Complete Care at Heritage LLC

Based on a review of medical records and interviews, it was determined that facility staff failed to ensure that two physicians' certificates of incapacity were obtained and that Advance Directives were completed in accordance with the Health Care Decisions Act. This was evident for one resident (Resident #1) out of the four residents reviewed for advance directives during the recertification/complaint survey.The findings included:On 9/08/25 at 1:29 PM, the surveyor reviewed Resident #1's medical records. The review revealed that the resident was admitted to the facility in August 2025 with an altered mental status. The form named physician certification related to medical condition, substitute decision making and treatment limitation was completed on 8/14/25 by one physician, who noted that the resident was unable to make decisions due to a state of confusion. However, a second physician's signature was missing.During an interview with Staff #5 (Social Worker) on 9/09/25 at 9:14 AM, she explained the process for physicians' certification regarding residents' decision-making…

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

Based on review of facility records and interview with staff, it was determined the facility staff failed to: 1) immediately report an allegation of suspected resident abuse and 2) timely report allegations of abuse to the State Survey Agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #42) of 35 residents reviewed for intakes during the facility's recertification/complaint survey.The findings include:The OHCQ is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. Allegations of abuse, serious bodily injury, and misappropriation of resident property are to be reported to the OHCQ in a timely manner (within 2 hours for the initial report and within 5 working days for the final report).A facility reported incident involving Resident #42 was reviewed on 9/15/25 at 6:00 AM. The facility report indicated that facility staff, Guest Services Director (GSD) became aware of the allegation of verbal abuse on 12/11/24 at 8:59 AM. Further review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the matrix, medical record review, and staff interview, it was determined that the facility staff failed to ensure Minimum Data Set (MDS) assessments diagnoses were updated. This was evident for 3 (Residents #82, #113, and #13) residents identified with a diagnosis of COVID on the matrix out of 74 resident records reviewed during the recertification/complaint survey process. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Active diagnoses documented on the MDS assessment should correlate with an accurate picture of the resident's current health status.The Facility Matrix is a tool used for assessing the care needs of residents and contains the active diagnoses pulled from the MDS. It also identifies care categories used to determine the appropriate level of care and resources required for each resident. The matrix is completed by the facility and must reflect all residents 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 interview with family, a review of resident medical records, and interviews with facility staff, it was determined that the facility failed to hold care plan meetings at least quarterly. This was evident for 2 (Resident #13, # 2) out of 4 residents reviewed for care plans during the facility's recertification/complaint survey.The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). 1) On 9/8/25 at 12:44 PM, Resident #13's responsible party (RP) was interviewed. During 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 interviews with residents, review of medical records, and interviews with facility staff, it was determined that facility nursing staff failed to follow professional standards of nursing practice when documenting medications given to residents. This was evident for 1 (Resident #102) out of 2 residents reviewed for timely medication administration during the recertification/complaint survey.The findings include:It is the standard of nursing practice to document administered medications immediately after administration. Failure to do so can result in an inaccurate medical record where it cannot be determined when a medication was given and therefore has the potential to result in medication errors (such as a resident receiving a dose twice or two doses of a medication being given too close in time).On 9/8/2025 at 9:42 AM in an interview with Resident #102 s/he stated that the facility staff waited until his/her pain medications ran out or almost ran out before reordering them and so s/he received 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 interviews with residents, review of medical records, and interviews with facility staff, it was determined the facility staff failed to provide care and services to maintain or improve a resident's ability to carry out Activities of Daily Living (ADLs). This was evident for 1 (Resident #6) of 2 residents reviewed for rehabilitative or restorative services during the facility's recertification/complaint survey.The findings include:ADLs are the basic, essential self-care tasks individuals perform to maintain their daily lives such as hygiene, eating, mobility, and toileting.On 9/8/25 at 8:32 AM in an interview with Resident #6 s/he stated s/he had requested an exercise band several times and was not provided with one. When asked who s/he made the request to s/he stated some aides and nurses, both of whom said Rehab [rehabilitation department: physical therapy (PT), occupational therapy (OT), and speech therapy] would have to make that determination. S/he stated a nursing staff member coordinated a phone…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a medical record review, it was determined that facility staff failed to provide personal hygiene services to totally dependent residents. This was evident in 2 (Residents #96 and #42) of the 5 residents reviewed for activities of daily living (ADL) care during the recertification/complaint survey. The findings include: The Minimum Data Set (MDS) is a standardized screening and assessment tool for the health status of all residents in long-term care facilities that are certified to participate in Medicare or Medicaid. Activities of Daily Living (ADLs) are the basic, essential self-care tasks people need to perform to maintain their health, safety, and well-being, such as bathing, dressing, eating, and toileting. 1) During a phone interview on 9/08/25 at 9:53 AM. with Resident #96's responsible party, they reported that the resident had long toenails, and one had fallen off. On 9/10/25 at 11:23 AM, a surveyor observed Resident #96's toenail with Staff #21 (Registered Nurse).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 intake, resident and staff interviews and record reviews, it was determined that the facility failed to provide quality of care services to their resident secondary to a delay in medication administration and wound treatments. This was evident for 2 (Residents #2, #174) of 37 residents reviewed for medication administration and wound treatment during the recertification/complaint survey.The findings include: 1) On 09/11/2025 at 2:39 PM review of a complaint incident #2580727 alleged that Resident #2's medications are given late and that this happens a lot. In an Interviews with Resident #2 on 9/9/25 at 9:30AM regarding late medication administration. The resident blamed it on the agency staff that the facility frequently uses and stated that his/her medications are given late most of the time. On 9/9/25 at 9:45 AM a review of the August 2025 Medication administration records (MAR) did confirm that numerous medications (Meds) were given 2-4 hours late on different days. For instance, on:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interviews, it was determined that the facility failed to provide adequate fall risk assessments for residents who experienced frequent falls. This was evident in the cases of 3 residents (Resident #15, #16, and # 94) out of the five reviewed for fall risks during the recertification/complaint survey. The findings included: 1) During an interview with Resident #15 on 9/08/25, at 8:41 AM, the resident reported a fall that led to a hospital transfer a couple of months prior. An observation of the resident's room revealed the bed was high, with no fall mat or other precautions in place. A review of Resident #15's medical record on 9/09/25, at 1 PM, showed the resident was found on the floor beside the bed on 7/22/25, at 9:23 PM. The resident complained of hip pain and was transferred to the hospital for evaluation. Imaging at the hospital revealed a partial dislocation of the left arm and a compression fracture in the spine. The resident was re-admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the resident's medical records and interviews with facility staff, it was determined that the facility failed to address a significant weight loss for a resident. This was evident for one (Resident #9) of 2 residents reviewed for nutrition during the recertification/complaint survey.The findings include:During an interview with Resident #9 on 09/08/25 at 11:10 AM, the resident reported a weight loss.A review of Resident #9's medical records on 09/09/25 at 8:32 AM revealed that the resident had experienced significant weight loss multiple times while residing in this facility: On 03/12/25, weight was 127.2 lbs. (via mechanical lift). On 03/27/25, weight was 111.4 lbs. (via mechanical lift). This was a loss of 15.8 lbs. (12.4%) within 15 days. The resident remained in the facility and was not transferred to a hospital or for a procedure. On 06/06/25, weight was documented as 105.2 lbs. (via wheelchair). On 06/11/25, weight was 100 lbs. (via lift). This was a loss of 5.2 lbs. (4.9%) within 5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 investigating complaints, medical record review, and staff interview it was determined that the facility failed to provide pain management timely. This was found to be evident for one (Resident #178) out of 10 residents reviewed for pain management during the recertification/complaint survey. The findings include: A complaint review on 09/11/25 at 9:00 AM showed that a complainant reported that Resident #178 experienced severe pain from approximately 9:00 PM on 05/12/24 until 10:20 AM on 05/13/24. The resident was reported to have cried and screamed in pain, but no pain assessment or medication was provided. On 9/11/25 at 9:57 AM, a review of Resident #178's medical records revealed that the resident was alert and oriented with a BIMS score of 15/15. A progress notes dated on 5/12/24 at 10:58 AM documented that the resident complained of bilateral leg pain with a pain level of 10/10, indicating severe pain. Additional progress noted dated 5/12/24 at 15:10 (3:10 PM) documented that “…MD ordered routine typenol 1000mg q 12 hrs and Tylenol 650 mg q 6 PRN (as needed), Tylenol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to properly label and store drugs and biologicals. This was evident in 2 of 4 medication carts observed during the recertification/complaint survey. The findings include: According to the CDC and American Diabetes Association (ADA) recommend refrigerating unopened insulin at 36-46 F (2-8 C) until the expiration date, while opened insulin vials can be kept at room temperature (below 86 F or 30 C) for about 28 days, depending on the manufacturer's guidelines. The standard of practice requires that, when opened, a vial or pen of insulin would be labeled with both an opened date and or a discard after date which is 28 days later.On [DATE] at 10:55 AM, during an observation of the 2nd floor East Hall medication Cart accompanied by Staff #35 (Agency Nurse) revealed the following: 1) A unsealed Lantus 100 unit/ml vial labeled with Resident #192's name and not labeled with the date it was opened.2) An opened box of Ipratropium/Solution Albuterol (a…

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

Based on clinical record review, review of facility report incidents, and staff interview it was determined that the facility staff failed to ensure residents' clinical records were complete and accurate. This was evident for 3 (Residents #4, #137, #190) residents out of the 74 in the survey sample of the recertification/complaint survey. The findings include: 1) During a recertification/ complaint survey conducted from 09/08/2025 through 09/16/2025 a review of facility complaint MD# 333479 was conducted. Review of the intake information revealed that the Baltimore County Fire Department was requested by the facility for a potential overdose of Resident #190 on 09/25/24. The Emergency Medical Response team complained that the facility did not allow them to review the residents' medication administration sheets. On 9/11/25 at 10:01 AM a review of the Resident #190's medical record noted that Oxycodone HCL Oral Tablet 10 MG (Oxycodone HCl) was ordered on 9/13/24, discontinued on 9/17/24 and reordered on 9/17/24 and placed on hold on 9/25/24 to 9/26/24. The narcotic count sheet…

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

Based on record review and staff interview, it was determined that the facility failed to offer pneumococcal vaccine as appropriate for residents. This was evident for 1(Resident #2) of 5 residents reviewed for immunizations during the recertification/complaint survey.The findings include:On 9/12/15 at 1:00 PM a review of Resident #2's immunization records failed to show that a pneumococcal vaccine which protects against Pneumonia, a lung infection, was offered to the resident or that resident refused and was educated.On 9/12/25 at 2:15PM Staff #3 the Infection Preventionist (IP) was asked if the facility offers the Pneumococcal vaccine to their residents. She stated that they do offer it on admission. She was asked if Residents #2 was offered the vaccine and she said she will check.On 9/15/25 at 10:44 AM Staff #3 provided a Pneumococcal vaccine Informed consent form dated 9/15/25 and said that the vaccine was not offered initially to the resident on admission and that she just spoke with Resident #2 who consented to get the pneumonia vaccine. She was made aware that it was a…

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

Based on record review and staff interviews, it was determined that the facility failed to offer COVID-19 immunization as required or appropriate for residents. This was evident for 2 (Residents #1 and #2) of 5 residents reviewed for immunizations during the recertification/complaint surveyThe findings include:A Covid -19 vaccine is a vaccine intended to provide acquired immunity against severe acute respiratory syndrome Coronavirus 2.On 9/12/15 at 1:00 PM review of Resident #1 and #2's immunization records failed to show that a Covid 19 vaccine was offered to the residents or that both refused and were educated. Further review did not produce the missing documents.On 9/12/25 at 2:15PM Staff #3 the Infection Preventionist (IP) was asked if the facility offered Covid -19 immunizations to their residents and she said they do and explained that they offer it on admission. She was asked if both residents were offered the Covid-19 Immunization on admission and she said she would check and get back to the surveyor.On 9/15/25 at 10:44 AM Staff #3 provided two Covid-19 vaccine consent forms…

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

Based on review of employee files and staff interview it was determined that the facility failed to demonstrate the implementation of a process to track nurse aide participation in required training's to ensure all nurses' aides received 12 hours of training that included abuse prevention and Dementia management, annually and addressed areas of weakness as determined in nurse aides' performance reviews. This was evident for 2 (GNA # 16 and #17) of 5 employees' files reviewed during this recertification/complaint survey.The findings included:On 9/11/25 at 9:40 AM, a surveyor reviewed five randomly selected Geriatric Nursing Assistant (GNA) employee files, which revealed the following: GNA #16: Hired in July 2024, this employee's training records show that the second page of their abuse and neglect prevention training was not completed on 7/17/24. GNA #17: Hired in December 2022, this employee's training records contained no evidence that they received the required training in 2023.During an interview with Staff #3 (an educator) and the Nursing Home Administrator (NHA) on 9/11/25 at…

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

Based on observations and interviews with facility staff, it was determined the facility failed to provide a clean and comfortable environment for residents. This deficient practice has the potential to affect all residents residing at the facility and was found to be evident during the facility's Medicare/ Medicaid recertification survey. Findings include: On 7/18/23 at approximately 11:00 AM, an observation was made of the hallways on the first and second floor. The rugs, that were the length of the entire hallway, had large dark brown stains noted throughout length of the carpet. There was also a pungent odor present. The surveyor walked the hallways with the Director of Nursing (DON), and she confirmed that the carpet in the hallways needed cleaning and that the carpet would be replaced. On 7/19/23 at 1:15 PM, an observation was made of the linen carts on the first floor hallway. There were large dark colored drippings noted on the side covers of the cart. There was linen on the shelves of the cart. An environmental staff, that was in the hall at the time, was asked who was…

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

Based on administrative record review and interviews with facility staff, it was determined the facility failed to 1.)perform quarterly interdisciplinary care plan meetings for Resident # 92, 2.) update the care plan to the address the specific needs for Resident # 103, a cognitively impaired resident that experienced sexual contact by a cognitively intact resident, and for resident # 166 that was administered Narcan for substance abuse. This was found to be evident for 3 of 90 residents reviewed during the investigation stage of the facility's annual Medicare/Medicaid survey. Findings include, 1. On 07/24/23 at 2:57 PM, a review of Resident #92's electronic medical record (EMR) revealed the resident did not have quarterly care plan meetings. The most recent meeting was held on 07/13/23 at 2:10 PM. The care plan meeting prior was held on 12/28/22 at 1:30 PM. The meeting prior to the December 2022 meeting was held on 08/24/22. During an interview with Licensed Master Social Worker (LMSW) #26 on 07/24/23 at 3:11 PM, they stated that resident care plan meetings are held quarterly. When…

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

Based on the medical record review and staff interview, it was determined the facility, 1.) failed to ensure that medications were administered to residents (#684, and # 438) as prescribed by the physician, 2.) failed to ensure that psychiatric consultations were done as ordered by the physician for resident (#123 and # 103) and 3.) failed to ensure that a Peripherally Inserted Central Line (PICC) was removed for resident (# 165) prior to discharge. This was evident for 5 residents of 90 residents reviewed during the investigation stage of the facility's annual Medicaid/Medicare survey. The findings include the following: 1. Ezetimibe is a medication used to lower high cholesterol levels. O 07/14/23 at 9:00 AM, a review of resident's (#684) medical record revealed that a physician ordered on 12/08/2022 to administer medication Ezetimibe tab 10 mg, give 1 tab by mouth one time a day, for cholesterol. Review of the 06/2023 Medication Administration Record, on 06/18/2023, 06/19/ 2023 and 06/21/2023 revealed that medication Ezetimibe was not documented as given to resident. On 7/14/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records and interview with staff, it was determined that the facility failed to: 1.) ensure pharmacy recommendations to nursing were addressed during the monthly pharmacy reviews 2.) ensure the monthly reviews were reviewed by the physician and that the physician acted on and addressed irregularities identified by the pharmacist. This was found to be evident for 3 (R#106, #37 and # 10 ) out of the 5 residents sampled for medication regimen review during the facility's Medicare/Medicaid recertification survey. The findings include: 1. On 8/4/23, Resident #106's medical records were reviewed and revealed that the resident was admitted to the facility in September 2023 for long term care. Review of the medication revealed the following: Hydroxyzine as needed, Seroquel, Remeron and Venlafaxine. Continued medical record review revealed that, on 12/29/22, 3/21/23, 6/29/23, the pharmacist recommended an Abnormal Involuntary Movement Scale (AIMS) test be performed at least every 6 months due to the prescribed medication Seroquel, an antipyschotic. Antipsychotics…

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

Based on medication administration observation, medical record review, and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 %. This was evidenced by 6 errors observed during the medication administration of 31 opportunities for errors, that resulted in a medication error rate of 19.35%. This was found to be evident for 3 (R #101, # 99 #55) out of 5 residents observed during the medication administration. The findings include: 1. On 7/10/23 at 11:30 AM, surveyor observed a red/pink medication administration screen during medication administration. The surveyor asked what that color screen indicated and LPN #100 revealed that it meant the medication was late or they hadn't signed off the medicine administration. On 7/10/23 at 11:40 AM, LPN #100 was observed on the 2nd floor nursing unit preparing the following medications for Resident #101: Depakote 500 milligram 2 times a day due at 9 am, given at 11:35 AM Keppra 750 milligram 2 times a day due 9am, given 11:37 AM Doxycycline 100 milligram by mouth 2 times day at 9 am,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interviews with facility staff, it was determined the facility failed to ensure that complete and accurate records were maintained for residents. This was found to be evident for 3 (Resident # 240, # 92, and # 438) of 90 residents reviewed during the investigation stage of the facility's Medicare/Medicaid recertification survey. Findings include: 1. Intake # MD00174320 was reviewed on 7/25/23 for allegations of abuse. According to the facility's investigation, on 11/13/21, GNA # 31 reported that upon entering the facility's dining room, she observed Resident # 103 sitting on the lap of Resident # 240 who was in a wheelchair. Resident # 240 was observed with his/her pants lowered and Resident # 103 was wearing a gown. The staff immediately separated the residents and notified the supervisor. The staff stated that she did not see any genitalia exposed from either resident. Skin checks were done, and no concerns were noted. On 7/26/23 at 1:00 PM, during an interview with the DON, she stated that Resident # 240 was placed on one-to-one…

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

Based on the record reviews and interviews, it was determined that the facility failed to that ensure 4 Geriatric Nursing Assistants (GNA)s received the required 12 hours of in-service training. This was found to be evident for 4 (GNA #11, #21, # 53, # 56) out of 5 employees reviewed for annual GNA training reviewed during the recertification survey. The findings include: On 07/20/2023 at 10:17 AM, The Director of Nursing (DON) #2 presented the surveyor with copies of the educational and human resources records for 5 employees. A discussion was held with the DON and the nursing home administrator (NHA) regarding the annual training requirements for GNAs. A minimum of 12 hours of nurse aide training per year are required. A record review of the human resources files for the following staff members on 07/21/23 at 09:30 AM revealed: 1. Staff # 11, Geriatric Nursing Assistant (GNA's) human resources file failed to show the required 12-hour clinical training between 06/15/21 through 08/22/23. 2. Staff # 21, (GNA)'s human resources file failed to show the required 12-hour clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, administrative review, and interview with facility staff, it was determined that the facility staff failed to: 1.) Promote respect and dignity of a cognitively impaired resident when an employee posted a picture of the resident on a mobile photo-sharing application and social network and 2.) promote care for a resident in a manner and in an environment that maintained or enhanced the resident's dignity and respect. This was found to be true for 2 (R#48 #76) out of 5 residents reviewed for dignity. The finding include: 1. Medical records review on 8/8/23 at 1030 AM revealed that Resident #48 was admitted to the facility with diagnoses that included, but were not limited to, Dementia and Depression. Review of the Quarterly MDS Assessment, dated 4/17/23, revealed that the facility staff entered a Brief Interview for Mental Status (BIMS) score of 6 out of 15. BIMS is an assessment that assists staff in determining a resident's cognitive status. A score of 00-07 indicates severe impairment. Review of the investigation notes revealed that the…

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

Based on observation and interviews, it was determined that the facility failed to provide a dignified existence to a vulnerable resident. This deficient practice was evidenced in 1 (#92) of 2 residents reviewed for dignity during a Medicare/Medicaid recertification survey. The findings include: During the initial observation rounds on 07/10/23 at 9:52 am, the surveyor observed Resident #92 sitting on the side of the bed with his/her hair and clothes in disarray. There was a urinal on the bedside table and spilled urine on the floor near the distal part of the bed. The wheelchair had brown matter around both wheels. On 07/18/23 at 10:25 am, the surveyor went to Resident#92's room and observed him/her lying in bed; the bottom of his/her feet were brown. There were two 120 ml cups of urine on the bedside table. When the resident transferred to the wheelchair, the surveyor observed a large wet spot on the back of his/her pants and the resident's hair was not combed. On 07/18/23 at 11:29 am, during an interview with Director of Nursing #2 reported that every resident had a shower…

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

Based on the medical record review and staff interview, it was determined the facility failed to notify the physician of a medication that was not administered to a resident. This was evident for 1 resident (#64) out of 8 residents reviewed at the time of the survey. The findings include the following: On 07/14/23 at 9:00 AM, review of resident #64's medical record revealed that a physician ordered on 12/08/2022 to administer Ezetimibe tab 10 mg give 1 tab by mouth one time a day for cholesterol. During the review of the 06/2023 Medication Administration Record, on 06/18/2023, 06/19/2023 and 06/21/2023, it was noted that medication Ezetimibe was not given to resident (#64). There was no documentation provided or found verifying that the doctor was made aware that the medication was not given. During an interview on 07/14/23 at 12:30 PM with Director of Nursing (DON) #2 , she stated that there was no documentation that the physician was made aware that the medication Ezetimibe was not administered to the resident (#64).

Based on administrative and medical record review and interviews with facility staff, it was determined the facility failed to ensure that a resident was kept free from physical restraints. This was found to be evident for 1 (Resident # 150) of 28 residents reviewed for abuse during the facility's annual Medicare/Medicaid survey. Findings include: Intake # MD00188916 was reviewed on 8/8/23 for allegations of abuse. According to the facility's investigation and a statement by staff # 62, a Registered Nurse (RN) stated that, on 2/12/23, he placed a sheet around resident # 150's Geri chair and tucked a sheet and blanket snugly around the resident and brought the resident close to the nurse's station. Resident # 150 was redirected to sit down upon standing and staff # 62 stated the resident was not restrained. Review of resident # 150 care plan on the same date reveals the resident was resistive to care, had cognitive and self-care deficits, history of falls and poor balance. During an interview with staff # 63 on 8/8/23 at 3:03 PM, she stated that, on 2/12/23, resident # 150 kept…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and medical record review and interviews with facility staff, it was determined the facility staff failed to report allegations of abuse to the State Office and Certification Agency. This was found to be evident for 2 (Resident # 103 and Resident # 144) of 28 residents reviewed for abuse during the facility's annual Medicare/Medicaid survey. Findings include: 1. Intake # MD00174320 was reviewed on 7/25/23 at 10:00 AM for allegations of abuse. According to the facility's investigation, staff # 31 reported observing resident # 103 sitting on the lap of resident # 240 who was sitting in their wheelchair. The two residents were alone in the dining room at the time of the observation. Resident # 240 was observed with his/her pants lowered and resident # 103 had on a gown. Staff # 31 immediately separated the residents. On 7/25/23 at 3:40 PM, a phone interview was conducted with staff # 31, a Geriatric Nurse Assistant (GNA) and she was asked about the incident that occurred on 11/13/21. She stated the following: On 11/13/21 at approximately 8:00 PM in the evening,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interviews with facility staff it was determined the facility failed to thoroughly investigate abuse allegations. This was found to be evident for 1 Resident # 103 of 28 residents reviewed for abuse during the facility's annual Medicare/Medicaid survey. Findings include: Intake # MD00188482 was reviewed on 7/25/23 at 10:00 AM for abuse allegations. According to the facility's investigation, staff # 31 reported observing resident # 103 sitting on the lap of resident # 240 who was sitting in their wheelchair. The two residents were alone in the dining room at the time of the observation. Resident # 240 was observed with his/her pants lowered and resident # 103 had on a gown. Staff # 31 immediately separated the residents. A phone interview was conducted with staff # 31, a Geriatric Nurse Assistant (GNA) on 7/25/23 at 3:40 PM and she was asked about the incident that occurred on 11/13/21 and she stated the following: On 11/13/21 at approximately 8:00 PM in the evening, she was going through the dining room to get to her locker, and she heard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interviews, it was determined the facility failed to ensure that residents were ordered treatments according to professional nursing standards. This deficient practice was evidenced in 2 residents (#78, #238) of 3 records reviewed for oxygen and/or colostomy orders reviewed during the Medicare/Medicaid recertification survey. The findings include: According to the Maryland Nurse Practice Act guide that governs nursing practice in the state of Maryland. Registered Nurses, Licensed practical Nurses, and certificate holders are expected to practice within the established regulations defined by the Nurse Practice Act. According to 10.27.09.03 (A) (1) The RN systematically shall evaluate the quality and effectiveness of nursing practice in the aggregate. According to 10.27.10.02 B (1) (a) (c) (iii) the LPN contributes to the nursing assessment by collecting data of the client through direct observation; from the review of the client's medical records including, but not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff, and family interview, it was determined that the facility staff failed to follow their own policies and procedures related to the use of siderails Additionally, the facility failed to obtain a physician's order for continued use of the siderails. This was evident for 1 of 1 (resident #144) reviewed for siderails. The findings include: Entrapment: An event where a resident becomes caught, trapped or entangled in the space in or about the bedrail. A review of Resident #144's medical record on 07/11/23 revealed the resident was admitted to the facility in December 2018 and totally dependent upon staff. The attending physician determined the resident to be lacking decision-making capacity (the ability to consent to treatment) on 10/09/20. On 08/18/23 at 12:30 PM, a review of Resident #144's medical records revealed that on 12/15/18, the resident was admitted with an order for side rails, however, there was no indication for their use. On 12/17/18, the order was discontinued, however,…

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

Based on record review and interviews, it was determined the facility failed to ensure that a Certified Nursing Assistant (CNA) received training to become a Geriatric Nursing Assistant (GNA) within the required 4-month timeframe. This was evidenced in 1 of 5 CNA/GNA employee records reviewed during the annual survey. The findings include: On 08/03/23 at 2:24 PM, during an interview with CNA#90, he/she reported receiving his/her CNA certificate in September 2022 and has been working at the facility since October 2022. On 08/03/23 at 2:45 PM, a review of CNA #90's employee file revealed the staff member was a CNA, which was confirmed on the Maryland Board of Nursing website. On 08/03/23 at 3:15 PM, during an interview with Director of Nursing #2, she stated the facility employed two CNA's. On 08/07/23 at 2:11 PM, during an interview with Human Resources Director (HRD) #16, the facility sponsored the two employees to go through a learning center to become Geriatric Nursing Assistants. They were supposed to see them through the certification process. HRD # 16 verbalized being aware…

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

Based on record review and interviews, it was determined that the facility failed to ensure that staffing information was complete and accurate. This deficient practice was discovered during the Medicare/Medicaid survey. The findings include: On 07/20/23 at 9:40 AM, a review of the assignment sheets received from the Director of Nursing #2 on 07/19/23 at 1:55 PM revealed the assignment sheets for 07/10/23 were not completed for Station 2 during 3PM -11 PM and 11PM-7AM shifts. The assignment sheet for 07/19/23 and 07/20/23 Station 1 7-3 PM shift were incorrect and did not have GNA #67 on the schedule. On 07/20/23 at 11:55 AM, the surveyor went to Station 1 to verify that GNA #67 was working, spoke with the Unit Manager (UM), LPN (#19) and she verbalized the GNA was working in the dining area assisting with lunch. The surveyor walked to the dining room and observed GNA # 67 in the dining area. The UM reported the staff was on light duty; she served the resident's drinks on the unit, assisted with giving meals, and does vital signs. She was not on the schedule because she was on light…

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

Based on medical record review and interviews with facility staff, it was determined the facility failed to keep a resident free from unnecessary psychotropic medications. This was found to be evident for 1 (Resident #106) of 5 residents reviewed for unnecessary medications during the facility's Medicare/Medicaid recertification survey. The findings include: On 8/3/23 at 11:30 AM, Resident #106's medical records were reviewed and revealed the resident was admitted to the facility with the following, but not limited to diagnoses: major depressive disorder (single episode) and anxiety disorder. Further review of the medical records revealed an order for Seroquel 200 milligram every night for depression, Mirtazapine 7.5 mg every night for depression and Venlafaxine 37.5 mg every day for depression. Continued review revealed a psychiatrist NP #97 note, dated 3/15/23, regarding follow-up on psychiatric issues of anxiety, depression, and insomnia and assessment, plan, orders and a recommendation to begin a slow gradual dose reduction of medication as the resident had been without 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 medical record review and family and staff interview, it was determined the facility failed to ensure that a resident was free of significant medication error as evidenced by the failure of the nurse to verify the correct dosage and/or medication prior to administration. This was evident for 1 (Resident # 10) of 6 residents reviewed during the annual survey for medications. The findings include: Diazepam used to treat anxiety disorders and severe muscle spasms, and spasticity associated with neurologic disorders. Methadone is an opioid medication used to treat severe pain and opioid addiction. When used to treat severe pain, methadone is available as a tablet or oral solution. Resident #10 was admitted to the facility with diagnoses that included, but were not limited to, Muscular Dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass) and anxiety disorder (persistent and excessive worry that interferes with daily activities). The resident was alert and oriented and cognitively intact. Complaint MD000179262 alleged that Resident #10 received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to store food and fluids in accordance with professional standards for food service safety, during the annual survey. The findings include the following: On 07/10/23 at 09:10 AM, An initial tour of the facility Kitchen was completed with Dietary Manager staff (#4) and the following was found: 1. Expired fluids noted in the facility's dry storage room that included: (6) boxes of Thickened Orange Juice from Concentrate, moderately thick that had expired on 06/14/2023. (4) boxes of Thickened Lemon-Flavored Water, moderately thick that had expired on 06/19/2023. (3) boxes of Thickened Apple Juice from Concentrate, moderately thick that had expired on 5/08/2023. 2. A bread crate containing bread was found directly on the facility's dry storage room floor. 3. Ice buildup was noted on the floor in the facility's kitchen walk-in freezer. 4. Raw meat was found uncovered in the facility's walk-in refrigerator (#1). 5. A red color substance was noted to have spilled all over metal shelves in the facility's walk- in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of medical records and facility policy, and interviews with facility staff, it was determined that the facility failed to ensure an effective infection control precaution during an outbreak of COVID-19 in the facility. This was evidenced by a nursing staff entering a COVID-19 isolated room without applying adaptable Personal Protective Equipment (PPE). The findings include: An N95 mask (respirator) is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles. On 10/23/23 at 08:10 AM, the facility's receptionist stated that the facility was currently in a COVID-19 outbreak. At 9:30 AM, during the initial tour of the facility, the surveyor observed that some of the residents' rooms had a sign of contact/droplet precaution on the 2-south unit. In the hall of each unit, a PPE drawer was placed with disposable gowns, N-95 masks, and hand sanitizers. On 10/24/23 at 8:51 AM, the surveyor observed a Geriatric Nurse Aide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, it was determined the facility failed to maintain effective pest control as evidenced by gnats in the residents rooms. This deficient practice was evidenced in 2 resident rooms (234 & 236) during the annual survey. The findings include: During observation rounds on 07/10/23 at 09:31 AM, the surveyor observed dozens of gnats flying around the living space of Resident #42 in room [ROOM NUMBER]. The gnats were observed flying around the light above the bed, on left side of curtain of the bed, and the trashcan. On 07/10/23 at 9:35 AM, Occupational Therapy Assistant #13 confirmed the surveyor's findings. On 07/10/23 at 9:44 AM, while the surveyor was in room [ROOM NUMBER], gnats were observed flying around in the bathroom. On 07/20/23 at 12:59 PM, during an interview with Maintenance Director #29 the facility does have a contract with a pest control company. The last time the company had been in the facility was 07/14/23; they treated three rooms for gnats not including room [ROOM…

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

Based on record reviews and staff interviews, it was determined that the facility failed to ensure that annual 12-hour competency training and annual Dementia and Behavioral Health training for geriatric nursing assistants (GNAs) were provided. Additionally, the facility failed to ensure that a computerized educational training program, Relias, was available to their staff to ensure mandatory annual training on abuse, resident neglect, and resident rights, as well as training related to the topics previously mentioned, were kept up to date for all employees. This was evident to be true for 4 (GNA #11, #21, # 53, # 56) out of 5 employees reviewed for annual GNA training. This deficient practice resulted in the facility employing GNAs who were not clinical prepared to care for all types of residents. The findings include: A review of the human resources files for the following staff members revealed: 1. Staff # 11, GNA's human resources file failed to show any dementia or behavioral health training completed between the years, 06/15/21 through 08/22/23. Additionally, the total number…

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

Based on the record reviews and interviews, it was determined that the facility failed to ensure the behavioral health and dementia training for geriatric nursing assistants (GNAs) were provided. This was evident to be true for 4 (GNA #11, #21, # 53, # 56) out of 5 employees reviewed for annual GNA training. The findings include: On 07/20/2023 at 10:17 AM, the Director of Nursing (DON) #2 presented the surveyor with copies of the educational and human resources records for 5 employees. A discussion was held with the DON and the nursing home administrator (NHA) regarding the annual training requirements for GNAs. The NHA #1 stated that the facility was working with a hospice organization to create a dementia training program for all facility staff. The NHA #1 stated that staff members were not receiving dementia training (including GNAs). On 07/21/23, a review of the human resources files for the following staff members revealed: 1. Staff # 11, geriatric nursing assistant's (GNA) human resources file failed to show that any dementia or behavioral health training was completed between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 while conducting the initial kitchen tour and observation of the walk-in refrigerator, it was determined that the dietary and facility staff failed to maintain the refrigerated food in a clean and sanitary manner. The findings included: On 1-16-19 at 8:50 AM during the initial kitchen tour with the Dietary Manager: The walk-in refrigerator had Jello and pudding stored in individual bowls without a cover. The pureed oatmeal was half covered and the shelf above had dried debris and lunch meat stored. The dessert refrigerator had 2 carrot cakes stored with out a covering to prevent against contamination. These findings were discussed with the Dietary Manager on 1-16-19 during the tour.

Based on observation and interview, it was determined the facility staff failed to maintain a resident's (#105) privacy. This was evident for 1 of 5 residents investigated for dignity. The findings include: On 1-16-19 at 12:16 PM with Unit Manager #4 it was confirmed that the facility had thumb tacked to the bulletin board in their room a copy of Resident #105's physician orders, initial nursing assessment, and care plans. This private information was left in view of anyone in the room and was unsecured. Unit Manger #4 did not know why the information was left on the bulletin board.

Based on observation and interview it was determined the facility staff failed to honor 2 resident's choices. This was evident for 1 of 5 residents (#131) selected for review for advanced directives and 1 of 4 (#28) resident reviewed for choices. The findings include: 1. 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. Resident #131's MOLST dated 12-20-18 and completed with his/her physician stated he/she did not want to have medical tests performed including blood drawn for laboratory testing. The physician ordered laboratory tests to be performed on 12/20/18, 12-30-18, 1-1-19, 1-3-19, 1-6-19, and 1-8-19. During interview with Resident #131 at 9:50 AM revealed he/she Stated sure it's okay to draw blood for laboratory testing. During interview with Physician #3 on 1-18-19 at 12:40 PM stated he/she wrote the MOLST with no laboratory tests to be performed because…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and facility policy review, it was determined that the facility failed to provide a safe, clean, comfortable homelike environment. The findings include: 1. On 1/16/2019 at 9:40 AM surveyors observed cracked caulking around the bathroom sink of room [ROOM NUMBER]. 2. On 1/16/2019 at 11:55 AM surveyors observed soiled chairs along with multiple chips and holes in the walls of room [ROOM NUMBER]. 3. On 1/16/2019 at 12:55 PM surveyors observed spills and debris on the floor of room [ROOM NUMBER]. 4. On 1/17/2019 at 8:26 AM surveyors completed a walkthrough of room [ROOM NUMBER] and identified multiple environmental issues. The table acting as the residents TV stand in room [ROOM NUMBER] was soiled and had multiple brown stains from spilled drinks. The heating unit under the window was observed to have broken fins and the linens on Bed A had multiple brown stains. A pile of soiled, wet, white rags with brown stains was observed piled in the corner of room [ROOM NUMBER]'s bathroom. The rim 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 record review and staff interview it was determined that the facility failed staff to provide residents and or their representative (RP) with the proper paper documentation of the facilities bed hold policy. This was evident for 1 (Resident 142) out of 3 residents reviewed for discharge during the investigative portion of the survey. The findings include: A bed hold policy is written information to the resident or resident representative that specifies the duration that the resident is permitted to return and resume residence in the nursing facility. It is given before a nursing facility transfers a resident to a hospital or the resident goes out on therapeutic leave. A medical record review for Resident #142 was conducted on 01/22/19 at 8:30 AM. Review of a progress note written on 10/14/18 revealed that the resident had an unplanned transfer to an acute care hospital. Further review of the medical record revealed that a copy of the facility's bed hold policy was not given to the resident or their RP. During an interview with the Administrator on 01/22/2019 at 1:15 PM 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 staff failed to initiate, provide and implement comprehensive care plans for residents. This was evident for 3 (Residents #23, #342 and #13) of 54 residents selected for review during the annual survey process. 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. Medical record review for Resident #23 revealed the resident was admitted to the facility on [DATE] with diagnosis that included but not limited to seizures. A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness. It was further noted; the facility staff assessed the resident on 10/9/18 and 1/8/19 and completed on the MDS-Section I 5400-Active Diseases: Y-Seizure Disorder- Yes. The Minimum Data Set (MDS) is part of the federally mandated…

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

Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure medical appointments were made for the residents (#52). This was true for 1 out of the 1 resident reviewed for communication and sensory issues. The findings are: Resident #52 was interviewed on 1/16/19 at 9:36 AM. Resident stated he/she was supposed to have had an appointment for glasses but has not as of that date. A review of the clinical record revealed that the primary physician wrote an order on 10/31/18 for: Please schedule for next optometrist appt & Podiatry. The Director of Nursing (DON) was interviewed on 1/22/19 at 11:06 AM. She was shown that the appointments have not been made nor was there evidence that an attempt to make the appointment was made. The DON confirmed on 1/22/19 at 12:27 PM that the appointment had not been made prior to this surveyor's review but she did share that appointments were made as a result.

Based on medical record review and interview, it was determined the facility staff failed to provide care in the highest practicable manner for Residents (#23 and # 116). This was evident for 2 of 54 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to thoroughly evaluate and determine if the correct blood test was ordered for Resident #23. Medical record review for Resident #23 revealed on 10/10/18 the facility staff obtained a potassium level with the results of 3.3 (normal range 3.5-5.5). Potassium is one of the most important minerals in the body. It helps regulate fluid balance, muscle contractions and nerve signals. At that time the physician was notified and ordered: potassium chloride 20 meq x 1 as a supplement to increase the potassium level. Further record review revealed the physician ordered laboratory blood work for 10/11/18. The facility staff took the laboratory blood test as BNP (Brain natriuretic peptide -BNP test is a blood test that measures levels of a protein called BPN that is made by your heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review and staff interview it was determined that the facility staff failed to ensure residents were being turned and repositioned as ordered. This was true for 1 out of 4 residents selected to be reviewed for pressure ulcers. The findings are: A review of Resident #28's clinical record revealed the primary physician wrote an order for the resident to not remain on his/her back. This surveyor observed on 1/16/19 at 11:16 AM a sign on the resident's wall behind the bed saying that the resident should stay on his/her back. The resident was observed on 1/18/19 at 9:37 AM, 11:07 AM, and 1:30 PM to be on his/her back. The Director of Nursing was interviewed on 1/22/19 at 11:02 AM. The observations were shared with her and she acknowledged what was said.

Based on medical record review and interview, it was determined the facility staff failed to obtain weights as ordered on Resident #109. This was evident for 1 of 54 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #109 revealed on 12/30/18 (a Sunday) the physician ordered: weigh every week on day shift on Wednesday for 4 weeks then monthly. Further record review revealed the facility staff failed to weigh the resident on 1/2/19 (Wednesday). On 1/3/19 at 4:25 PM, the physician ordered: weigh 1/4/19; however, the facility staff failed to obtain the weight as ordered by the physician. On 1/7/19, the dietician in collaboration with the physician: ordered weigh 1/8/19; however, the facility staff failed to obtain the weight as ordered. (Of note, the facility staff obtained weight on 1/9/19). As noted, the documented weights obtained by the facility staff: 12/8/18: 161.8 (Saturday), 12/12/18: 157.6 (Wednesday)' 12/21/18: 153.5 (Friday) a 5.13. % noted weight loss 1/4/19: order to obtain weight, 1/8/19: order 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 medical record review and interview, it was determined the physician failed to determine the significance and need of an ordered laboratory blood test for Resident #116. This was evident for 1 of 54 residents selected for review during the annual survey process. The findings include: Medical record review for Resident # 116 revealed on 12/8/18 the physician ordered: Eliquis 5 milligrams by mouth 2 times a day for A fib. Atrial fibrillation (A Fib) is the most common type of irregular heartbeat. The abnormal firing of electrical impulses causes the atria (the top chambers in the heart) to quiver (or fibrillate). It means the heart's normal rhythm is out of whack. Because the blood isn't moving well, blood can also pool inside the heart and form clots. Eliquis belongs to the group of medications called anticoagulants. Anticoagulants prevent harmful blood clots from forming in the blood vessels. They do this by reducing the ability of the blood to clot. Eliquis may also be used to prevent stroke or blood clots in people with atrial fibrillation. Further record review 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 review of employee files and staff interview, it was determined that the facility failed to provide at least 12 hours of nursing aides' in-services within a year. This was evident for 3 of 5 randomly selected staff members reviewed during an annual recertification survey. The findings include: Review of the facility assessment on 01/18/19 revealed the facility does care for residents that suffer from cognitive, behavior, and substance abuse issues. 1) Review of Employee #13's employee and education records on 01/22/19 revealed Employee #13's only received 4 hours of nursing aides' in-services in 2018. It was also noted that Employee #13 did not receive any additional dementia training in 2018. 2) Review of Employee #14's employee and education records on 01/22/10 revealed Employee #14's only received 4 hours of nursing aides' in-services in 2018. It was also noted that Employee #14 did not receive any additional dementia training in 2018. 3) Review of Employee #15's employee and education records on 01/22/19 revealed that Employee #15 did not receive any hours of nursing…

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

Based on review of the medical record, facility policies, and staff interview it was determined that the facility failed to have an effective system in place to ensure pharmacists' review recommendations were addressed and acted on by the physicians in a timely manner. This was found to be evident for 1 (Resident #342) of 3 residents reviewed for drug regimen review during the investigative portion of the survey. The findings include: On January 22, 2019 at 10:52 AM a medical record review was conducted for Resident #342. The resident was admitted in December 2018 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), and chronic pain. Review of the Medication Administration Record (MAR) for the month of January 2019 revealed that the resident had orders for 2 types of laxatives, (Miralax and Glycolax). In addition, surveyor noted that the resident received 2 types of breathing medications, (Breo and Fluticasone). A review of the January 15, 2019 pharmacist review consultation report for Resident #342 confirmed the duplicate therapies and recommended that the…

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

Based on review of the medical record, facility policies, and staff interview it was determined that the facility failed to have an effective system in place to ensure residents are free from unnecessary drugs. This was evident for 1 (Resident #342) of 3 residents reviewed for Unnecessary Medications during the survey. Findings include; A review of the pharmacist review consultation report dated January 15, 2019 for Resident #342 was conducted on 01/22/19 at 11:19 PM. The report revealed that that pharmacist noted duplicate therapies for breathing medications; Breo and Fluticasone, and 2 types of laxatives; Miralax and Glycolax. Further review of the report revealed the pharmacist recommended that the resident's physician evaluate if one of the breathing medications and the Miralax order should be discontinued. However, review of the resident's medical record revealed that there was no order to discontinue the laxative. Further record review failed to indicate a reason from the resident's physician to not discontinue the Miralax as recommended. A review of the facility's Pharmacy…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to obtain a medication error rate less than 5%. This was evident for 1 of 4 residents observed for medication pass and 2 of 25 opportunities for error. The findings include: Error #1: The facility staff failed to administer medications to Resident #56. Medical record review for Resident #56 revealed on 1/19/18 the physician ordered: Duloxetine HCL delayed release 60 milligrams by mouth every day for depression. Duloxetine is used to treat depression and anxiety. Surveyor observation of medication pass on 1/17/19 at 8:10 AM revealed facility staff #16 failed to administer the medication to Resident #56. Error #2: The facility staff failed to administer medications to Resident #56. Medical record review for Resident #56 revealed on 4/10/18 the physician ordered: Vitamin D 3, 2000 international units by mouth, every day as a supplement. Vitamin D is essential for strong bones, because it helps the body use calcium from the diet. Vitamin D 3 can be taken as a supplement to improve…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff failed to ensure medications were kept in a locked and secured location (2nd floor). This was evident for 1 out of the 2 facility nursing stations. The findings include: It was observed on 1-18-19 at 9:30 AM that the medications for a discharged resident (#344) were left unsecured and unattended on the desk top of the 2nd floor nursing station. The following medications were left unattended ascorbic acid, risperdene, sertraline, melatonin, aspirin, iron, famotidine, eye drops timolol, dorzolamide, igtanoprost, and 2 bottles of liquid antacid. From 9:30 AM to 9:45 AM no facility staff were in the nursing station. Staff #3 returned at 9:45 AM and stated the practice is for the medicine aides to pull discharged resident's medication from their cart and place it at the nursing station until the registered nurse can inventory and remove them. On 1-18-19 at 9:45 AM Staff #3 confirmed the medications were left unattended and unsecured. On 1-18-19 at 10:00 AM the Administrator was notified of the medications…

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

Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record for a residents (#342 and #13) in the most complete and accurate form. This was evident for 2 of 54 residents selected for review during the annual survey process. The findings include: 1. 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. On 1-22-19 at 10:00 AM a review of Resident #342's medical record revealed that the physician had completed an initial History and Physical (H&P) on 1-2-19 and a followup visit on 1-8-19. The chart had a signed form from the physician that the work was dictated however the H&P and followup note were not on the medical record. Interview with Staff #9 on 1-22-19 at 10:00 AM confirmed the physician had dictated the visits but had not faxed to the facility to be included in the 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 observation and resident and staff interviews it was determined the facility staff failed to assess a Resident's (#343) ability to perform their own wound care. This was evident for 1 of 2 residents reviewed for infections. The findings include: During initial resident interview on 1-16-19 at 12:50 PM Resident #343 stated the staff have given him/her the supplies to complete the daily ordered care to the open areas on the skin where the external orthopeadic devices were attached to his/her lower extremities. Resident #343 had continued to complete the daily wound care since admission. On 1-18-19 at 1:30 PM Unit Manager #4 confirmed Resident #343 does his/her own wound care. Unit Manager #4 confirmed the facility nurses had signed on the treatment record that they completed the daily ordered wound care when in fact the resident had accomplished the wound care themselves. Unit Manager #4 also confirmed the facility had not assessed Resident #343's knowledge and ability to complete the ordered wound treatment unsupervised.