window air conditioning units and from the base molding on the 300 and 400 resident wings on 7/22/19 at 2:44 PM and 7/23/19 at 11:14 AM Interview with Resident #54 who resided on the 400 wing revealed the fly problem is worse in the hot summer months and mice had been seen in December 2018 and January 2019. Resident #54 revealed on 7/24/19 at 4:10 PM he/she and their daughter had fly swatter contests some evenings to see…

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.