Pines Nursing And Rehab

Based on observation and interview, the facility staff failed to maintain the temperatures of the shower on the Wye Oak Unit. This was evident for 1 of 2 showers on the Wye Oak Unit and 1 of 4 nursing units observed during the complaint survey.The findings include:After review of a complaint about not having hot showers on the Wye Oak Unit, the Surveyor went to the Wye Oak shower room on 3/10/26 at 11:55 AM. The shower room contained 2 showers. The left shower water temperature was 87 degrees and the right shower was 110 degrees. The left shower faucet could not be turned towards H for hot.The Surveyor returned with the Director of Maintenance and Housekeeping (Staff #11) on 3/10/26 at 11:48 AM to the Wye Oak shower room. Staff #11 confirmed the left shower water temperature was 87 degrees and the faucet could not be turned toward H for hot. Staff #11 confirmed the water temperature should be between 100 and 120 degrees. Staff #11 stated he was unaware there was an issue with the left shower faucet. Observation of the Wye Oak shower room revealed there were no signs for staff not to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and documentation review, it was determined the facility failed to have an effective pest control program as evidenced by numerous gnats seen in resident rooms and on the unit. This was evident on 1 (Homestead) of 4 nursing units during a complaint survey.The findings include: On 3/9/26 at 9:06 AM observation was made of a gnat flying around in room [ROOM NUMBER]. There was also a soiled sheet sitting on top of the trashcan by the sink in the room. The sheet was covered with at least 9 gnats.Observation was made in room [ROOM NUMBER]. There were gnats flying around the toilet area.While on the Homestead unit frequent gnats were observed flying around in the hallway.On 3/10/26 at 8:35 AM observation was made of Resident #22 lying in bed. Empty plastic juice containers were on the bed tray table in front of the resident. Gnats were flying around Resident #22's chin. Staff #7 was called into the room, and she confirmed that gnats were sometimes present because staff did not remove…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 food was stored and prepared in a sanitary manner. This was evidenced by: (1) undated and unlabeled food items in the facility's kitchen refrigerators and freezers; (2) kitchen staff not wearing proper protective gear while preparing food for residents; (3) failure to label and date food items and monitor temperatures in all unit pantry refrigerators; and (4) water nesting on insulated plates and lids used to serve residents, as well as improper sanitization of kitchen sanitization buckets. These deficiencies were observed during the survey of the kitchen and have the potential to affect all residents.The findings include:Definitions:Tube feeding formula is a liquid mixture containing all the necessary nutrients-protein, carbohydrates, fats, vitamins, and minerals-that is delivered directly into the gastrointestinal tract via a feeding tube when a person cannot eat enough or has difficulty swallowing. Insulated plates and lids are food service equipment designed to be used together to 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.

Based on observations, interviews and record reviews, it was determined that the facility failed to use appropriate infection control practices such as 1) improper storage of clean linens 2) improper storage of urine specimen 3) improper storage of leftover pudding inside the medication cart and 4) failure to implement enhanced barrier precautions for residents with pressure ulcers. This was evident for 1) 1 of 1 linen cart 2) 1 of 4 medication storage refrigerators 3) 2 of 10 medication carts and 4) 2 of 2 (Residents #12 and #116) residents with wound sampled during the recertification survey.The findings include: 1) On 8/19/2025 at 6:12 AM, during an initial tour of the facility, the surveyor observed a cart in the hallway with exposed clean linens, with its cover flipped back. On 8/19/2025 at 6:18 AM, the surveyor informed Registered Nurse (RN #20) about the concern, and he/she acknowledged to cover the cart. On 8/19/2025 at 6:25 AM, a follow-up inspection was done and found that the linen cart remained uncovered. On 8/19/2025 at 6:50 AM, The Director of Nursing (DON) and 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 ensure there was an effective pest control program for the kitchen. This was evident during the survey of the kitchen. This deficiency has the potential to affect all residents.The findings include: On 08/19/2025 at 06:32 AM, this surveyor conducted an interview with the Dietary Manager regarding pest concerns in the kitchen. She reported that the primary issue observed in the kitchen was the presence of flies.On 08/29/2025 at 10:51 AM, this surveyor observed five flies that were flying above the food preparation area where Dietary [NAME] #44 was preparing crab cakes for the residents. On 08/29/2025 at 10:58 AM, this surveyor informed the part-time Dietary Director of the concerns regarding the flies. He confirmed his understanding of the issue.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview it was determined that the facility failed to ensure Residents were provided a dignified existence. This was evident for 14 (Resident #116, #84, #12, #91, #107, #57, #36, #14, #31, #21, #61, #115, #155 & #40) out of 38 Residents observed for dining during the recertification survey.The findings include: 1. During an interview with Resident #116 in his/her room on 8/19/25 at 1:58 PM a rapid knock occurred on the closed door, the door immediately opened and Geriatric Nursing Assistant (GNA) #3 entered the room. She yelled out, It's me and continued to the roommates (Resident #84) side of the room. Resident #84 was not in the room at this time. When Resident #116 was asked who the GNA was that entered the room he/she reported they had seen her before but didn't remember her name. During an interview with GNA #3 on 8/19/25 at 2:13 PM she reported that she went to the roommate's side of the room to get something for Resident #84. She said she should have identified herself 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 record reviews and interviews, it was determined that the facility failed to ensure the residents and the residents' representatives were offered the opportunity to develop an advanced directive. This was evident for 4 (Residents #12, #8, #3 and #40) of 7 residents reviewed for advanced directives during the recertification survey. The findings include: 1. An Advance Directive is a legal document in which a person specifies their wishes regarding medical treatment in situations where they may no longer be able to express informed consent. It can include instructions about end-of-life care and may appoint a healthcare proxy (someone to make medical decisions on their behalf). A BIMS assessment is the Brief Interview for Mental Status, a short screening tool used in long-term care to quickly identify changes in a resident's cognitive function. On 8/20/2025 at 7:17 AM, a review of Resident #12's medical record and paper chart revealed no evidence that an advanced directive was documented on file. Further review of the resident's medical record showed a BIMS (Brief Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews it was determined that the facility failed to provide a clean, safe and homelike environment. This was found to be evident during multiple tours and random observations of the facility during the recertification survey. The findings include: During the initial tour of the facility conducted on 08/19/2025 at 6:00 AM, the carpets throughout the entire facility had multiple large stains. In Resident rooms #117 and #205 there were large black markings and a sticky substance on the white tile floors that caused Surveyors' shoes to stick to the floor when they walked in the rooms. During a tour of the Homestead Nursing unit conducted on 08/19/25 at 6:23 AM, this Surveyor shoes were sticking to the white tiled floors as he/she entered the nursing unit. The white tiled flooring had a sticky substance and black markings throughout. In Resident room [ROOM NUMBER] there were large black markings and a sticky substance on the floor throughout the entire room. The sticky substance and…

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

Based on interviews, record reviews and observations, it was determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately. This was found to be evident for 3 (Resident #6 , #91 and #107) out of 3 Residents reviewed for reporting abuse allegations. The findings include: 1. On 08/20/2025 at 8:30 AM, this surveyor conducted an interview with Resident #6 and #91. The Resident's both reported that approximately one week prior, an individual entered their room, pulled up the individual's gown, and exposed themselves, appearing to seek sexual contact. Resident #6 and Resident #91 provided descriptive information about the individual and reported that he/she believed the person to be another resident living on the unit. Resident #6 also reported that this individual had previously urinated in the hallway. On 08/20/2025 at approximately 10:30 AM, this surveyor conducted an interview with the Administrator and the Chief Nursing Officer. The surveyor made them aware of the statements provided by Resident #6 and Resident #91 regarding an…

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

Based on interviews, record reviews and interviews, it was determined that the facility failed to ensure that all alleged violations involving abuse are investigated. This was found to be evident for 3 (Resident #6, #91 and #107) out of 3 Residents reviewed for investigating abuse allegations. The findings include: 1. On 08/20/2025 at 8:30 AM, this surveyor conducted an interview with Resident #6 and #91. The Resident's both reported that approximately one week prior, an individual entered their room, pulled up the individual's gown, and exposed themselves, appearing to seek sexual contact. Resident #6 and Resident #91 provided descriptive information about the individual and reported that he/she believed the person to be another resident living on the unit. Resident #6 also reported that this individual had previously urinated in the hallway. On 08/20/2025 at approximately 10:30 AM, this surveyor conducted an interview with the Administrator and the Chief Nursing Officer. The surveyor made them aware of the statements provided by Resident #6 and Resident #91 regarding an allegation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility failed to ensure Resident Care Plans were developed. This was found to be evident for 4 (Resident #92, #107, #12 and #8) out of 23 Residents reviewed for Care Plans during the recertification survey. The findings include: 1. During an interview conducted on 08/19/2025 at 12:17 PM, Resident #92 reported that he/she does not participate in activities because of a vision deficit. When asked if one-on-one activities were provided the Resident responded no. A care plan is a formal, personalized, written document outlining a patient's specific medical, functional, and psychosocial needs, and the services and support required to address them. Developed through a comprehensive assessment by an interdisciplinary team, these plans guide care, foster communication among providers, involve the patient and their family, and track progress to help individuals achieve their health goals. A review of Resident 92's Care Plan was conducted on 08/19/25 at 12:20 PM. The review did not reveal a Care Plan for Activities. 2. During 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and interviews it was determined the facility failed to 1) have quarterly care plan meeting with the interdisciplinary team. This was found to be evident for 1 (Resident #116) out of 22 residents reviewed for Care Plan Meetings, 2) review and revise the care plans to meet resident's needs, This was evident for (Resident #8, #12 and #107) of 23 residents reviewed for care plan timing and revision during the recertification survey. 3) develop a comprehensive care plan within the required timeframe. This was evident for 1 (#11) of 23 residents reviewed for pressure injuries during the recertification survey.The findings include: 1. Care plan meetings are meetings with a team of care providers including the attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of food and nutrition services, the resident, and the resident's representative if applicable to ensure the care plan is continually…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 reviews, interviews and observations it was determined that the facility failed to ensure medical records were accurate, complete and readily assessible. This was found to be evident for 3 (Resident #92, #116 and #84) out of 3 Residents reviewed for accurate, complete and readily accessible medical records during the recertification survey. The findings include: 1. During a review of Resident #92's Medication Administration Record (MAR) for August 2025 conducted on 09/02/25 at 7:30 AM, the following order was discovered weigh every morning after void and before breakfast call provider with the weight gain of more that 3 pounds an 1 day one time a day for monitoring call provider for weight gain more than 3 pounds in 24 hrs (hours) start date 07/13/25 0630. Further review of the Resident's MAR showed it had a column for each day of the month and a box under the day for the nursing staff to initial. However, there was no place to document the actual weight. A review of the Resident #92's medical record conducted on 09/02/25 at 7:41 AM showed weights under 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, record reviews and interviews it was determined that the facility failed to 1) maintain the nurse call system in working order. This was evident for 2 (#19 and #11) of 6 residents reviewed for call systems and 2) ensure residents had access to call bells. This was evident of 4 residents (Resident#54, #5, #14 and #40) out of 4 residents review during recertification and compliant survey process.The findings include: 1. During an initial tour of the facility on 8/19/25 at 6:27 AM, surveyors observed the call light outside of Resident #19's room flashing on and off with an audible beeping sound heard at the nurses station. At 9:54 AM, during a second random observation by this surveyor, the same call light was observed flashing in the corridor without an audible sound. In an interview on 8/19/25 at 9:40 AM, LPN #31 confirmed she was assigned to Resident #19 and stated, “the call light is broken.” In an interview on 8/20/25 at 10:28 AM, Resident #19 stated the call light had been broken for months and “the light just stays on.” Resident #19's family member also…

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

Based on interview and record review, it was determined that the facility failed to invite the resident to participate in the care planning process. This was evident for 1 (Resident #8) of 5 residents reviewed for care planning during the recertification survey.The findings include:According to CMS (Centers for Medicare and Medicaid Services), a care plan meeting is a structured, interdisciplinary conference where staff, residents, and families discuss and review the resident's care plan, ensuring needs are met and goals are achievedOn 8/20/2025 at 7:56 AM, Resident #8 stated he/she had never been invited to any care plan meetings. On 8/20/2025 at 4:46 PM, a review of Resident #8's clinical record revealed a BIMS (Brief Interview for Mental Status) score of 5 which indicated severe impairment. On 8/21/2025 at 1:20 PM, in an interview with Social Worker Assistant, she confirmed that care plan meeting invitations were typically verbal, sent via email or were hand-delivered. On 8/26/2025 at 11:17 AM, the Regional Social Worker (SW) stated that a care plan meeting form was utilized 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 interview and record review, it was determined that the facility failed to provide the right to self-determination. This was found evident in 1 (Resident #121) out of 1 Resident reviewed for Self-Determination. The findings include:On 08/19/2025 at 11:56 AM, this surveyor conducted an interview with Resident #121. During this interview, he/she reported being unsure why he/she was placed on the secluded Homestead Unit. On 08/19/2025 at 2:46 PM, this surveyor conducted an interview with the Director of Nursing (DON). During this interview, the DON was informed of concerns that Resident #121 did not know why he/she was placed on the Homestead Unit, which is a locked/secured unit. The DON stated that this was her fourth week of employment at the facility and acknowledged that she was not yet familiar with this Resident. She confirmed that she could not provide information as to why Resident #121 had been placed on the Homestead Unit. The DON reported that she would speak with the Resident and consider the possibility of relocating him/her to another room on a different unit.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 observations, interviews and record review it was determined that the facility failed to 1) provide a private meeting for the Resident Council, 2) address grievances in a timely manner for 6 (Resident# 81, #44, #92, #12, #66, and #54) out of 12 Residents, and 3) provide grievance feedback. This was found to be evident for 1 out 1 observation of the Resident Council Meeting (RCM) during the recertification survey.The findings include: 1)During an interview conducted on 08/27/25 at approximately 11:30 AM, the Nursing Home Administrator (NHA) advised this Surveyor that the Resident Council Meeting would be held in the Main Dining Room or another room on 08/28/25 at 2:00 PM. During an interview conducted on 08/28/25 at 9:19 AM, Resident #54 invited this Surveyor to attend the Resident Council Meeting on 08/28/25 at 2:00 PM in the Main Dining Room. During an observation of the Resident Council Meeting (RCM) conducted on 8/28/2025 at 2:00 PM, it was discovered that the Main Dining Room was located off 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, interviews and record review it was determined that the facility failed to ensure Residents were notified of all the Resident [NAME] of Rights. This was found to be evident during the Resident Council meeting during the recertification survey.The findings include: A Nursing Home Resident's [NAME] of Rights ensures residents are treated with dignity, receive quality care, and are free from abuse, neglect, or restraint. Mandated by the federal Nursing Home Reform Act of 1987, it includes rights like the right to participate in care decisions, privacy, access to information, the ability to voice complaints without fear, and the freedom to make independent choices about daily life and activities.During an interview with the members/residents of the Resident Council meeting conducted on 8/28/25 at 3:37 PM, the members/residents were asked if they were informed of the Resident [NAME] of Rights. The group of members/residents unanimously replied no. The Activities Director, who was in attendance, advised the Resident Council members that she would begin to verbally…

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

Based on interview and record review, it was determined that the facility failed to notify resident's representative of a change in condition. This was evident for 1(Resident #8) of 1 resident reviewed in a complaint investigation.The findings include: On 8/26/2025 at 11:57 AM, during a telephone interview, Resident #8's Representative expressed surprise that the Foley catheter was discontinued without notification, stating it was previously deemed necessary. The representative emphasized, the facility doesn't call me at all! On 08/26/2025 12:44 PM, a review of Resident #8's progress from 8/1/25, indicated Foley came out. Provider was made aware. Provider has ordered a voiding trial. However, the note did not include any mention of the Resident #8's Representative being notified. On 8/27/2025 at 9:46 AM, Licensed Practical Nurse (LPN #18) confirmed that the nurses were expected to notify both the Physician and the Resident's Representative about any change of condition or order changes, and to document these notifications in the medical record. On 8/27/2025 at 9:56 AM, the Director…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide adequate privacy to the resident by exposing their body parts. This was evident for 1 (Resident #42) of 1 resident sampled during the medication administration.The findings include: On 8/21/2025 at 8:28 AM, during the medication administration, Resident #42 was observed in bed with their blanket pulled below the knee and gown above the abdomen, exposing their thighs and brief. The privacy curtain and door were wide open, making the resident's body parts visible to visitors and staff. On 8/21/2025 at 8:31 AM, the surveyor informed Certified Medication Aide (CMA #10) of this concern. CMA #10 acknowledged and stated that the privacy curtain should have been pulled during the medication administration. On 8/26/2025 at 7:43 AM, the Director of Nursing (DON) was informed of this concern.

Based on interviews and a review of pertinent documentation it was determined that the facility failed to ensure grievances were addressed in a timely manner. This was found to be evident for 1 (Resident #122) out of 1 Resident reviewed for grievances during the recertification survey.The findings include: During an interview conducted on 09/02/25 at 5:30 PM, Resident #122's family member stated that he/she is having issues getting the Resident clothes returned when taken to the facility's laundry to be cleaned. Because the clothes are not returned the Resident is forced to wear the same clothes until some of the clothes are returned. This has been an ongoing problem. The family member further stated that when he/she asked staff about the missing clothes he/she was told that they were short-handed, or a washer broke down. We recently spent close to $300.00 to replace the missing clothes and hangers only just to have them again never to return. The family member also reported that a sibling put name tags on every item: pants, tops, nightgowns, etc. During an interview conducted 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 record review and interviews it was determined that the facility failed to ensure 1) a Resident received a bed hold notice and 2) the Ombudsman was notified of transfers and discharges. This was found to be evident for 1 (Resident #107) out of 1 Resident reviewed for hospitalization during the recertification survey.The findings include:1) During a telephone interview conducted on 08/19/2025 at 1:29 PM Resident #107's Representative stated that the Resident was recently hospitalized . A review of Resident #107's medical record conducted on 09/01/2025 at 5:26 PM showed that the Resident was transferred to a local hospital on [DATE] and returned same day.During an interview with the Nursing Home Administrator (NHA) conducted on 09/02/25 at approximately 7:49 AM, this Surveyor requested the bed hold notification for the past 6 months.During an interview conducted on 09/04/25 at approximately 10:00 AM, the Regional Social worker advised that the facility provided bed hold notification to Residents who had…

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

Based on record review and interview, it was determined that the facility failed to complete an admission MDS (Minimum Data Set) assessment within the required timeframe. This was evident for 1 (Resident #102) of 1 resident reviewed for resident assessments during the recertification survey.The findings include:Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. According to Centers for Medicare and Medicaid Services Resident Assessment Instrument's (CMS RAI) Version 3.0 manual, nursing homes are required to submit an Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source. On 8/25/2025 at 7:50 AM, a review of Resident #102's medical record showed an admission or entry date of 8/1/25. According to CMS's RAI manual, For the admission assessment, the MDS…

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

Based on record review and interview, it was determined that the facility failed to transmit a Minimum Data Set (MDS) assessment within 14 days of completion. This was evident for 1 (Resident #102) of 1 resident reviewed for resident assessments during the recertification survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. Nursing homes are required to submit the Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source to Centers for Medicare and Medicaid Services (CMS') Internet Quality Improvement and Evaluation System (iQIES). Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days 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 record reviews and interviews, it was determined that the facility failed to accurately code and assess the Minimum Data Set (MDS) assessment. This was evident for 2 (Resident #8 and #13) of 2 residents reviewed during the recertification survey. The findings include: 1. Minimum Data Set (MDS) is a federally mandated comprehensive clinical assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. A foley catheter is a flexible tube inserted into the bladder to continuously drain urine into a collection bag. On 8/20/2025 at 4:46 PM, a review of Resident #8's pertinent physician orders confirmed that he/she was on Foley catheter from 6/4/25 to 8/4/25. On 8/26/2025 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record reviews, and staff interviews, it was determined that the facility failed to: 1) follow physician orders for turning and repositioning, 2) ensure physician orders were obtained for hospice or end-of-life care and 3) ensure the provision of sufficient supply of linens for residents. This was evident for 2 residents (#40 and #3) out of 2 residents reviewed for quality of care during the recertification and complaint survey process.The findings include: The process of regularly changing a resident's body position to reduce pressure on bony prominences, improve circulation, prevent skin breakdown (pressure injuries), and maintain comfort. This includes moving residents in bed, adjusting their position in a chair, or assisting them to sit or lie in a different position, typically on a scheduled basis (e.g., every 2 hours). 1) During rounds on the Chesapeake Unit, the surveyor observed Resident #40 on 08/20/2025 at 6:30 AM, 8:30 AM, and 10:30 AM, and on 08/21/2025 at 8:15 AM and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews it was determined that the facility failed to (1) implement recommendations made by the wound care team to treat pressure ulcers and (2) failed to initiate care upon admission for a resident with a pressure ulcer. This was evident for 2 (Residents #116 & #131) of 2 residents evaluated for pressure ulcer care during the survey.The findings include:1) A pressure ulcer, also known as a bed sore or decubitus ulcer, is a localized area of skin damage that develops when prolonged pressure or shear forces disrupt blood flow to the tissues resulting in damage to the underlying tissue. Pressure ulcers are staged based on 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) or Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon).A Deep tissue…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observations and interviews it was determined that the facility failed to implement an intervention, determined to be necessary, for a resident who was identified as a fall risk. This was evident for 1 (Resident #84) of 6 residents reviewed for accidents during the recertification survey. The findings include: During a phone interview with the family member of Resident #84 on 8/19/25 at 2:52 PM he/she reported that the facility called today because Resident #84 rolled out of bed and fell to the floor. The family member reported that the resident had a history of rolling out of his/her bed. During a medical record review for Resident #84 on 08/20/2025 at 11:41 AM it was discovered that the resident had fallen on 8/19/25 and found near his/her bed lying on stomach wrapped in blankets. The Resident did not have any injuries and the family was notified at 10:35 AM. A perimeter mattress has a raised, padded edge, or perimeter, that prevents residents from accidentally falling out of bed During an additional review of Change in Condition Evaluation reports it was…

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

Based on medical record review, observation, and interviews with facility staff, it was determined that the facility staff failed to consult the resident's physician to clarify orders regarding the medication route, G-tube feeding residual parameters, and ensuring the resident received feedings as ordered. This was evident for 1 resident (#40) out of 1 resident reviewed during the recertification survey process. On 08/25/2025 at 10:22 AM, review of Resident #40's medical record revealed the following physician orders: Thiamine HCl Oral Tablet 100 mg: Give 1 tablet by mouth once daily for supplementation, ordered on 05/10/2025 and Melatonin Oral Tablet 3 mg, give 1 tablet by mouth at bedtime for insomnia, ordered on 05/09/2025.On 08/25/2025 at 1:30 AM, further review of Resident #40's medical record revealed a physician's order for diet texture: Nothing by Mouth (NPO). Check residual: hold feeding x1 hour if residual is >___cc and recheck every shift. During rounds on 08/21/2025 at 10:00 AM, the surveyor observed Resident #40's G-tube feeding bag hanging on the pump and connected to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews it was determined that the facility failed to maintain respiratory equipment in a sanitary manner for 3 (Resident #26, #118 and #69) out of 3 residents observed for respiratory care. The findings include: A nasal cannula is a device that gives you additional oxygen through your nose. It's a thin, flexible tube that goes around your head and into your nose. There are two prongs that go inside your nostrils that deliver the oxygen. A nebulizer is a medical device that converts liquid medication into a fine mist, allowing the resident to inhale it through their nose or mouth. 1. During an observation on 8/20/25 at 12:12 PM it was observed that Resident #26 was on oxygen and there was no sign for oxygen in use at the doorway. Further observation revealed the resident was receiving oxygen via a nasal cannula. The nasal cannula was not dated or labeled. Resident #26 also had a portable oxygen bottle with a nasal cannula connected to the bottle on his/her…

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

Based on observations and interviews it was determined that the facility failed to ensure staff postings were updated. This was found to be evident for 4 out of 4 staff assignment boards and 1 facility staff posting observed during the recertification survey.The findings include: During the initial tour of the nursing units conducted on 08/19/2025 from 6:04 AM through 6:20 AM this surveyor observed the assignment board for Mill Landing, Wye Oak, and Chesapeake. Each board was dated for 08/18/25 shift 7-3 with the staff assignment by room number, ratio, unit manager, and census. A review of the assignment books also showed that the staffing sheet for each nursing unit had not been completed since 08/17/25.During an interview conducted on 08/19/25 between 6:06 AM and 6:22 AM, License Practical Nurse (LPN) #21, Registered Nurse (RN) # 20, and LPN #23 confirmed that the assignment boards had not been updated and reported that the facility's expectation is to update the board at the beginning of each shift. During a continued tour conducted on 08/19/25 at 6:25 AM, this Surveyor observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 act on the consultant pharmacist's medication regimen review (MRR) recommendations in a timely manner. This was evident for 1 (#7) of 5 residents reviewed for unnecessary medications during the annual survey.The findings include: On 9/3/25 at 9:48 AM, this surveyor requested Resident #7's medication regimen reviews for June, July, and August 2025. The facility provided the June and August MRRs, which the surveyor reviewed on 9/3/25 at 11:15 AM. The July 2025 MRR was not provided. At approximately 12:17 PM on 9/3/25, this surveyor made a second request to the DON for the July 2025 MRR. At 1:34 PM, the Rehab Director provided this surveyor a handwritten note from the DON which stated, July med recs faxed to NP and currently is working on them.In an interview on 9/3/25 at 2:24 PM, the DON confirmed that Resident #7's July 2025 MRR had been completed by the consultant pharmacist on July 9, 2025, but the recommendations were not addressed. The DON further stated that the July 2025 MRR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that the facility failed to ensure that 1) oral nutritional supplements and medication were properly stored and labeled. This was evident for 1 storage closet and 1 of 3 medication storage rooms. and 2) medications were stored properly. This was found to be evident for 1 out of 4 medication carts observed during the initial tour of the facility during a recertification survey.The findings include: 1. During an initial tour of the facility conducted on [DATE] at 6:17 AM this Surveyor observed Resident #102's Rosuvastatin tab 40 mg (milligram) blister pack and a large blue pharmacy bag of medications on top of the medication cart on the Mill Landing nursing unit. Resident #102 was observed sitting in a chair near the medication cart. No staff were present at the time of the observation. During a continued tour of the Mill Landing nursing unit this Surveyor observed Registered Nurse (RN) #20 in the 400 hallway which was located around the corner from where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident and staff interviews and record review, it was determined that the facility failed to ensure timely provision of necessary or recommended dental services for 1 resident (#34) out of 1 resident reviewed for dental care during the recertification and complaint survey.The findings include:On 09/02/2025 at 7:45 AM, during an interview with Resident #34, he/she stated, The facility cancelled my dentist appointment at the last minute in July 2025, and I really need to see the dentist because my tooth is bothering me.During review of Resident #34's medical record on 09/02/2025 at 8:15AM, it was revealed that on 07/14/2025, the physician requested a dental appointment for the resident.On 09/02/2025 at 8:30 AM review of Resident #34's medical record revealed that on 07/30/2025, nurse's notes documented that the resident's dental appointment needed to be postponed due to insurance. On 09/02/2025 at 9:00AM, during an interview with the Director of Nursing (DON) regarding Resident #34's dental appointment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation and staff interviews, it was determined that the facility failed to provide liquids consistent with resident's needs. This finding was evident for 1 (#119) of 7 residents reviewed for hydration during the recertification survey. The findings include: Dysphagia is the medical term for difficulty swallowing.Aspiration is the inhalation of food, liquid or other foreign material into the lungs.Aspiration pneumonia is a type of lung infection that occurs when foreign materials, such as food, vomitus, or saliva, enter the lungs. During a medical record review for Resident #119 on 08/19/2025 at 5:35 PM it was revealed that he/she had a history of dysphasia and aspiration pneumonia. The resident had a current doctor's order for fluids to be thickened to a nectar consistency. During continued medical record review a progress note written by the Dietician was discovered and it reported that the resident had a high aspiration risk. During an observation on 9/02/25 at 8:44 AM Geriatric Nursing Assistant (GNA) #37 was observed giving a cup of water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, it was determined that the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) meetings had the required committee members. This was found to be evident for 2 out of 2 quarterly committee attendance sheets reviewed during the recertification survey.The findings include:According to Centers of Medicare and Medicaid Services (CMS) QAPI stands for Quality Assurance and Performance Improvement, a systematic, data-driven, and proactive approach to maintaining and improving the safety and quality of care in nursing homes, as mandated by the Affordable Care Act. It combines Quality Assurance (QA), which sets and ensures standards for care, and Performance Improvement (PI), which involves continuously studying and improving processes to prevent problems and enhance services and quality of life for residents. The QAPI framework involves staff, residents, and families in identifying problems and implementing solutions through comprehensive programs and detailed plans.During the review of the QAPI attendance sheets conducted 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 interviews, it was determined that the facility staff failed to screen and offer pneumococcal vaccines to eligible residents. This was evident for 1 (Resident #114) of 5 residents screened for immunizations.The findings include:On 8/28/25 at 9:40 AM a review of Resident #114's clinical record revealed that the resident was admitted to the facility in May 2025 with diagnoses which included Dementia, Adult Failure to Thrive, Muscle Wasting and Atrophy.Further review of Resident #114's clinical record failed to reveal the resident's pneumococcal vaccination status. The record did not indicate whether the facility offered or educated the Resident/Responsible Representative (R/RP) on the risks and benefits of receiving the pneumococcal vaccine. The resident's Minimum Data Set (MDS) assessment dated [DATE] Section O, 0300B stated If Pneumococcal vaccine not received, state reason: Answer 3. Not offered.On 8/29/25 at 9:35 AM in an interview RN Staff #13 stated that pneumococcal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation it was determined that the facility failed to ensure essential equipment was operational. This was found to be evident for 2 out 2 Laundry equipment and the facility's telephone system observed during the recertification survey.The findings include: 1) During an observation conducted on 08/29/2025 at approximately 9:30 AM the Surveyor observed 1 washer in operation in the laundry room. Laundry Aide #29 stood in front of a large grey bin which was half filled with wet white linen. The Aide stated that the linen was already washed and was waiting for the load to dry so that she could place another load in the dryer. During the observation of the laundry room, it was discovered that the facility had 1 operational washer machine and 1 operational dryer machine. During an interview conducted on 09/03/25 at 2:29 PM, the Maintenance/ EVS Director reported that the facility has had 1 dryer machine operational for close to 1 year and 1 washer machine. Recently a second washer machine was delivered however the washer machine that was operational stopped…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that the facility failed to maintain 1) a safe environment. This was evident in 1 out of 2 rooms closed off for construction or repairs and 2) a sanitary environment in the laundry room. This was evident on all the floors throughout the laundry room.The findings include: 1. During an interview with Resident #19 on 8/20/25 at 7:37 AM the resident reported the Resident Room beside room [ROOM NUMBER] had been closed and under construction for 2 years because it had a leak in the roof. During an observation of the room next to room [ROOM NUMBER] on 8/20/25 at 7:40 AM it was revealed that the room was not labeled but had a sign on the door stating the room was Under Construction and Authorized Personnel Only. There was no lock on the door or any other barrier to prevent entry from wandering or interested Residents. During continued observation of the room under construction on 8/20/25 at 7:30 AM it was discovered to have a puddle of water inside the room 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 review of staff educational files and interviews it was determined that the facility failed to ensure Geriatric Nursing Assistant (GNA) completed a required annual education course. This was found to be evident for 5 (#17, #35, #39, #40, & #41) out of 5 GNA educational files reviewed during the recertification survey.The findings include: A compliance and ethics program is a systematic effort by an organization to prevent, detect, and resolve violations of law, regulations, and company policies by promoting a culture of integrity, ethical behavior, and legal adherence among its employees and agents. Key components typically include a written Code of Conduct, clear policies and procedures, robust training, risk assessment, a confidential reporting system for allegations, disciplinary actions for violations, and oversight by high-level management. During a record review of Geriatric Nursing Assistant (GNA) #17, #35, #39, #40, & #41 educational files conducted on 09/02/25 at 6:30 AM revealed there was no training record for the required annual Compliance and Ethics Program.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2) On 3/18/25 at 7:00 AM a review of complaint MD00208729 alleged that in July and August 2024 there were no washcloths, and the staff were tearing up bed sheets to use as washcloths. Review of complaint MD00204843 alleged there were no linens for bathing or incontinence care in January 2025. A review of the 2/27/25 resident council meeting minutes documented that minutes of previous council meeting were: EVS (environmental services) not bringing residents clothes back to residents after they are washed. New business was, residents do not get wash towels when they ask aides for them. A review of the 11/22/24 resident council meeting minutes documented, clothes not being given back from laundry, clothes not being picked up from laundry. A review of the 9/26/24 resident council meeting minutes documented, Residents complained of not getting their laundry back for extended periods of time. On 3/18/25 at 7:20 AM an interview was conducted with the Environmental Services Manager, Staff #7. Staff #7 was asked if there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, resident council meeting minute reviews, staff and resident interviews, and observation, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 10 of 42 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, multiple staff interviews, 3 of the 4 resident council meeting minutes reviewed and review of staffing schedules and employee time punches. This deficient practice had the potential to affect all residents. The findings include: 1) Ten out of forty-two complaints that the Office of Health Care Quality (OHCQ) received and reviewed on this survey alleged the facility did not have sufficient nursing staff to provide essential care to the residents that resided at the facility. Complaints consisted of geriatric nursing assistants (GNAs) having 15 to 30 residents to take care of during any given shift. There were concerns that the residents were not receiving timely care,…

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

Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 5 out of 5 personnel files (GNA #49, #52, #50, #51, #47) reviewed during a complaint survey. The findings include: A review was conducted of GNA personnel files on 3/17/25. A review of GNA #49's personnel file revealed GNA #49 was hired on 2/8/23. A review of GNA #52's personnel file revealed GNA #52 was hired on 7/12/22. A review of GNA #50's personnel file revealed GNA #50 was hired on 9/5/23. A review of GNA #51's personnel file revealed GNA #51 was hired on 2/3/23. A review of GNA #47's personnel file revealed GNA #47 was hirted on 8/23/20. There were no yearly performance reviews found in any of the personnel files. On 3/17/25 at 5:23 PM an interview was conducted with the Nursing Home Administrator (NHA). The NHA confirmed that they were behind on yearly reviews and education. The NHA stated that the new Director of Nursing had just started 2 weeks prior and would be putting processes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident council meeting minutes and interview, it was determined the facility failed to employ a qualified social worker on a full time basis. Failure to have a qualified social worker has the potential to affect all the residents of the facility. This was evident during a complaint survey. The findings include: Review of Resident Council Meeting minutes from January and February 2025 provided by the Administrator revealed the residents discussed not being able to see social workers to address concerns about their case. Interview with the Social Work Assistant (SWA) on 3/12/25 at 11:06 AM, the SWA stated she works at the facility part time 3 days a week and the other 2 days the Regional Social Worker comes to the facility. The SWA stated she is currently pursing her Associate's degree in nursing and does not have a Bachelor's degree in social work or a human services field. The SWA stated she was unable to hold any care plan meetings in January because she was by herself until the 3rd week or so in January 2025 when the Regional Social Worker starting coming 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.

2) On 3/10/25 at 11:00 AM a review of complaint MD00213615 and complaint MD00210751 revealed an allegation that the facility had been having issues with the water being cold at night when it was time for showers. Review of complaint MD00208729 alleged that there was no hot water in August 2024 and residents had to get a bath with cold water. On 3/10/25 at 2:00 PM an interview was conducted with Resident #5 who stated that there have been on and off issues with the hot water for a couple of months and the problem has not been fixed. On 3/10/25 at 2:31 PM an interview was conducted with the Director of Maintenance, Staff #7. Staff #7 stated, it was going on and off which started in mid-January (2025) when it got real cold outside. The switch on the boiler clicks off and back on. I went over to the unit, and I looked at the boiler and it was reading the code, and we got someone to service it. They are here today. They came last Thursday. It has been going on since January. First it happened in the Chesapeake area and then it happened in the Wye Oak area. It went out and I would reset…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure nurse aide competency training occurred no less than 12 hours per year. This was evident for 1 (GNA #52) of 5 geriatric nursing assistant files reviewed and had the potential to affect all residents during the extended survey of a complaint survey. The findings include: On 3/17/25 a review was conducted of geriatric nursing assistant (GNA) personnel files. A review of GNA #52's personnel file revealed GNA #52 was hired on 7/12/22. There was no formal way to validate the yearly training and number of hours GNA #52 received by reviewing the personnel file. Review of a binder that contained in-service signature sheets for various topics throughout the year was reviewed to validate education and give credit for education received. The binder contained 9 in-service sheets that GNA #52 had signed as attended throughout the year. It was not known the amount of time credited for each in-service. On 3/17/25 at 5:13 PM an interview was conducted with Staff #67, staff educator, who had just started on…

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

Based on medical record review and interview, it was determined the facility staff failed to treat a resident with dignity (Resident #1). This was evident for 1 of 44 residents reviewed during a complaint survey. The findings include: Review of Resident #1's medical record on 3/10/25 revealed the Resident was admitted to the facility in October 2024 with a diagnosis to include disease of the spinal cord. Further review of Resident #1's medical record revealed the facility staff assessed the Resident on 12/17/24 to be dependent on care for showering/bathing. During interview with Resident #1 on 3/11/25 at 2:00 PM, Resident #1 stated recently he/she was left in the shower room naked and uncovered facing the door. Resident #1 went on to say he/she remembered 2 nursing assistants had placed him/her naked in a shower chair, turned on the water and left him/her uncovered when Nurse #22 needed them to help with a new admission. Resident #1 was not positive the names of the 2 nursing assistants but did remember GNA #71 is the staff member who discovered him/her. Resident #1 stated he/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.

Based on reviews of facility reported incidents, record review and interview it was determined the facility failed to have documentation of when the final report was submitted to the regulatory agency, Office of Health Care Quality (OHCQ) and failed to report allegations of abuse within 2 hours of the allegation to OHCQ. This was evident for 3 (#17, #8, #29 ) residents reviewed for 5 of 18 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 3/10/25 at 9:52 PM a review of facility reported incident MD00208337 was conducted and revealed Resident #17 was found to have a right hip fracture on 8/2/24. On 3/10/25 at 1:30 PM the NHA was interviewed and stated that she could only find the initial email confirmation of when the incident was sent to OHCQ which was on 8/2/24 at 9:07 AM. The NHA could not provide documentation as to when the final report was submitted to OHCQ. 2) On 3/10/25 at 10:10 AM a review of complaint MD00212393 was conducted and revealed a police officer came to the facility after being called by Resident #8. Resident #8 made 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 review of facility reported incidents, medical records, and staff interview, it was determined the facility failed to provide documentation that allegations of abuse, injuries of unknown origin, and a gas leak were thoroughly investigated. This was evident for 9 (#17, #8, #16, #29, #21, #24, #41, #39, #23) of 44 residents reviewed and for 1 facility reported incident that involved the kitchen during a complaint survey. The findings include: 1) On 3/10/25 at 9:52 AM a review of facility reported incident MD00208337 was conducted and revealed Resident #17 was found to have a right hip fracture on 8/2/24. On 3/10/25 at 1:30 PM the NHA (Nursing Home Administrator) was interviewed and stated that she could not find any paperwork regarding the incident. 2) On 3/10/25 at 10:10 AM a review of complaint MD00212393 was conducted and revealed a police officer came to the facility after being called by Resident #8. Resident #8 made an allegation to the police officer that he/she had been abused by staff on 11/1/24…

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 medical record review and interview, it was determined the facility failed to provide ADL (activities of daily living) care for residents who were dependant for all ADL care. This was evident for 4 (Resident #11, #8, #1, #36) out of 44 residents reviewed for complaints during a complaint survey. The findings include : 1) On 3/10/25 at 10:30 AM a medical record review was conducted for Resident #11. Family made a complaint that resident had not been bathed or received showers. Resident #11 needs extensive assistance with all activities of daily living. On 6/15/24 Neurocognitive Health evaluated Resident #11. The resident was found he/she can be difficult with care. She/he cannot drink from a glass as she/he will spill into her/his food. She/he plays with toddler toys, and music keeps her/him calm. Resident #11 will independently lay on the floor. Resident behaviors are worse at night Resident #11 was Hallucinating during apt. with Neurocognitive health apt. on 6/15/24. According to care records, resident had 1 shower 8/13/24 am shift; Resident #11 did not have shower or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3) Facility staff failed to follow-up on a medication for a specific medical condition. On [DATE] at 1:00 PM a review of Resident #8's medical record was conducted and revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included Ankylosing spondylitis (AS), which is a chronic inflammatory disease that primarily affects the spine, causing inflammation and potentially leading to the fusion of vertebrae, resulting in stiffness and reduced flexibility. Review of Resident #8's [DATE] Medication Administration Record (MAR) documented Resident #8 was to receive the medication Enbrel via injection from a prefilled syringe every Monday for Pain. A [DATE] and [DATE] nursing note documented that the medication Embrel was not available from the pharmacy. Enbrel is a prescription medication that belongs to a class of drugs called tumor necrosis factor (TNF) inhibitors. It is used to treat autoimmune conditions such as Rheumatoid arthritis (RA), Psoriatic arthritis (PsA), Ankylosing spondylitis,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complaint, medical record review, and staff interview, it was determined the facility's registered dietician failed to document assessments in the resident's medical record and the facility currently failed to have a registered dietician that came on site to see resident's to see and assess residents for their current nutritional needs. This was evident for 1 (Resident #8) of 44 residents reviewed during a complaint survey and had the ability to affect all residents that resided in the facility. The findings include: On 3/17/25 at 11:15 AM a review of complaint MD00204843 alleged Resident #8 had not been given dinner and that the resident weighed 79 pounds. Review of the weight section of Resident #8's electronic medical record documented the last weight recorded for Resident #8 was on admission to the facility, 3/1/24, and Resident #8 weighed 176 pounds. Resident #8 has refused weights since admission. Review of Resident #8's medical record revealed there have been no nutritional notes or nutritional assessments from 3/4/24 to 3/7/25. 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.

Based on review of complaints, interview, and medical record review, it was determined the facility failed to provide timely medication to meet the needs of the residents. This was evident for 3 (#18, #8, #5) of 44 residents reviewed during a complaint survey. The findings include: 1) On 3/10/25 at 8:16 PM a review of Resident #18's medical record revealed Resident #18 did not receive the medication Escitalopram 20 mg. on 3/9/25 and 3/10/25 for depression due to the medication being on order. On 11/27/24, 11/28/24, 11/29/24, and 11/30/24, Resident #18 did not receive the transdermal patch Nicotine for smoking cessation and the patch was on order. On 3/13/25 at 8:28 AM an interview was conducted with Licensed Practical Nurse (LPN) #36. LPN #36 was asked what she did if a medication was not available. LPN #36 stated she would call the provider and let them know that the medication was not available or to see if they wanted to order an alternative. First I check the cubex. If it is a medication that requires prior authorization the DON (Director of Nursing) will handle and fax over to…

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

Based on review of resident council minutes, observations and interviews, the facility staff failed to prepare and serve food that was palatable, attractive and at a safe and appetizing temperature. This was evident for 5 (#9, #41, #42, #43, #36) of 44 residents interviewed and during a test tray observation during a complaint survey. The findings include: 1) During interview with Resident #9 on 3/11/25 at 7:00 AM, Resident #9 complained the food was bad and not getting what is on the menu. The Surveyor noted the menu posted on the Chesapeake Unit stated lunch was salisbury steak, parsley potatoes, butter carrots, dinner roll and vanilla pudding. Observation of Resident #9's lunch meat tray ticket on 3/11/25 at 12:20 PM said diet: bite sized, double portion. Observation of Resident #9's lunch tray at that time revealed it contained ground up meat with gravy, diced hash browns and vanilla pudding. The tray did not contain carrots or any vegetable or a dinner roll. The Dietary Manger was brought to the Chesapeake Unit to observe Resident #9's lunch tray on 3/11/25 at 12:40 PM and…

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

Based on observations and interviews with staff it was determined that the facility failed to store food and monitor temperatures in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: Due to multiple complaints of food quality, the Surveyor began a kitchen tour with the Dietary Manager on 3/17/25 at 9:20 AM. At that time the Surveyor observed the following concerns and the Dietary Manager confirmed: In the dry storage area was a large bag of cornmeal on the bottom shelf. The bag had a ripped open area that was not sealed. 4 large containers of dry goods located on the floor labeled thick it, flour, panko and sugar. None of the 4 large containers were dated to be able to determine how long the dry goods had been in the bins. A plastic container of walnuts had a crack in it, not allowing it to be sealed. In the freezer was a tray of 16 individual plastic containers of sherbert that were not dated. The sink next to the food prep area did 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 3) On [DATE] at 11:15 AM a review of Resident #8's medical record revealed geriatric nursing assistant (GNA) tasks for bathing. Review of bathing records for Resident #8 documented that Resident #8 received a bed bath for 12 of 30 days in [DATE]. Review of the geriatric nursing assistant (GNA) bathing task for [DATE] revealed blank spaces for the 7-3 shift on 9/1, 9/4, 9/5, 9/6, 9/8, 9/9, 9/11, 9/16, 9/18, 9/19, 9/21, 9/22, 9/23, 9/24, 9/25, 9/27, and [DATE]. There were blank spaces for the 3-11 shift on 9/2, 9/8, 9/9, 9/11, 9/13, 9/17, 9/18, 9/20, 9/23, 9/26, and [DATE]. There were blank spaces for the 11-7 shift on 9/2, 9/11, 9/14, and [DATE]. Review of bathing records for Resident #8 documented that Resident #8 received a bed bath for 13 of 31 days in [DATE]. Review of the GNA bathing task for [DATE] revealed blank spaces for the 7-3 shift and there were 7 days of documented refusals. There were no bed baths documetned on 10/1, 10/3, 10/4, 10/5, 10/10, 10/11, 10/12, 10/13, 10/14, 10/15, 10/16, 10/18, 10/19,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility failed to maintain the resident call bell system in working order. This was evident for 1 of 4 nursing units during a complaint survey. The findings include: During investigation of a complaint of non-working call bells on the Homestead Unit, the Surveyor began a tour with Staff #11 on 3/10/25 at 1:15 PM of the Homestead Unit. The following occupied rooms were observed to not have a functioning call bell: 300A, 300B, 301A, 301B, 302A, 302B, 303A, 303B, 304A, 305A, 305B, 306B, 307A, 307B, 310A, 310B, 312A, 312B, 313B, 315A, 315B, 316A, 316B, 317A, 317B, 318A, 318B, 319A, 319B, 320A, 320B, 321A, 321B, 322A and 322B. room [ROOM NUMBER]B had a manual call bell on top of a dresser but was not in reach of the Resident. No other rooms had manual bells at the residents' bedside. Interview with the Administrator on 3/10/25 at 1:30 PM confirmed the call bell system is not in working order on the Homestead Unit and no contractor is currently in the building working 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 observations, interviews, and documentation review, it was determined the facility failed to have an effective pest control program as evidenced by numerous flies and gnats seen in the kitchen and parts of the facility along with ants. This was evident on 2 of 2 days observed during a complaint survey. The findings include: On 6/16/25 at 9:30 AM observation was made of several gnats and a fly in the conference room. On 6/16/25 at 9:27 AM observation of the laundry room in the washer area and dryer area with Staff #9 present revealed multiple flies and gnats. At that time there was standing water on the ground between and behind the washing machines. On 6/16/25 at 1:25 PM observation was made of flies in the kitchen over the food preparation area. The flies were hanging on 2 black electric cords that were hanging down from the ceiling over the food serving station and there were flies flying over the food. There was a minimum of 12 flies seen at that time. The surveyor then went into the kitchen general storage area and the dry storage area where gnats were observed. Staff…

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

Based on medical record review and staff interview It was determined the facility staff 1) failed to inform the resident and/or resident representative when there was a change in the resident's treatment plan related to medication, and 2) failed to inform the resident/representative of the risks and benefits of the medication and obtain consent prior to initiating psychotropic medication. This was evident for 2 (#12, #3) of 44 residents reviewed for complaints. The findings include: A psychotropic describes any drug that affects behavior, mood, thoughts, or perception Schedule II (C2) controlled drugs refer to drugs with a high potential for abuse and addiction that are regulated by the government and include anxiolytic (anti-anxiety) benzodiazepine medication and opioid (analgesic) (narcotic) medication. 1) On 3/11/25 at 9:00 AM, a review of complaint #MD00209003 alleged Resident #12, who was terminally ill, but not on hospice or receiving palliative care, was prescribed and administered Ativan (anxiolytic) and Morphine (Opioid) for end of life, without notifying the resident's…

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

Based on medical record review and interview, the facility staff failed to notify a resident's physician of a change in status and failed to notify the physician when a medication was not available. This was evident for 2 (#30, #3) of 44 residents reviewed during a complaint survey. The findings include: 1) Review of Resident #30's medical record on 3/12/25 revealed the Resident was admitted to the facility in May 2023 for rehabilitation. Further review of the Resident's record revealed a nurse's note on 5/27/23 at 2:49 PM stated, Resident reported during transfer back to bed from chair staff member accidentally stepped on his/her foot. Resident currently denying any pain on left foot. The existing bruise on right foot, xray done previously. Further review of Resident #30's medical record revealed no notification to the Resident's physician to determine if any further treatment should be ordered for the Resident's left foot. Interview with the Director of Nursing on 3/13/25 at 5:28 PM confirmed the facility staff failed to notify Resident #30's physician on 5/27/23 when the Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident complaint, and interviews with facility staff, it was determined that the faciity failed to keep residents personal items safe. This was evident for 1 out of 1 resident (#2) with misappropriation of property. Findings include: On 2/4/25 Resident #2 entered the facility. Resident resided on the dementia unit in room [ROOM NUMBER] A. Resident had just been discharged from the hospital with the following diagnosis: Severe Sepsis with shock, Pneumonia, Autoimmune hepatitis, Pericardial effusion, anemia, volume overload, covid positive, hyponatremia, Folate deficiency, Hypomagnesemia, hypokalemia. Resident has a Bims score of 14/15 conductd on 2/13/25. (Bims is a mini mental score, indicating resident is alert and orriented.) On 3/12/25 at 4:31 pm, a review of Resident's #2's medical chart was reviewed. The complaint states resident's wallet was stolen. It had all her/his insurance cards, credit cards and debit card. On 2/12/24 nurses note states purse was locked up at nurses station because they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 conduct a complete and accurate assessment by failing to assess a resident's cognition, mood, and behavior on a quarterly assessment. This was evident for 1 (#16) of 44 residents reviewed for 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 these individualized needs, and that the care is provided as planned to meet the needs of each resident. On 3/12/25 at 10:24 AM a review of Resident #16's medical record was conducted. Resident #16 was admitted to the facility in October 2022 with diagnoses that included, but were not limited to, Bipolar disorder, dementia, and Wernicke's encephalopathy. Review of Resident #16's medical record revealed Resident #16 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2 (#16, #17) of 44 residents reviewed for complaints 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 3/10/25 at 10:12 AM a review of Resident #16's medical record revealed a quarterly MDS assessment with an assessment reference date of 1/13/24. Review of Section E behaviors, E0200 coded behavior not exhibited. Behaviors that would be coded in Section E0200, A. would be physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and observation, it was determined the facility failed to have regular care plan meetings and failed to update interventions on the care plan. This was evident for 3 (#21, #15, #16) out of 44 residents reviewed during a complaint survey. The findings include: 1) The Stepmom of Resident #21 called to say, the patient was admitted to the facility in April in 2024 and has had only one care plan meeting on 8/19/24. On 8/19/24, the Interdisplinary Team met, including social services assistant and nursing to complete a quarterly care plan meeting. Resident was present and is alert and oriented. Family was present including his/her sister. Social services discussed MOLST - resident is a Full Code. BIMS is 15/15. Discharge plan is to continue long term care at facility - eventually resident would like to possible transfer to [NAME] to be closer to family. Therapy discussed - if resident experiences a fall or decline, therapy will reevaluate. Diet discussed - resident's diet is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 or pertinent documents, medical record review and interview, it was determined that 1) the practitioner failed to follow professional standards of clinical practice by prescribing end-of-life medication to a full code resident without ensuring the resident and/or resident representative were fully informed about the use of end-of-life medications, and 2) the facility nursing staff failed to follow professional standards of nursing practice when administering psychotropic medication by failing to document in the medication administration record when the medication was given to a resident. This was evident for 1 (#12) of 44 residents reviewed during a complaint survey. The findings include: Schedule II (C2) controlled drugs refer to drugs with a high potential for abuse and addiction that are regulated by the government and include anxiolytic (anti-anxiety) benzodiazepine medication and opioid (analgesic) (narcotic) medication. A psychotropic describes any drug that affects behavior, mood,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers. This is evident for 1 (#30) of 44 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 Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a complaint, medical record review, and interview, it was determined the facility staff failed to follow up and obtain a motorized wheelchair for a resident in a timely manner. This was evident for 1 (#5) of 44 residents reviewed during a complaint survey. The findings include: On 3/12/25 at 5:30 PM a review of complaint MD00213409 alleged that Resident #5 had a power wheelchair that was no longer working. Resident #5 was supposed to get a new power wheelchair, however still had not received the wheelchair and alleged that the facility was not going to pay for the wheelchair. Review of Resident #5's medical record revealed Resident #5 had been a resident at the facility since 2015 and had diagnoses that included, but were not limited to, multiple sclerosis, type 2 diabetes mellitus with hyperglycemia, arthritis, low back pain, peripheral vascular disease, chronic venous hypertension, and absence of the left toe. On 3/10/25 at 2:00 PM an interview was conducted with Resident #5 who stated he/she had been waiting on the facility to get his/her motorized wheelchair.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assess a resident for removal of a catheter. This was evident for 1 (#1) of 44 residents reviewed during a complaint survey. The findings include: Review of Resident #1's medical record on 3/10/25 revealed the Resident was admitted to the facility in October 2024 with a diagnosis to include neuromuscular dysfunction of bladder. Further review of Resident #1's medical record revealed the Resident was admitted to the facility with an indwelling urinary catheter. During interview with Resident #1 on 3/11/25 at 2:00 PM, the Resident stated he/she feels like he/she is having more feeling, can tell when urinating and stated was told there would be a voiding trial but it has not happened. A voiding trial is a procedure used to assess a patient's ability to urinate without the need for a urinary catheter. It is typically performed after a period of catheterization, such as after surgery or hospitalization. During interview with the Medical Director on 3/12/25 at 10:44 AM, the Medical Director stated…

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

Based on 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 parameters for administering a blood pressure medication. This was evident for 1 (#3) of 44 residents reviewed during a complaint survey. The findings include: On 3/14/25, at 9:00 AM, a review of complaint # MD00214414 alleged that Resident #3's representative was not notified when a new medication was prescribed for the resident or prior to the resident receiving the new medication. On 3/14/25 at 10:00 AM, a review Resident #3's electronic medical record) (EMR) revealed Resident #3 was admitted to the facility in late December 2024 following an acute hospitalization and discharged from the facility in late February 2025. The medical record documented that Resident #3 had multiple diagnoses including hypertension (high blood pressure (BP), cirrhosis of liver (scarring of liver), hepatic encephalopathy (brain disorder caused by liver dysfunction), kidney failure, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. This was evident for 1 (#12) of 44 residents reviewed during a complaint survey. The findings include: Schedule II (C2) controlled drugs refer to drugs with a high potential for abuse and addiction that are regulated by the government and include anxiolytic (anti-anxiety) benzodiazepine medication and opioid (analgesic) (narcotic) medication. A psychotropic describes any drug that affects behavior, mood, thoughts, or perception On [DATE] at 9:00 AM, a review of complaint #MD00209003 alleged Resident #12, who was terminally ill, but not on hospice or receiving palliative care, was prescribed and administered Ativan (anxiolytic) and Morphine (Opioid) for end of life , without notifying the resident's representative, and obtaining consent. The complaint alleged that giving the medications together contributed 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, interviews and review of pertinent documentation, it was determined the facility failed to keep residents free from a significant medication error by failing to ensure medication was available in a timely manner for the facility to administer, and failing to accurately document when medications were not given or not available. This was evident for 1 (#3) of 44 residents reviewed during a complaint survey. The findings include: On 3/14/25, at 9:00 AM, a review of complaint # MD00214414 alleged the facility failed to inform and acquire consent from Resident #3 and his/her responsible party, when a medication was ordered for the resident, and prior to Resident #3 being given the medication. At 3/14/25 at 10:00 AM, a review Resident #3's electronic medical record) (EMR) revealed Resident #3 was admitted to the facility in late December 2024 following an acute hospitalization and discharged from the facility in late February 2025. The medical record documented that Resident #3 had multiple diagnoses including hypertension (high blood pressure (BP),…

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

Based on observation and staff interview, it was determined that facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 3 nursing units observed during a complaint survey. The findings include: On 3/11/25 at 2:22 PM observation was made of an unlocked and unattended medication cart on the Homestead Unit, which is a locked memory care unit. The unattended medication cart was sitting next to the nurse's station which was adjacent to the dining/activity room. The top drawer of the medication cart was opened by the surveyor and observation was made of resident's medications and a pair of scissors on the left-hand side of the drawer. Subsequent drawers were opened by the surveyor and observation was made of anti-hypertensive, anti-psychotic, anti-depressants, and other varieties of medications. There were residents ambulating in the unit in the hallways and the dining/activity area. There was no nursing staff available in the unit. The surveyor stood at the medication cart until 2:29 PM when the AIT (Administrator in Training) came back 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 resident complaint, record review, and staff interview, it was determined that the facility staff failed to provide a resident with a bedtime snack and 3 meals daily. This was evident for 2 (#8, #10) of 44 residents reviewed for complaints during a complaint survey. The findings include: 1) On 3/10/25 at 9:30 AM an interview was conducted with Resident #8 who complained he/she was not always getting an evening snack. On 3/17/25 at 11:15 AM a review of complaint MD00204843 alleged Resident #8 had not been given any food the day before. Review of Resident #8's medical record revealed a physician's order for peanut butter crackers 3 times daily and as needed. On 3/18/25 at 11:06 AM Staff #30, the Dietary Director was interviewed and stated the resident received beer battered fish for breakfast, lunch, and dinner per his/her request along with peanut butter crackers. Staff #30 stated that there were a lot of times the resident would tell her that he/she didn't get fish, however the food cart would come back and the fish was in there. Staff #30 stated she would go back and warm…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews with the administrator, the facility failed to make an appointment for a resident to have a sleep study done so a CPAP can be ordered for a diagnosis of sleep apnea. This is evident for 1 (#29) of 44 residents reviewed during a complaint survey. The findings include: On 3/10/25 at 11:18 AM a medical chart was reviewed for Resident #28. Resident was admitted [DATE] and discharged on 2/23/24. On 1/20/24 Doctor ordered a sleep study to be scheduled to rule out sleep apnea. The order was taken off by the former Director of Nursing, however the appt. was never made. I spoke to the current administrator who was not here during that time and has no information regarding Resident #28. The former DON is no longer here to discuss Resident #28 to see why apt. was not made. Resident was discharged to another facility on 2/23/24.

Based on record review, resident, and staff interview, it was determined that the facility failed to have a process in place to ensure that concerns and suggestions from the resident group were reviewed and responses provided to the group in writing. This was evident for 3 of 3 months of Resident Council meeting minutes reviewed during an annual recertification survey. The findings include: A review was conducted of the 2 PM Resident Council meeting minutes from 07/26/22 on 09/12/22. The following concerns were noted: Staffing on Saturday 07/23/22, there was a shortage of GNA's and RNs in the building which led to a resident walking around the building naked. Staffing has been an issue on the weekends with a lack of care shown towards the residents and leading them to receive the wrong medications or no medications at all. The issues with the aides refusing to help the residents is an ongoing issue, it has been discussed in prior meetings with no improvements. The lack of bathing and showers is still an ongoing problem. The residents have voiced concern over the number of meetings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 surveyor observation and staff interview it was determined the facility staff failed to have a process to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair. This was evident throughout the survey and on all nursing units. Additionally, the facility failed to supply heated water between 100- and 120-degrees Fahrenheit. The findings include: On 9/28/22 at 12:48 the Environmental Services (EVS) Director (staff #19) indicated that in addition to his title as the EVS Director he assumed the role of the Maintenance Director. A tour of the environment of care was conducted on 9/28/22, in response to team discussions of prior findings during the survey. The following limited observations were collaborated with the Director of EVS and Maintenance beginning at 1:30 PM on 9/28/22. On the Homestead unit in room [ROOM NUMBER] the EVS Director was informed of the initial observations of this room occurred on 9/12/22 at 8:45 AM. A shower curtain and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 8) On 9/12/22 at 2:14 PM, Resident #141 was not observed in his/her room and the GNA (Staff #51) revealed the resident was at dialysis. Resident #141's medical record was reviewed on 9/16/22 at 8:15 AM. Resident #141 was admitted to the facility on [DATE]. Review of Resident #141's medical records revealed the resident was diagnosed to have acute renal failure and was receiving hemodialysis three times per week. Review of Resident #141's care plan revealed the plan of care was initiated on 9/7/22 by a Healthcare Virtual Assistant (Staff #78). Review of the resident's care plan did not address care and services related to acute renal failure and scheduled hemodialysis three times per week. On 09/16/22 at 9:03 AM an interview was conducted with the nursing home administrator. She provided information related to the Healthcare Virtual Assistant (HVA). She indicated that the HVA does not meet with the resident or family and the HVA is utilized for paper compliance. She was informed, the resident's care plan was 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 interview, observation, and medical record review, it was determined the facility failed to implement an ongoing program of activities based on the abilities, interests and treatment needs of residents that resided in the facility. This was evident for 5 (#34, #62, #36, #5, #45) of 7 residents reviewed for activities and 2 (#9, #63) of 17 residents observed on the Homestead Unit, however affected all residents in the facility. This was evident during the annual survey. The findings include: 1) On 9/13/22 at 12:51 PM an interview was conducted with Staff #3. Staff #3 was asked about activities at the facility. Staff #3 stated, [name], who was the activities director just left 2 weeks ago. He was trying but now there are only 2 activity aides here. He was trying to do things with them, doing crafts and movies. The issue was being given money. There is no budget to do things with the residents. 2) On 9/16/22 at 9:30 AM Staff #27, (activities assistant) was interviewed and stated she had been employed at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation it was determined the facility failed to have an activities program that was directed by a qualified professional. This was evident during the 14 days the surveyors were onsite for the annual survey and had the potential to affect all residents. The findings include: On 9/13/22 at 12:51 PM an interview was conducted with Staff #3 who stated the facility was without an activity's director. Staff #3 stated the activities director had left and the replacement just left 2 weeks ago. He was trying to do things with them, doing crafts and movies. The issue was being given money to do things with the residents. There is no budget. Now there are only 2 activity aides here. On 9/16/22 at 9:30 AM an interview was conducted with Staff #27, an activities assistant, who stated she had been employed at the facility since June 2022. Staff #27 stated, we do not have a director and the other full timer is suspended pending investigation. Staff #27 stated, no activities happened yesterday. Staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 7) A review of the Resident Council minutes from the past three meetings (08/30/22, 08/05/22, 07/26/22) on 09/13/22 at 10:18 AM revealed continued complaints of a lack of staffing in the facility. The Resident Council documented the following unresolved issues: 08/30/22 - Poor staffing is still an issue, but it is mainly an issue on the weekends. 08/05/22 - The social worker is too busy to be involved in the resident's needs. 07/26/22 - Poor staffing is still an ongoing issue. Residents are not bathed or getting showers. Obtaining assistance from nursing assistants is still an ongoing issue. During the Resident Council meeting held on 09/13/22 at 10:18 AM, the residents complained of still not getting showers, staff will answer a resident's call light and then leave the room and never come back to assist the resident. 8) In an interview with Resident #5 on 09/11/22 at 10:40 AM, Resident #5 stated that the facility is short-staffed. During the week you may have 1 to 2 staff members between 30 residents, but on…

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

Based on review of employee files and interview, it was determined that the facility failed to put a system in place to ensure Geriatric Nursing Assistant's (GNA's) were competent with their skills sets. This was found to be evident for 3 out of 3 GNA (GNA #37, #44 and #45) employee files reviewed for competencies and skill sets. The findings include: On 9/20/22 at 9:32 AM a review of GNA employee files were conducted for GNA #37, #44 and #45. The review of employee files did not reveal documentation that indicated the GNA's had completed their competency skills and techniques to safely provide care to the residents. During an interview conducted on 9/20/220 at 11:26 AM, Staff #20, (Director of Human Resources) stated, I have not seen any yearly reviews since I have been here. I have not seen evidence of yearly evaluations or training. They did not have anything in place. On 9/20/22 at 11:38 AM an interview was conducted with the Nursing Home Administrator (NHA), the Interim Director of Nursing (DON) and Staff #7. The Interim DON stated, we do not have a Staff Developer. We had 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 review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 3 out of 3 personnel files (GNA 337, #44, #45) reviewed during the annual survey. The findings include: A review was conducted of GNA personnel files on 9/20/22 at 9:32 AM. A review of GNA #37's personnel file revealed GNA #37 was hired on 8/4/21. A review of GNA #44's personnel file revealed GNA #44 was hired on 9/14/20. A review of GNA #45's personnel file revealed GNA #45 was hired on 4/21/20. On 9/20/22 at 11:26 AM an interview was conducted with Staff #20, Director of Human Resources and the Business Office Manager. Staff #20 stated, I have not seen any yearly reviews since I have been here. I have not seen any evidence of yearly evaluations. They did not have anything in place. On 9/20/22 at 11:38 AM an interview was conducted with the Nursing Home Administrator (NHA), the Interim Director of Nursing (DON) and Staff #7. The Interim DON stated, we do not have a Staff Developer. We had a…

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

Based on interview and reviews of administrative documents, it was determined that the facility failed to ensure that nursing staff received and completed minimum training for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. This had the potential to affect all residents. The findings include: On 9/20/22 at 11:26 AM an interview was conducted with Staff #20, Director of Human Resources and the Business Office Manager. Staff #20 stated, So right now there is nothing for existing staff on yearly training related to dementia management. Staff #20 stated that Corporate should have a training program and different modules for training throughout the year. I have not set it up yet. I just did my yearly set-up at [name of sister facility]. It is in modules, and I know how I want to set it up. They did not have anything in place here. Staff #20 stated, when hiring nursing assistants and nurses, I have a check off list that I have. They get a new hire packet and they turn in the tests before they start.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, staff interview, and documentation review it was determined that facility staff failed to 1) keep medication and treatment carts locked when unattended, 2) discard expired medications and patient supplies, 3) maintain medication room refrigerators and freezers and monitor temperatures, 4) date medication and biologicals when opened, and 5) maintain narcotic medication reconciliation records. This was evident on 4 of 4 nursing units observed during random observations made during the annual survey. The findings include: Facility staff failed to lock medication and treatment carts when unattended: This was a repeat citation from a complaint survey that ended on 3/9/22. 1) On 9/11/22 at 7:15 AM, upon entry to the facility, observation was made of an unlocked medication and treatment cart in the 200 hallway, and an unlocked medication cart in the 100 hallway. By the time the surveyor walked back through the hallways, after finding someone who could assist the surveyors, the carts had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident interviews, and observations of the kitchen services with the testing of a food tray, it was determined that the facility failed to serve food at a preferable/palatable temperature. Food complaints and concerns were identified for 09 (#16, #19, #20, #23, #44, #58, #75, #87, #141) of 24 residents selected in the final sample and a failed test tray was identified on the unit that was served last. This had the potential to affect all residents. The findings included: Upon initiation of the survey on 9/11/22 random food complaints from residents included: Interview of Resident #58 at 8:28 AM was asked about the food and responded, the milk tastes sour, some days the food is cold and somedays it's hot. At 10:05 AM Resident #43 stated the food is terrible; not enough food to eat. At 10:06 AM Resident #23 indicated the food, is fair some days it's bad. At 10:45 AM Resident #16 indicated food is bad and Resident #75 indicated the meals were bad and not hot with cold eggs and toast. At 11:15 AM, during…

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

2) An environmental kitchen food service inspection was conducted in the facility's kitchen on 09/16/22 at 2:15 PM. The lunchtime dishwashing service was concluding at the time of the observation. The certified dietary manager (staff #61) was asked to restart the dishwashing machine and run trays through the machine. Observations of the temperature gauge for the hot water wash temperature remained at 140 degrees Fahrenheit (F.) as she placed multiple trays to run through the machine. A sign on the wall above the dishwashing machine indicated the minimum hot water wash temp was 160 degrees F. and the minimum rinse temperature was 180 degrees. The signage was very concise, instructing staff to inform a manager if the minimum hot water temperatures were not archived. During the observation, the wash water temperature did not rise above 140 degrees F. The Dietary Manager revealed that the repair vendor for the dishwashing machine (Ecolab) was at the facility earlier in the day to service the dishwasher. The certified dietary manager was asked to show the dishwashing machine temperature…

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

Based on interview, observation and record review, it was determined that the facility administration failed to provide effective oversight activities for the facility to ensure that resources were used effectively in order to meet the health and safety needs of each resident and identify and correct inappropriate care processes/standards, as evidenced by failing to 1) ensure that the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, and ensure the nursing staff had training which included dementia training and yearly in-service training; 2) ensure the food served to residents was palatable and served at the correct temperatures, 3) ensure there was an ongoing program to support residents in their choice of activities along with having an activities director to lead the program, and 4) ensure that the facility had a qualified social worker who was available to meet 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 facility records and interview with staff, it was determined the facility failed to conduct and document an accurate/current facility-wide assessment that was up to date. This was evident during the review of the sufficient and competent nurse staffing task of the annual survey and the extended survey. This had the potential to affect all residents within the facility. The findings include: A facility-wide assessment is conducted to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment is to include the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. A copy of the Facility Assessment was provided at the initiation of the survey. The Date of the assessment or Update was Change of Leadership 9/20/21. Date assessment reviewed with QAA/QAPI (Quality Assessment and Assurance/ Quality Assurance and Performance Improvement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 written and verbal complaints, reviews of medical health records and staff interview, it was determined the facility failed to obtain a full time social worker when the certified number of beds exceeded 120 in the facility. Currently the facility was licensed for 170 certified beds. This was evident for 1 out of 1 required personnel and had the potential to affect all residents. The findings include: Review of complaint MD00181590 on 09/11/22 revealed an allegation that there was not a full time Social Worker in the facility. During the Resident Council interview that occurred on 09/13/2022 at 10:18 AM, the active Resident Council members complained that there was not a full time social worker in the facility and that the current social worker does nothing for the residents and will not answer resident or family member phone calls. In an interview with the facility social worker on 09/13/22 at 12:51 PM, the facility social worker stated that S/he is the only social worker in the facility and works twice a week on Tuesdays and Fridays. The facility social worker stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, reviews of facility documentation, resident records, and current survey findings, it was determined that the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) plan to ensure care and services were maintained at acceptable levels of performance and continually improved. The annual survey process resulted in 77 Federal citations with areas of potential systematic concerns identified by the survey process. This had the potential to affect all residents within the facility. The findings include: On 9/28/22 at 5:30 PM an interview was conducted with the Medical Director (MD) and the Interim Director of Nursing (DON) regarding Quality Assurance (QA) activities. The interim DON was responsible for maintaining the QA notes and binder. During the interview the entire survey team was present. The survey team brought up the following concerns to determine if the QA committee was aware of the concerns and if so, what interventions were put into place. 1) Food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident medical records, review of facility documentation, and interview with facility staff, it was determined that the facility failed to ensure that they developed and maintained an effective infection control program. This was evidenced by 1.) failing to destroy a used COVID-19 kit in the laundry room, 2.) failing to place an order for COVID-19 care/treatment for residents with confirmed COVID-19 infection. This was evident in 1 (Resident #63, #348) of 5 Residents reviewed for the COVID-19 order, 3.) failing to have a system in place to report a positive test for COVID-19 to the local health department. This was evidenced by lack of documentation for COVID-19 line listing from January 2022 to April 2022, 4.) failing to develop a facility policy for Personal Protect Equipment (PPE) during an outbreak in the facility; 5.) failing to ensure the facility provide updated COVID-19 education to staff, 6.) failing to maintain Alcohol Base Hand Rub dispensers and supplies. This 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 interview and review of the facility records, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident by facility staff failing to submit antibiotic stewardship records to the surveyor to verify the facility had an antibiotic stewardship program as part of the facility's overall infection prevention and control program. This was evident during the annual survey and had the potential to affect all residents. The findings include: On 9/14/22 at 1:55 PM, an interview was conducted with the Interim Director of Nursing (DON), who also had responsibility for the Infection Control Preventionist (ICP) in this facility. The Interim DON stated that the facility had an antibiotic stewardship program for monitoring and tracking resident's antibiotic use, and she explained that, all documentation was filed in the Infection control binder. The surveyor asked the Interim DON to bring the antibiotic stewardship documentation in for surveyor review. The surveyor re-requested the Interim DON to bring the facility antibiotic…

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

Based on interview and record review, it was determined that the facility failed to have an effective system in place to ensure staff who were not up to date with COVID-19 immunizations, including unvaccinated staff, were tested according to state and federal guidelines. This was found to be evident for 58 out of 92 staff (regardless of vaccination status) who were not tested for COVID-19 the week of 9/4/22 (the facility had a COVID-19 outbreak), and 27 out of 92 staff (regardless of vaccination status) that were not tested the week of 7/10/22 while the facility had a COVID-19 outbreak. This deficient practice had the potential to affect all residents, staff, and visitors in the facility. The finding includes: The line listing is one type of epidemiologic database and is organized like a spreadsheet with rows and columns. Typically, each row is called a record or observation and represents one person or case of disease. (Center for Disease Control and Prevention) On 9/11/22 at 8:16 AM, an entrance conference was conducted with the Nursing Home Administrator (NHA), and she 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.

Based on interview and documentation review, it was determined the facility failed to ensure a training program was set up and in place for their staff to be educated on abuse, neglect, exploitation, and misappropriation of resident property along with dementia management and resident abuse prevention. This was evident for current staff and had the potential to affect all residents. The findings include: On 9/20/22 at 11:26 AM an interview was conducted with Staff #20, Director of Human Resources and the Business Office Manager. Staff #20 was asked about in-service training and she stated, only for new hires is there abuse training. Right now there is nothing for existing staff on yearly training related to abuse and dementia management. Review of the packet for new hire training revealed printed papers for self study on Resident Abuse Prevention and Reporting, Resident Rights and Facility Responsibilities, Compliance and Ethics Program, and HIPAA Security. Each stapled packet had a Pre/Post Test. Staff #20 explained that a new hire would receive the packet and then have to return…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review and interview, it was determined the facility failed to ensure nurse aide competency training occurred no less than 12 hours per year as determined in nurse aides' performance reviews. This was evident for 3 of 3 files reviewed and had the potential to affect all residents. The findings include: A review was conducted of GNA personnel files on 9/20/22 at 9:32 AM. A review of GNA #37's personnel file revealed GNA #37 was hired on 8/4/21. A review of GNA #44's personnel file revealed GNA #44 was hired on 9/14/20. A review of GNA #45's personnel file revealed GNA #45 was hired on 4/21/20. There was no evidence that 12 hours of training occurred for the three GNA's. On 9/20/22 at 11:26 AM an interview was conducted with Staff #20, Director of Human Resources and the Business Office Manager. Staff #20 stated, I have not seen any yearly reviews since I have been here. I have not seen any evidence of yearly evaluations. They did not have anything in place. Staff #20 was asked about…

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

Based on observation and staff interview, it was determined that the facility staff failed to treat each resident in a dignified manner by 1) not knocking on the resident's door before entering, 2) standing over a resident while feeding the resident, 3) not changing a resident's wet clothing before proceeding with assisting the resident with his/her meal, 4) serving the breakfast meal on disposable paper when the facility had glass plateware available, and 5) pulling a resident backward down the hallway. This was evident for 6 (Resident #44, #6, #1, #65, #24, #19) of 54 residents reviewed during the annual survey. The findings include: 1) During an observation of Resident #44 on 09/11/22 at 8:30 AM, the surveyor observed Geriatric Nursing Assistant (GNA) #12 failing to knock on the residents door before entering Resident #44's room. 2) During an observation of Resident #6 on 09/11/22 at 8:35 AM, the surveyor observed GNA #12 failing to knock on the resident's door before entering Resident #6's room. 3) During an observation of Resident #1 on 09/21/22 at 1:10 PM, the surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 clinical record review and staff interviews, it was determined that the facility failed to ensure the resident/responsible party was offered the opportunity to develop an advance directive for 3 (#10, #69, #27) of 3 sampled residents for advance directives. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4) A review of Resident #141's medical record related to nutritional concerns was conducted on 9/20/22 at 2:15 PM. A nutritional assessment was completed on 9/8/22 by the dialysis dietitian. The dietitian documented a weight of 200 pounds (Lbs.) that was taken on 9/6/22. The nutritional summary revealed, Resident is at nutrition risk related to inadequate oral intake with elevated nutritional needs for wound healing and likely inadequate nutrient intake. A review of the vital signs weight section of the electronic health record revealed a second weight was documented on 9/19/22 at 10:03 PM as 160.8 Lbs. by a nurse (staff #47). The electronic health record automatically documented a weight comparison noting a 19.6 % significant weight loss of 39.2 Lbs. Further review of the medical record did not reveal any type of physician or dietician notification. A review of the facility's Weight Monitoring policy dated 9/28/20 with a Reviewed/Revised date of 2/11/21 revealed Weight Analysis: The newly recorded weight should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility 1) failed to ensure the discharge of a resident was documented in the medical record to include, the resident's status at the time of discharge, any required discharge instructions, the reason for the discharge and 2) failed to document that information was provided to the acute care facility when a resident was transferred there emergently. This was identified for 3 (#148 #10, #27) of 9 residents reviewed for discharge during the annual survey. The findings include. 1) On 09/22/22 at 4 PM, Resident #148's closed medical record was reviewed in relation to complaint intake MD00177030. Resident #148 was discharged on 5/13/22. Progress notes indicating the resident discharge were not found. Documentation related to the resident's status at the time of discharge, discharge instructions, a discharge plan, or the reason for the discharge was not found in Resident #148's medical record. On an electronic Transfer/Discharge Report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#10, #27) of 6 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 9/21/22 at 7:44 AM observation was made of Resident #10's room, and it was noted the resident was not in the room. Registered Nurse (RN) #14 was asked where Resident #10 was and RN #14 stated Resident #10 was sent out to the hospital on 9/16/22 due to the resident's toe, looked bad. Review of Resident #10's medical record on 09/21/22 at 08:05 AM revealed a 9/16/22 at 13:10 (1:10 PM) nurse practitioner progress note which documented the chief complaint was, recurring right great toe trauma that has now developed into an arterial ulcer. The plan documented, wound significant worse, suspected fasciitis. Pt. started on PO (by mouth) ABX (antibiotics) day prior. Recommend transfer to ED (emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility staff failed to 1) conduct an accurate, comprehensive assessment by failing to accurately assess a resident's dental status, mood and cognitive status, bowel and bladder status, and dialysis on comprehensive (Minimum Data Set) assessments and failed to 2) complete an admission MDS assessment within 14 days of a resident's admission to the facility. This was evident for 4 (#27, #59, #103, #291) of 23 residents reviewed for 4 different care areas and 1 (#141) of 1 newly admitted resident reviewed for the annual 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 these individualized needs, and that the care is provided 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 interview and record review, it was determined that the facility failed to provide residents and or resident's responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications. This was evident for 9 (#62, #97, #103, #107, #450, #36, #88, #141, #96) of 54 residents reviewed during the annual survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1) On 9/12/22 at 10:48 AM an interview was conducted with the responsible party (RP) for Resident #62. The RP was asked about care plan meetings, and she stated, they called me when [he/she] was admitted in April of this year. I had 1 care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1) review and revise resident care plans to reflect accurate and current interventions, and 2) ensure the full interdisciplinary team including residents and/or their responsible parties were invited to the care plan meetings. This was evident for 10 (#55, #5, #34, #62, #92, #107, #106, #99, #141, #19) of 54 residents reviewed during the annual survey. The findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements. The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents (regardless of payer) of long-term care facilities certified to participate in Medicare or Medicaid. Each care plan provides 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaints, reviews of medical records, and staff interviews, it was determined that the facility failed to 1) ensure residents received medications as ordered by the physician, 2) document care given to a resident prior to being transferred to the hospital, 3) follow physician's orders, implement interventions and document when resident had a fall and 4) change a resident's nebulizer tubing and documenting when changed. This was evident for 8 (#45, #27, #92, #34, #97, #38, #36, #19) of 54 residents reviewed during an annual survey. The findings include: 1) In an interview with Resident #45 on 09/13/22 at 2:48 PM, Resident #45 complained that he/she does not receive his/her medications on time. Resident #45 stated that he/she currently has a supra-pubic catheter to urinate because he/she cannot just urinate. Resident #45 stated that he/she needs to make sure the nursing staff administers the bladder antispasmodics on time. Resident #45 stated that he/she is scheduled for another bladder procedure to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interviews it was determined the facility staff failed to ensure wounds were accurately assessed on admission and failed to provide appropriate treatment and services to promote healing of pressure ulcers. This was evident for 4 (#141, #95, #55, #108) 5 residents reviewed for pressure ulcers. 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). 1) 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 reviews of a medical record, interview, and observation it was determined that the facility failed to 1) ensure that a resident received nebulizer treatments as ordered by the physician, and 2) develop a resident-centered care plan for a resident with Chronic Obstructive Pulmonary Disease (COPD) and oxygen use with resident-centered and measurable goals and 3)have physician's orders for the administration of oxygen. This was evident for 2 (#23, #10) of 2 residents reviewed for respiratory care during the annual survey. The findings include: 1) In an interview with Resident #23 on 09/11/22 at 1:20 PM, Resident #23 stated that he/she wass supposed to be receiving Nebulizer treatments for COPD. A review of Resident #23's medical record on 09/13/22 at 9 AM, revealed that Resident #23 was admitted to the facility on [DATE] with diagnoses that include but are not limited to insulin-dependent diabetes, end-stage renal disease on hemodialysis, Parkinson's disease, hypertension and chronic obstructive pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, administrative policy review, and interviews, it was determined the facility failed to assess residents for risk of entrapment from bed rails, obtain informed consent, and ensure bed rails were properly installed prior to the utilization of side rails for any resident. This was evident for 3 (Resident #141, #34, #36) of 9 residents reviewed for accidents during the annual survey. The findings include 1) Resident #141 was admitted to the facility on [DATE]. Upon initiation of the survey on 9/11/22 Resident #141 was observed daily lying-in bed with bilateral half-side rails in the up position. A review of the medical record on 9/22/22 revealed that the Peak Side Rail Evaluation was initiated by a Healthcare Virtual Assistant (Staff #78) and was not completed and was not signed by a nurse in the facility. The Peak Fall Risk Assessment was listed as In progress and was not completed. Informed consent for use of the side rails was not obtained. There was not a physician's order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 physician progress notes were not in the resident medical records the day the resident was seen. This was evident for 6 (#105, #94, #141, #10, #34, #450) of 54 residents reviewed during the annual survey. The findings include: 1) Resident #105 was admitted to the facility on [DATE]. Resident #105's closed medical record was initially reviewed on 9/26/22 in relation to complaint MD00173347. A review of the resident's attending physician (staff #76) documentation revealed a History and Physical Note with a Visit date of 4/27/21 that was electronically signed on 5/2/21 and uploaded to the electronic medical record on 5/5/21. Continued review of Resident #105's medical record for the attending physician's notes revealed one SOAP Note with a visit date of 8/5/21, signed on 8/8/21 and uploaded to the electronic medical record on 8/11/21. On 9/27/22 an interview of the Nursing Home Administrator (NHA) was conducted at 1:13 PM. She was informed 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 medical record review and staff interview it was determined the physician failed to see a resident once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. This was evident for 4 (#62, #10, #102, #107) of 54 residents reviewed during the annual survey. The findings include: 1) On 9/15/22 at 9:21 AM a review of Resident #62's medical record was conducted. Resident #62 was admitted to the facility in April 2022. There were physician visits dated 4/5/22, 4/21/22, 5/17/22, and 8/31/22. The resident was not seen in June 2022 or July 2022 as there were no physician visits found in the electronic or paper medical record. 2) On 9/15/22 at 10:30 AM a review of Resident #10's medical record was conducted. Review of physician visits revealed visits dated 1/6/22 and 4/19/22. There were no other physician visit notes in the electronic or paper medical record. 3) On 9/23/22 at 7:30 AM a review of Resident #102's medical record was conducted. Resident #102 was admitted to…

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

Based on review of medical records and interview with staff it was determined that the facility failed to 1) have an effective system in place to ensure that drug regimen reviews were done for all residents at least monthly and 2) develop policies and procedures related Medication Regimen Review to include time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This was evident for 6 (#5, #6, #20, #64, #450, #63) out of 10 residents reviewed for medications during the annual survey. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough monthly evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. 1) A review of Resident #5's medical…

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

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 reconcile and transcribe medication orders accurately to the medication administration record as evidenced by transcribing a medication twice. By failing to transcribe orders accurately the resident did not receive medications at the prescribed time of day and/or received up to twice the amount of medication ordered. This was identified for 1 (#141) of 5 residents reviewed for unnecessary medications. The findings include: Resident #141 was admitted to the facility on [DATE]. A review of Resident #141's medical record revealed admitting diagnosis that included Diabetes, high blood pressure, and acute renal failure requiring hemodialysis. The medication administration record (MAR) was initially reviewed on 9/19/22 and revealed a duplicate transcribed medication order for Insulin Glargine. The insulin Glargine was ordered as inject 5 units subcutaneously (under the skin) one time a day for DM (diabetes mellitus) into 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 staff, it was determined that the facility failed to follow a physician's order to 1) administer the antihistamine medication Benadryl twice daily for 2 days and then discontinue and 2) follow physician ordered blood pressure parameters. This was evident in 3 (#26, #32, #24) out of 3 residents reviewed for significant medication errors during a follow-up survey. The findings include: Benadryl (diphenhydramine) is a brand-name medication that's classified as an antihistamine. It's used to help relieve symptoms of hay fever (seasonal allergies), other allergies, and the common cold, as well as itchy skin due to insect bites, hives, and other causes. Benadryl is effective for decreasing itchy skin from hives. It's often considered a first-choice treatment for hives. But although it's effective for decreasing symptoms of seasonal allergies, Benadryl isn't often used for this purpose. This is due to side effects such as sleepiness. 1) A review of Resident #26's medical record on 01/05/23 revealed a physician's order instructing 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 complaint, and resident and staff interviews, it was determined that the facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This was evident for all residents in the facility reviewed during the annual survey. The findings include: In an interview with Resident #23 on 09/11/22 at 10:06 AM, Resident #23 stated that he/she does not receive diabetic beverages to drink (unsweetened drinks). Resident #23 stated there was no other choice of beverages for resident's who are diabetic, except water and unsweetened tea. All of the beverages coming from the kitchen were some forms of juice that had sugar added. In an interview with Resident #5 on 09/11/22 at 10:40 AM, Resident #5 stated that he/she does not receive daily meal menus. Resident #5 also stated that you get whatever the kitchen sends out. Residents do not have any choice of meals. In an interview with the facility dietician on 09/23/22 at 11:35 AM, the dietician confirmed that the facility kitchen does not serve sugar free beverages for the residents that have diabetes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complaint, and resident and staff interviews, it was determined that the facility failed to prepare and serve a resident's nutritional wishes and plan of care. This was evident for all residents that can eat and drink in the facility and suffer from diabetes. The findings include: In an interview with Resident #23 on 09/11/22 at 10:06 AM, Resident #23 complained that he/she does not receive diabetic beverages to drink (unsweetened drinks). Resident #23 stated there was no other choice of beverages for resident's who are diabetic, except water and unsweetened tea. All of the beverages coming from the kitchen were some forms of juice that had sugar added. In an interview with the facility dietician on 09/23/22 at 11:35 AM, the dietician confirmed that the facility kitchen does not serve sugar free beverages for the residents that have diabetes, and that the kitchen only has water and unsweetened tea to serve diabetic residents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident complaint, record review and staff interview, it was determined that the facility staff failed to provide a resident with a bedtime snack. This was evident for 1 (Resident #23) of 12 residents reviewed for nutrition during the annual survey. The findings include: In an interview with Resident #23 on 09/11/22 at 1:20 PM, Resident #23 complained that the facility dietician does not follow the diabetics in the facility and the kitchen does not know how to prepare food for diabetics and that this has concerned him/her since admission. Resident #23 stated that he/she suffers from insulin dependent diabetes and end stage renal disease for which he/she receives hemodialysis. Resident #23 stated that his/her meals consist of carrots, greens, and potatoes. Resident #23 stated that I am not served any dietary protein and served some type of juice that has sugar added. A review of Resident #23's 09/11/22 lunch meal ticket at 1:20 PM revealed that the kitchen prepared and sent a: carbohydrate controlled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews and observations it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. Furthermore, the facility failed to assure the completeness, and accuracy of documentation related to the use of Healthcare Virtual Assistant Transcription Support services. This was evidenced by review of resident's medical records with multiple examples of incomplete documentation initiated by HVAs and documentation of staff performing assessments and documented progress notes at times the staff were not in the facility. This practice was evident for 13 (#141, #45, #49, #69, #97, #93, #103, #34, #10, #291, #97, #38, #99) of 54 residents reviewed. The findings include: 1) Review of electronic medical records revealed documentation by Healthcare Virtual Assistants (HVA). The nursing home administrator (NHA) and the director of nursing (DON) provided explanations to the survey team as the role of the HVAs and how the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Party (RPs) were provided education regarding the benefits, risks, and potential side effects of Influenza and Pneumococcal vaccines before requesting consent. This was evident for 4 (Resident #49, #4, #58, #11) of 5 residents reviewed who were eligible for Influenza and Pneumococcal vaccines during the annual survey. The findings include: Pneumococcal vaccine helps prevent pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the…

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

Based on medical record review and staff interview, it was determined the facility failed to document that education was provided to residents and staff regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine. This was evident for 4 (Resident #49, #11, #58, and #37) of 5 residents and 1 (Staff # 85) of 5 facility staff members reviewed for COVID-19 vaccinations during the annual survey. The findings include: On 09/15/22 at 08:47 AM, five residents were randomly selected for review of the COVID-19 vaccination. A review was conducted of paper and electronic medical records. 1) A review of Resident #49's medical record revealed Resident #49 had resided in the facility since December 2019 and received COVID-19 vaccines at the facility. However, there was no documentation Resident #49 received education regarding the benefits, risks, and potential side effects of the second dose of COVID-19 vaccine (administrated on 1/19/21). 2) A review of medical records revealed that Resident #11 had resided in the facility since September 2020. Resident #11…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 keep a bathtub and ice machine in operating condition. This was evident during environmental rounds of the facility for 1 of 1 bathtub found out of 2 observed bathing areas of the facility and in 1 of 1 nourishment rooms observed. The findings include. 1) On 9/28/22 beginning at 1:30 PM, an environmental tour of the facility was conducted with the director of EVS and maintenance (staff #19). In the Wye Oak unit's bathing suite, an out-of-commission bathtub was identified. The drainpipe of the tub was noted to be cut from the wall and the tub was moved against the wall. Upon interview with the EVS/maintenance director, he did not know how long the tub had been out of commission. The bathtub was not in operating condition. 2) Observation was made on 9/13/22 at 12:01 PM in the Homestead unit pantry/nourishment room of the ice machine. The ice machine was empty. Staff #26 walked into the nourishment room and stated, the ice machine has been broken for a while and we have to go to the kitchen to get ice for…

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

Based on observation, medical record review, and staff interview it was determined the facility failed to have a process in place to conduct regular inspections of bed frames, mattresses, and bed rails. This was evident for 1 (#34) of 8 residents reviewed for accidents during the annual survey. The findings include: On 9/21/22 at 7:39 AM observation was made of Resident #34 lying in bed with bilateral 1/2 side rails in the raised position. On 9/21/22 at 4:30 PM a medical record review was conducted for Resident #34 and revealed a recent side rail assessment had not been done. There were no physician's orders for side rails and there was not a care plan for side rail use. On 9/27/22 at 11:13 AM an interview was conducted in Resident #34's room with the Director of EVS (environmental services) and Maintenance, Staff #19, and the Regional Director of Plant Operations. Staff #19 was asked if he had a process in place to check side rails along with the beds and mattresses. Staff #19 stated he would have to check. He has only been in the position for the past 2 weeks. The surveyor showed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, observation, and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order and within reach. This was evident for 2 of 3 nursing units observed during the annual survey. The findings include: 1) A review of complaint MD00178416 on 09/11/22 at 7:30 AM, revealed an allegation that resident call bells have been broken for months. During an initial observation of the 200-hall nursing unit on 09/11/22 at 8:15 AM, the nurse surveyor observed the following: An observation of Resident #70 on 09/11/22 at 8:30 AM, revealed a call bell wall receptacle in disrepair. An observation of Resident #6 on 09/11/22 at 8:35 AM, revealed a call bell wall receptacle in disrepair. An observation of Resident #34 on 09/11/22 at 8:56 AM, revealed a call bell wall receptacle in disrepair. Resident #34 was supplied with a handheld call bell that was located on his/her bedside table. When asked, Resident #34 was unable to demonstrate how to use the handheld…

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

Based on staff collaborated observations of two restrooms utilized by staff and residents, a nursing station and a shower room, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff as identified in 2 of 2 staff bathrooms observed and for 1 (200 hall) of 4 nursing units observed during the annual survey. The findings include. 1) An observational environmental tour of the facility was conducted on 9/28/22 with the environmental services director/maintenance director #19 beginning at 1:30 PM. Observation of the staff restroom that was shared with residents on the Chesapeake unit did not have a paper towel dispenser and the paper towels were kept on the back of the toilet. The environmental services director was informed that a hand-washing sink for the staff is required to be equipped with a goose-neck spout, with a separate soap dispenser, and a disposable paper towel dispenser. Observation of the staff restroom that was shared with the residents on the Wye Oak unit did not have a staff hand washing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, review of facility reported incident MD00180950 and complaint MD00176593, and resident and staff interviews, it was determined that the facility failed to ensure a resident was free from misappropriation of resident property and exploitation. This was evident for 1 (Resident #113) of 13 residents reviewed for abuse, neglect and exploitation during the annual survey. The findings include: A review of the facility Abuse, Neglect and Exploitation policy, on 09/26/22, revealed that the policy was last reviewed/revised and implemented on 10/12/20 and defined Misappropriation of Resident Property as: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident's belongings or money without the resident's consent, Reviews of Facility Reported Incident MD00180950 and Complaint MD00176593 on 09/26/2022 revealed an allegation that Resident #113 went to retrieve his/her $2500.00 in cash, credit cards, and gift cards from the administrator on 04/29/2022 at 2:30…

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

Based on observation, medical record review and interview, it was determined the facility staff failed to conduct a complete and accurate assessment by failing to assess a resident's oxygen use and failing to assess cognition and mood. This was evident for 1 (#10) of 2 residents reviewed for respiratory, 1 (#62) of 8 residents reviewed for accidents, and 1 (#59) of 9 residents reviewed for quality of care. 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 these individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 9/11/22 at 9:26 AM observation was made of a portable oxygen tank on the back of Resident #10's wheelchair in the resident's room. On 9/14/22 at 2:10 PM Registered Nurse (RN) #14 was asked about the oxygen and the…

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

Based on record review and interview with facility staff, it was determined that the facility failed to ensure that a recapitulation of the resident's stay was completed following a resident's discharge from the facility. This was evident for 1 (#93) of 3 closed records reviewed during the annual survey. The findings include: On 9/22/22 at 10:51 PM a record review was conducted for Resident #93 that revealed Resident #93 was admitted to the facility in June 2022 due to a fractured ankle. A 7/7/22 at 11:41 AM care conference note documented that Resident #93 wanted to go home. A 7/11/22 at 14:20 (2:20 PM) nursing progress note documented, this nurse, accompanied by the head of Therapy and the ADON (assistant director of nursing) spoke to patient about the risks and dangers associated with leaving AMA (against medical advice). Resident acknowledged teachings and warnings. The note continued, not satisfied with night shift care which was the main reason for [his/her] decision to leave AMA. PT (physical therapy) advised of dangers associated with leaving AMA due to physical weakness and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a resident complaint, medical record reviews, and staff interview, it was determined that the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in their range of motion. This was evident for 2 (Residents #5, #45) of 4 residents reviewed for range of motion. The findings include: 1) In an interview with Resident #5 on 09/12/22 at 1:59 PM, Resident #5 stated that he/she has some movement in his/her left leg but needs more therapy to walk again. In an interview with Resident #5's family member on 09/12/22 at 2:02 PM, Resident #5's family member stated that Resident #5 was only receiving 30 minutes of therapy a day due to his/her health insurance policy when he/she was admitted to the facility, but that was 3 years ago. Resident #5's family member stated that the hospital physician informed Resident #5 that he/she should be able to walk again with continued therapy. A review of Resident #5's medical record 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, staff interview, and facility administrative documents, it was determined that: 1) the facility staff failed to protect a resident, who was totally dependent upon staff for all aspects of care from continued falls, 2) investigate the root cause of the falls and initiate nursing interventions to prevent further falls, and 3) update the resident's fall prevention care plan. This was evident for 1 (Resident #55) of 8 residents reviewed for accidents during the annual survey. The findings include: A review of Resident #55's medical record on 09/26/22 revealed that Resident #55 was admitted to the facility on [DATE] with diagnoses that include but were not limited to diabetes, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, and bilateral above the knee amputation of the right and left leg. Resident #55 has been assessed as being dependent upon the facility staff for many aspects of his/her care. Resident #55 had a Brief Interview for Mental Status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complaint, reviews of a medical record, and staff interviews, it was determined the facility staff failed to ensure that a resident was provided pain medication when requested and that a resident had ordered pain medication on admission. This was evident for 2 (#5, #98) of 9 residents reviewed for pain management during the annual survey. The findings include: 1) A review of complaint MD00181990 on 09/11/22 revealed an allegation that residents in the facility were not receiving their medications. In an interview with Resident #5 on 09/12/22 at 2 PM, Resident #5 stated that he/she did not receive any pain medication for 3 days, due to being unavailable, after being readmitted to the facility on [DATE]. A review of Resident #5's medical record on 09/14/22 revealed that Resident #5 suffers from a stroke, left-sided weakness, diabetes, neuropathy, obesity, Atrial fibrillation, chronic pain, and a cardiac valve replacement. Resident #5 is dependent upon the facility staff for several aspects of 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 record review, staff interview, and observation, it was determined that the facility failed to ensure a physician supervised the care of a resident, as evidenced by the physician failing to evaluate a resident upon admission to the facility and failure to review a resident's weight loss. This was evident for 2 (#99, #106) of 33 complaints reviewed and 1(#34) of 12 residents reviewed for nutrition during the annual survey. The findings include: 1) On 9/26/22 at 10:54 AM, a review of the complaint MD00166828 revealed that Resident #99 was admitted to the facility on [DATE] for ambulatory dysfunction s/p (status post) fall. Further review of the medical record identified that a telehealth provider wrote the initial patient and medication assessment on the admission date with detail; patient has just arrived at this facility today and is awaiting full initial evaluation by primary team. [agency company name] is consulted today to check on patient status and to review medications and orders. However, there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility staff failed to 1) obtain lab tests as instructed by the resident's physician, and 2) place the results in the resident's medical record. This was evident for 1 (Resident #55) of 6 residents reviewed for unnecessary medications during the annual survey. The findings include: Review of Resident #55's medical record on 09/19/22 revealed physician orders, dated 08/21/22, 08/25/22, 08/26/22, 09/11/22, and 09/12/22 instructing the nursing staff to obtain laboratory specimens for the following: 1) 08/21/22 at 11:59 PM - obtain a CBC (complete blood count) and a CMP (comprehensive metabolic profile) on 08/26/22, one time only for type II diabetes and hallucinations for 1 day. 2) 08/25/22 at 12:45 AM - obtain a CBC (complete blood count) and a CMP (comprehensive metabolic profile) on 08/26/22, one time only, for hallucinations, agitation, and anxiety for 7 days. 3) 08/26/22 at 12:01 AM - obtain a CBC, CMP, and urine sample for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (#27) of 1 residents reviewed for dental while admitted to the facility under Medicare. The findings include: On 9/12/22 at 1:08 PM an interview was conducted with Resident #27. Resident #27 was asked if he/she had natural teeth or dentures. Resident #27 stated, I have dentures but they got lost when I went to the hospital. On 9/15/22 at 2:45 PM Resident #27's spouse was in the room and expressed concern to the surveyor about the missing dentures that got lost the evening that Resident #27 fell and was sent to the hospital. Resident #27 stated the dentures were on the floor and they haven't seen them yet. The spouse stated she told the administrator and was told they were being looked for. On 9/16/22 at 8:44 AM a medical record review was conducted for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined the facility failed to provide rehabilitation services, evidenced by failing to provide physical therapy as initially planned. This was evident for 1 (Resident #58) of 7 residents reviewed for rehabilitation during the annual survey. The findings include: 1) During an interview with Resident #58 on 9/11/22 at 9:37 AM, the resident stated he/she received rehabilitation therapy six months later after admission. The resident also reported, since the facility did not offer the therapies, I had to learn myself. If they helped me on time, I might not need this wheelchair now. On 9/20/22 at 12:39 PM, the surveyor reviewed Resident #58's medical record. Resident #58 was admitted to the facility in January 2021 and needed rehabilitation therapy due to general weakness. Further medical record review revealed that Resident #58's physician ordered, evaluate and treat in skilled Physical/Occupational Therapy on 1/25/21. On 9/27/22, the surveyor requested a copy 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 the interviews with eight members of the resident council and a review of resident council notes from the past 12 months it was determined that the facility staff had not been addressing the residents' concerns. The findings include: This surveyor met with members of the resident council on 10/24/18 at 2:00 PM. The residents brought up concerns that they said they had brought up many times and on an almost monthly basis. The issues included: -quality of the food and the fact that the kitchen often runs out of one of the entree choices prior to all the residents having the opportunity to request it; -they also said that pie is often on the menu but is rarely available and is most often substituted with green Jell-O and that the former Dietary Manager told the resident council via the Recreation staff person that the issue is the facility budget. There was no indication that any adjustments to either the budget or how the kitchen staff prepare food was presented to the resident council. A review of the resident council meeting notes revealed the following: -10/31/17:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 observation of resident rooms during the initial tour of the facility, it was determined that the facility staff failed to maintain a safe and clean environment as evidenced by unattended maintenance and/or housekeeping needs, and broken items (room [ROOM NUMBER] and 314). The findings include: During the initial tour of the facility on October 25, 2018 the survey team observed the following evidence of unattended maintenance and/or housekeeping concerns: 1. room [ROOM NUMBER] was found with a dirty Tube Feeding pump and pole with old dried tube feeding solution, cob webs from the ceiling, smell of urine, and a suction canister with an open and used suction catheter on the end table. In an interview on 10/25/18 the Director of Nursing was made aware of these concerns. 2. During an observation of the Homestead Unit on 10/22/18 at 10:30 AM, the surveyor observed a broken glass picture frame on the sink in room [ROOM NUMBER].

Based on medical record review and interview, it was determined that the facility failed to notify the resident or the resident's responsible party in writing of transfer to the hospital. The facility also failed to send a copy of the written transfer notice to the Office of the State Long-Term Care Ombudsman. This was evident for 3 of 47 residents (#64, #122, #123) sampled for investigations. The findings include: 1. Resident #64 was sent to the hospital on 5/24/18, 7/7/18, and 8/24/18. An interview with the Corporate Regional Nurse on 10/23/18 at 10:50 AM revealed the facility had not notified Resident #64 in writing of the transfers nor the reason for the transfers. The facility did not send the Ombudsman a copy of the transfer notice. 2. A review of Resident #123's clinical record on 10/23/18 at 3:00 PM revealed that the resident was discharged to the hospital on 7/27/18. A review of the reasons for the hospitalization revealed that there was an incident that resulted in the need for observation and/or treatment at the hospital. There was no evidence that the ombudsman 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 review and revise Resident #275's care plan to reflect accurate and current interventions and failed to ensure the full interdisciplinary team including residents and/or their responsible parties are invited to the quarterly care plan meetings (#76 and #92). This was evident for 3 of 47 residents selected for review during the annual survey. The findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. 1. Medical record review for Resident #275 revealed the resident was admitted the facility with diagnosis that included but not limited to: retention of urine and had an indwelling urinary catheter. Urinary retention is an inability to completely empty the bladder. A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Because it can be left in place in the bladder for 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 interviews with residents from the resident council it was determined that the facility staff failed to ensure sufficient staffing for the facility. The findings include: This surveyor interviewed residents from the resident council on 10/24/18 at 2:00 PM. Residents stated that food is often delivered late and they are told the reason is that they are short staffed. They said staff will often not answer call lights during lunch because they don't have enough staff to serve trays, feed residents, and to clear the trays while still providing nursing care. Nursing staff refuses to provide any assistance with going to the bathroom or provide incontinence care during meal time. The residents said staff are so busy that they often forget to tell residents that they have mail and it is up to the residents to ask if they received any mail. A review of the resident council meeting notes revealed that staffing issues were raised on 2/27/18, 6/26/18, and 9/25/18. The facility staff were informed of these concerns at the exit conference.

Based on observation during the initial tour of the main kitchen it was determined that the facility staff, failed to store, and prepare, food under sanitary conditions. The findings include: On 10/22/18 10:33 AM, during the initial tour and observation of the main kitchen with the Food Service Director, it was found that: 1. The dry storage room door was propped open and it was noted to have cereal spilled on the floor and shelves, crackers and sugar packets was noted on the floor. 2. The storage room floor was dirty. 3. The storage room walls had chipping paint. 3. The main kitchen floor was wet and very slippery. 4. The handwashing sink next to the prep table was leaking and had standing water on the floor. The wall behind the sink had chipping paint. Flies were seen in the area of the standing water. 5. The floor drains noted to have food pieces. 6. The walk-in refrigerators/freezer had black specks on the ceiling and the floor was dirty with black marks and food debris. 7. Greased was noted behind the stove, grill and oven on the floor, walls and pipes. 8. The refrigerator had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical records in the most accurate form for Residents (#33, #43, #64, #65, #67 and #92). This was evident for 6 of 47 residents reviewed in the annual survey. The findings include: 1. Review of Residents #43, #64, #65 and #67's medical record revealed no current physician orders for medications or treatments. On 10/23/18 at 1:40 PM, the Regional Corporate Nurse stated the physician had signed the current orders for October, but the medical records staff had not filed in the current orders in each resident's chart. The current orders were with the medical records staff and not in the record. 2. Reviews of Resident #33's medical record on 10/23/18 revealed that the facility psychiatrist assessed Resident #33 on 10/04/18 and recommended reducing Resident #33's antipsychotic medication, Olanzapine, from 7.5 milligrams (mg) to 5 mg orally every evening. The facility psychiatrist recommended a gradual dose reduction (GDR) for Resident #33 at this time. Review of Resident #33's October…

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

Based on observation, and interview with staff it was determined that the facility failed to maintain all essential mechanical, electrical, equipment in safe operating condition on the lower level of the facility. The findings include: 10/23/2018 at 3:45 PM, during the tour of the lower level of the facility with the Maintenance Director the following observation was made: 1. The tour of the lower Unit level revealed Power strips in the patient's rooms. Six of the patient's rooms had portable air conditioners/heater units connected to a powder strip. The portable air conditioner displayed a tag on the cord that revealed safety precautions that read do not use an adapter or an extension cord and a warning that read Following theses basic precautions will reduce the risk of fire, electrical shock, injury or death when using your air conditioners. At that time the power cords were removed from the power strip, and the portable air conditioners/Heaters were connected to the electrical supply as required by the manufactory's recommendations. 2. On 10/24/18 at 7:59 AM, a tour 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 medical record review and staff interview, it was determined the facility failed to notify a resident/resident representative in writing of a room change. This was evident for 1 (Resident #38) of 47 residents reviewed during an annual recertification survey. The findings include: Review of Resident #223's medical record on 10/23/18 revealed that Resident #223 was transferred to room [ROOM NUMBER] A on 10/09/18. In an interview with the facility Nursing Unit Manager on 10/24/18 at 11:19 AM, the Unit Manager stated that Resident #223's room change on 10/09/18 was staff initiated and that Resident #223 and Resident #223's family did not receive written notification of the room change.

Based on a review of a facility reported incident, a resident clinical record, and staff interview it was determined that the facility staff failed to ensure a resident's right to move about the facility and to exit the facility was honored (#174). This was true for 1 out of the 5 residents reviewed for facility reported incidents as part of the survey process. The findings include: A review of Resident #174's clinical record revealed the resident had an elopement risk assessment completed on 12/29/17. The elopement risk assessment determined the resident was not a risk for elopement. The facility nursing staff put a WanderGuard bracelet (device that alerts facility staff that a resident is leaving a safe area) on the resident on 12/29/17 to alert them if the resident attempted to leave the facility. Record review did not reveal that resident was informed of the reason for the WanderGuard or the right to refuse to wear it. The resident cut off the WanderGuard bracelet on 1/7/18 and left the facility to get fresh air sometime between 3:30 PM and 3:40 PM. The resident was returned to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined the facility staff failed to address the initiation of a MOLST form with Resident #89 and failed to properly void an old MOLST form when a new one was created for Resident #275. This was evident for 2 (Resident #89 and #275) of 47 residents reviewed for advance directives during an annual recertification survey. The findings include: A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient. Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must be accurately and legibly complete the form and then sign and date it. Voiding the Form: to void this medical order form, 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 review of a medical record review and staff interview, it was determined the facility staff failed to notify a resident's family member of a recommendation to lower a Resident's antipsychotic medication after a psychiatric consultation. This was evident for 1 (Resident #33) of 47 residents reviewed during an annual recertification survey. The findings include: Reviews of Resident #33's medical record on 10/23/18 revealed that the facility psychiatrist assessed Resident #33 on 10/04/18 and recommended reducing Resident #33's antipsychotic medication, Olanzapine, from 7.5 milligrams (mg) to 5 mg orally every evening. Review of Resident #33's October 2018 medication administration record revealed that Resident #33 was still currently receiving the same dose of 7.5 mg every evening. In an interview with the facility Social Worker on 10/23/18 at 4:45 PM, the facility Social Worker stated that the facility did not receive a copy of the 10/04/18's psychiatrist's assessment with recommendations until 10/11/18. The facility Social Worker stated that the psychiatric consultants do…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 facility's investigation of a facility reported incident and staff interview it was determined the facility failed to protect Resident (#29) from abuse. This was true for 1 out of 47 residents selected for review during the annual survey process. The findings include: A review of the facility staff's investigation (MD00125458) revealed on 4/11/18 Resident #29 reported to the facility staff GNA (Geriatric Nursing Assistant) #1 told him/her they were disgusting for laying in stool for several hours and should have put the call light on. The resident explained the call light was put on, another GNA answered the light and reportedly stated that they would relay the message to the appropriate care giver. At the time of allegation, GNA#1 was placed on administrative leave and not allowed to finish her shift. The resident was assessed, and no injuries were noted. The Ombudsman and responsible party for the resident was notified. At the end of the investigation and witness statements, the GNA#1 was terminated. Surveyor interview with Resident #29 on 10/24/18 at 10:45…

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

Based on medical record review and interview, it was determined that the facility failed to notify the resident or the resident's responsible party in writing of the facilities bed-hold policy (#64, #122) before transferring them to the hospital. This was evident for 2 of 47 residents sampled for investigations. The findings include: 1. Resident #64 was transferred to the hospital on 5/24/18, 7/7/18 and 8/24/18. An interview with the Regional Corporate Nurse on 10/23/18 at 1:50 AM confirmed the facility did not give Resident #64 a copy of the facilities bed hold policy with each of these hospitalizations. 2. Review of the medical record for Resident #122 revealed the resident was transferred to an acute care facility on 5/24/18, 7/7/18 and 8/24/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital. On 10/23/18 at 1:50 PM, the Director of Nurses confirmed that Resident #122 and the Resident's responsible party did not receive the facility bed hold policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 document accurate assessments for Resident (#66) on the MDS. This was evident for 1 of 47 residents selected for review during the survey process. The findings include the following: The minimum data set (MDS) is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Review of Resident #66 MDS, with an ARD of 05/30/18, revealed it was inaccurate. Section L Dental (D), was coded that the resident did not have broken natural teeth or cavity. Review of Resident #66 medical record revealed that the resident had a Dental Consult on 2/15/18 and 9/12/18 that revealed 4 retained roots and fracture tooth. On 10/25/18 at 10:00 AM, an interview with the MDS Coordinator confirmed not documenting the broken teeth.

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 the resident and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Resident #223) of 47 residents reviewed during an annual recertification 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. Review of Resident #223's medical record on 10/24/18 revealed Resident #223 was readmitted to the facility on [DATE]. Review of the medical record failed to reveal documentation that a copy of the baseline care plan was provided to Resident #223 or Resident #223's responsible party within 48 hours after admission. In an interview with the facility Social Worker on 10/24/18 at 10:49 AM the facility Social Worker confirmed the facility staff did not supply Resident #223 nor his/her responsible party with a copy of…

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

Based on review of medical record and staff interview, it was determined the facility staff failed to follow an established comprehensive care plan addressing nutrition for a resident (#34). This was evident for 1 of 47 residents selected for review during the annual survey. The findings include: On 10/22/18 at 1:00 PM Resident #34's care plan review revealed that he/she was to be setup for feeding, supervised, cued, and assisted with feeding as needed and to be sat up for meals. On 10/22/18 at 1:45 PM resident #34 was found in his/her room lying flat in bed with lunch plate on overbed table. The lunch meal was cold. The Director of Nursing(DON) confirmed the finding at 1:50 PM. The DON then got a nurse and resident #34 had incontinent brief changed and food warmed and assisted with lunch. The DON confirmed the care plan was not followed.

Based on medical record review, observation and interview, it was determined the facility staff failed to administer a medication as ordered to Residents #120 and #275 and the facility staff failed to clarify the accuracy of a medication order for Resident #275. This was evident for 2 of 47 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to administer a medication to Resident #120 as ordered by the physician. Medical record revealed on 9/23/18 the physician ordered: Exemestane 25 milligrams by mouth 1 time a day with a meal. Exemestane is indicated for the treatment of advanced breast cancer. Review of the Medication Administration Record revealed the facility staff documented the administration of the Exemestane from 9/24/18 to 9/30/18 and 10/1/18-10/23/18 at 8:00 AM. Observation of medication pass on 10/24/18 at 8:00 AM revealed the Certified Medication Aide (CMA #1) failed to administer the Exemestane as ordered. It was further noted the medication was not in the facility. It is the expectation the facility nursing staff…

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

Based on medical record review, observation and interview, it was determined the facility staff failed to provide treatment/services to prevent/heal pressures ulcers for residents with pressure ulcers (Residents #275). This was evident for 1 of 47 residents selected for review during the investigation stage of the survey process. 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. Medical record review for Resident #275 revealed on 9/24/18 the physician ordered: make sure heels are off loaded. When it comes to wound care, the term float the heels means that a resident's heel should be positioned in such a way as to remove all contact between the heel and the bed. Surveyor interview with Resident #275 on 10/23/18 at 11:00 AM revealed the resident stated he/she was moved to another room; however, the facility staff failed to take the pillows with her/him and the feet had not been elevated since last night. Medical record review revealed on 10/22/18 at 5:37 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 medical record review and interview, it was determined the facility staff failed to obtain weights as ordered for Resident (#275). This was evident for 1 of 47 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #275 revealed on 9/11/18 the physician ordered: weights every week, Tuesday, 3-11 shift. Review of the medical record revealed the facility staff failed to obtain weights on: -9/18/18-- the resident refused and indicated he/she was in pain and would be weighed in morning; however, there is no evidence the facility staff attempted to obtain that weight; -9/25/18-- the resident refused and indicated he/she was in pain and would be weighed in the morning; however, there is no evidence the facility staff attempted to obtain that weight; -10/2/18 -- no evidence weight was obtained. Interview with the Director of Nursing on 10/24/18 at 1:00 PM confirmed the facility staff failed to obtain weights as ordered on Resident #275.

Based on medical record review and interview, it was determined the facility staff failed to thoroughly intervene and offer alternative pain management for Resident #275. This was evident for 1 of 47 residents selected for review during the annual survey process. The finding includes: Medical record review for Resident #275 revealed on 9/18/18 the physician ordered: Oxycodone 10 milligrams by mouth every 6 hours as needed for moderate to severe pain. Oxycodone is intended for the management of moderate to severe pain in patients who require treatment with an oral opioid analgesic and Oxycodone tablets are an immediate-release formula. Further medical record review revealed the facility staff documented the administration of the Oxycodone on: -9/18/18 at 7:35 PM and re-evaluation of pain at 9:37 PM with verbalized pain level of 10, -9/20/18 at 6:40 AM and re-evaluation of pain at 8:34 AM with verbalized pain level of 10, -9/20/18 at 12:30 PM and re-evaluation of pain at 5:35 PM with verbalized pain level of 10, -9/21/18 at 9:00 AM and re-evaluation of pain at 9:23 AM with verbalized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 consultant pharmacist failed to identify and bring to the facility staff's attention for Resident #275 the irregularity of the ordering of Potassium. This was evident for 1 of 47 residents selected for review during the survey process. The findings include: Medical record review revealed for Resident #275 revealed the facility was admitted to the facility with the discharge summary of medication ordered on 9/11/18: Potassium 95 milligrams by mouth every day. Potassium is a mineral that is found in many foods and is needed for several functions of the body, especially the beating of your heart. Further record review revealed the consultant pharmacist failed to identify and notify the facility staff of the irregularity in the ordering of the Potassium. Potassium is not a medication ordered or administered in milligrams but in the ordering system of milliequivalent (mEq). Interview with the Director of Nursing on 10/23/18 at 2:00 PM revealed the consultant pharmacist will immediately notify the facility 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.

Based on medical record review and reviews of a relevant medical resource, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication. This was evident for 2 (Resident #33 and #117) of 6 residents reviewed for unnecessary medications during an annual recertification survey. The findings include: 1. Review of Resident #33's medical record on 10/23/18 revealed a physician order, dated 05/11/18, instructing the nursing staff to administer the medication, Divalproex (Valproate) sprinkles, 250 mg, orally, twice a day for the indication of dementia with behavioral disturbance. Valproate preparations are given to treat residents who suffer from seizures and bipolar disorder. A review of the National Institute for Health Care Excellence, 10 March 2015 article, Management of Aggression, agitation and behavioral disturbance in dementia: Valproate preparations determine that evidence from randomized controlled trials (RCT's) suggest that valproate preparations (including sodium valproate and valproate semisodium) are no…

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

Based on medical record review and staff interview it was determined that the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs. This was evident for 1 (Resident #33) of 6 residents reviewed for unnecessary medications during an annual recertification survey. The findings include: Reviews of Resident #33's medical record on 10/23/18 revealed that the facility psychiatrist assessed Resident #33 on 10/04/18 and recommended reducing Resident #33's antipsychotic medication, Olanzapine, from 7.5 milligrams (mg) to 5 mg orally every evening. The facility psychiatrist recommended a gradual dose reduction (GDR) for Resident #33 at this time. Review of Resident #33's October 2018 medication administration record, on 10/23/18, revealed that Resident #33 was still currently receiving the same dose of 7.5 mg every evening. A review of Resident #33 medical record also revealed a care plan titled: Resident is at risk for complications related to the use of psychotropic drugs, mood stabilizers, and insomnia medications. Nursing interventions included:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, reviews of a medical record, and staff interview, it was determined that the facility staff failed to offer and obtain dental services for a resident. This was evident for 1 (Resident #27) of 7 residents reviewed for dental services. The findings include: During an observation of Resident #27 on 10/22/18 at 1:25 PM, Resident #27 was observed with missing teeth. Review of Resident #27's medical record revealed a physician order, dated 08/02/17, instructing the nursing staff to obtain a dental consult for patient health and comfort. Further review of Resident #27's medical record failed to reveal any documentation a dental consult had been offered or obtained since Resident #27 was admitted to the facility on [DATE]. In an interview with the facility nursing unit manager on 10/24/18 at 10:26 AM, the nursing unit manager stated that Resident #27 had never been referred to a dentist since being admitted . The nursing unit manager also stated the facility had a dentist that came to the facility…

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

Based on resident complaint and staff interview, it was determined that the facility staff failed to provide a resident (Resident #43) with a bedtime snack as requested. This was evident for 1 (Resident #43) of 47 residents reviewed during an annual recertification survey. The findings include: During an interview with Resident #43 during the annual recertification survey, Resident #43 stated that s/he did not receive a bedtime snack, a peanut butter and jelly (PBJ) sandwich, that s/he had requested. In an interview with the facility dietitian on 10/25/18 at 10:20 AM, the facility dietitian confirmed that Resident #43 did not receive his/her bedtime sandwich last evening. The facility dietitian stated that the dietary staff failed to deliver the bedtime snacks to Resident #43.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility staff failed to post an isolation sign on room [ROOM NUMBER]A door to alert visitors, residents, and staff to see the nurse before entering the room. This was true for 1 out of 47 residents selected for review during the annual survey process. The findings include: The facility staff failed to post a sign on a resident door indicating isolation. On 10/22/18, an observation outside resident's room [ROOM NUMBER]A was a box. When opened contained items necessary for respiratory isolation, gowns, masks, and gloves. The box had no signage indicating the items needed to be worn before entering the room or to see the nurse before entering. The resident had an infection requiring isolation. No one entering without previous knowledge would be alerted that the box meant isolation was expected. On 10/22/18 the Director of Nursing confirmed there was not signage to indicate to stop and see a nurse before entering room [ROOM NUMBER]A.

Based on surveyor observation, it was determined that the facility staff failed to maintain a resident's call bell within reach. This was evident for 2 (Residents #223, #35) of 47 residents observed during an annual recertification survey. The findings include: 1) During an observation of Resident #35 with the unit charge nurse on 10/23/18 at 9:55 AM, the surveyor observed Resident #35's call bell to have been placed on top of Resident #35's over bed light away from Resident #35's reach. 2) In a second observation with the unit charge nurse of Resident #223 on 10/23/18 at 10:05 AM, the surveyor observed that Resident #223's call bell was on lying the floor away from Resident #223's reach.